Now that we know at first hand what a pandemic is, this might be a sensible time to learn more about the 1918 flu–that thing most of us know as the Spanish flu. 

Spain’s connection was minimal. The disease first got public recognition there and that’s about it. World War I was still being fought, and newspapers were still censored in Germany, Britain, France, and the US–and possibly in assorted other countries that don’t get a mention. They weren’t allowed to mention the flu. You couldn’t publish anything that might lower morale.

Epidemics, you might have noticed, do lower morale.

Spain, though, sat on the sidelines in World War I. It didn’t censor its papers–at least not for any mention of morale-lowering diseases, although I wouldn’t rule out the possibility of censorship on other issues. So Spain broke the story and its reward was that the world blamed it for the disease it had mentioned. 

Recent epidemiological research hints that the virus might have been circulating for two years before reaching pandemic levels, and US troops could have been–well, I don’t know if calling them the source of the epidemic would be correct, but the first known cases were in Fort Riley, Kansas, and they didn’t stop the US from shipping soldiers to fight in Europe. So you could make an argument that the US was the source. 

Alternative theories, on the other hand, point to China, Britain, and France. 

 

Numbers

Although a lot of us learned to call the 1918 flu an epidemic, it was a full-blown international pandemic. (Hands up: How many of us even knew the word before last year?) The only part of the world that didn’t report an outbreak was Marajo, which I never heard of until I started researching this post. It’s an island in Brazil’s Amazon Delta. 

The pandemic ran from 1918 to 1919 and killed over 50 million people worldwide. Or possibly 100 million. No one was keeping count, so we’ll have to settle for guesswork. And to confuse the picture further, even if folks had been counting, the symptoms were easy to confuse with other diseases. 

An estimated 500 million people were infected–a third of the world’s population.

In Britain, 228,000 people died of the flu; 1918 was the first year on record in which deaths outnumbered births. And Britain got off more lightly than many countries.

By way of comparison, worldwide Covid deaths are currently just under 4 million, although that’s generally agreed to be an underestimate. Britain’s had 128,000 Covid deaths.. 

The flu pandemic killed between 10% and 20% of the people who became infected, and more people died of it in a single year than died of the Black Death between 1347 and 1351. I believe that’s in Britain. Or in England. Or somewhere. Who cares? It’s a sobering comparison.

It hit young adults particularly hard–people between 20 and 40, who you’d expect to have the most resistance–but it also hit children under 5 and people over 65. Most of us, though, will have heard about  the 20-to-40 age group because it’s unusual for a disease to zero in on them.

 

Spreading the flu

The flu spread both through the air on droplets–those things that people breathe, sneeze, coughe, or talk into the air. It also spread on surfaces. You’d touch a surface that had germs on it, give them a ride to your face, and have yourself a nice little bout of the flu. 

Soldiers returning home from northern France get a special mention in any discussion of how the virus spread. In France, they’d been coming down with la grippe, which consisted of sore throats, headaches, loss of appetite, and the cramped trenches it circulated merrily. But they tended to recover quickly. Doctors called it a three-day fever. 

From that, though, the disease evolved into something deadly. We’ll come back to that. In the meantime, let’s go back to those British soldiers returning home on cramped troop transports and trains. Following their path, the flu spread from railroad stations to city centers, from city centers to suburbs, and from suburbs to the countryside. 

 

The pandemic’s waves

The first wave of the pandemic hit in the spring of 1918 and was relatively mild. The second came in the winter and was the most deadly. In the past, when I’ve read that the second wave was worse than the first, I assumed that meant only that more people got sick. No such luck. The disease itself had changed. In the second wave, you could be fine at breakfast and dead by nighttime. 

Let’s go to Historic UK for the gory details: “Within hours of feeling the first symptoms of fatigue, fever and headache, some victims would rapidly develop pneumonia and start turning blue, signalling a shortage of oxygen. They would then struggle for air until they suffocated to death.”  

The third wave hit in the early spring of 1919, and was somewhere between the first and third in its virulence. Smaller, localized outbreaks went on into the mid ‘20s. But in August 1918, an observer could reasonably have thought that the disease had ended, and since the government still had a war to fight it kept its attention on that. 

For the most part, pubs stayed open. The Football League and FA Cup had been canceled because of the war, but men’s regional tennis competitions went ahead and so did women’s football, which in the absence of men’s games attracted big crowds.  

Hospitals were overwhelmed, and it didn’t help that medical personnel had been vacuumed up by the war. Medical students were brought in to help fill the gaps. Doctors and nurses worked themselves to the point of exhaustion. 

Graveyards were also overwhelmed. Think of them as the kind of high-end restaurants where you need advance bookings. The draft meant the country had a shortage of grave diggers, of funeral workers, of coffin builders. Horses had been drafted as well, so even getting the dead picked up was a problem. In Sunderland at one point, 200 bodies were left unburied for over a week. 

When the war ended (November 11, 1918, in case anyone asks, at 11 a.m.), crowds turned out to celebrate, helping to spread the disease. There just might be a lesson hidden in there for us.

 

The expert advice

Sir Arthur Newsholme, the chief medical officer of the Local Government Board, wrote a memorandum in July 1918 advising people to stay home if they were sick and to avoid large gatherings. It wasn’t bad advice, and he promptly buried it. Britain had that war to fight.

Looking back on it in 1919, he said it could have saved many lives, but “there are national circumstances in which the major duty is to ‘carry on’, even when risk to health and life is involved.”

Keep smiling. Keep morale up. If you have to die, do it off stage.

The cabinet never discussed the epidemic. No lockdown was imposed, and I’m not sure the concept was available to be discussed. In 1917, it talked about forming a ministry of health to prevent disease and coordinate health care, but it did nothing about it until 1919, leaving localities to respond to the pandemic as well or badly as they could. 

In places, theaters, dance halls, movie theaters, and churches were closed for varying lengths of time, and in some places streets were sprayed with disinfectant. Some people wore masks. Some didn’t. Whatever happened, happened locally.

Public health messages ranged from the vaguely useful to the batty. Some factories relaxed no-smoking rules because cigarettes were known to prevent infection–or at least some people knew about it and probably thought the ones who didn’t were idiots or deliberately suppressing information.

But that’s just a guess.

In a Commons debate, M.P. Claude Lowther asked, “Is it a fact that a sure preventative against influenza is cocoa taken three times a day?”

The News of the World told people to “wash inside nose with soap and water each night and morning; force yourself to sneeze night and morning, then breathe deeply. Do not wear a muffler; take sharp walks regularly and walk home from work; eat plenty of porridge.”

Cleaning your teeth was also recommended. It might not keep you alive, but at least you’d die with clean teeth. Brandy and whisky were popular preventatives. So was ventilation, which would have actually helped, along with warm clothes. Worrying about your health, on the other hand, would make you more vulnerable. Besides, it could interfere with the war effort.

Predictably, in the absence of solid information, individuals were often blamed–for catching the disease; for spreading it; for taking risks that no sensible person would take, like passing up that third cup of cocoa.

People rushed to chemists to buy quinine, which was useful against malaria but roughly as helpful against the flu as turkey feathers. 

We can–and we might as well–laugh, but remember that there weren’t any antibiotics yet, which could have been useful against flu’s secondary infections. And there were no antivirals. The first vaccine for the flu wasn’t licensed until 1940. 

Many doctors prescribed what they had available: aspirin. Its patent had expired in 1917, so new companies moved in to produce it–I’d assume cheaply. Patients were told to take up to 30 grams a day, which is now considered a toxic dose. If you take anything above four grams these days, red lights start flashing and sirens go off. 

The symptoms of aspirin poisoning include hyperventilation and pulmonary edema, which is a buildup of fluid in the lungs. Some flu deaths may have been either caused or speeded up by aspirin poisoning.

To be fair, some of the recommended public health measures were useful, including ventilation, disinfection, limiting or banning large gatherings, quarantine, and isolation of patients, but they were applied unevenly. 

 

The pandemic’s legacy

Industrialized countries went into the pandemic with atomized health systems. Doctors worked for themselves or for charities or religious institutions. Public health policies–and this isn’t particularly about Britain–were colored by eugenics, a theory that, to simplify wildly and irresponsibly, managed to show that the people at the top of society were there because they were better genetic specimens and the people at the bottom were degenerate and a mess. So public health policy–or so the Smithsonian tells me–tended to be about protecting the elites from the diseases of the poor. 

When the pandemic died down and they had some space to think, the lesson many countries took from it was that healthcare had to be available to all, and free, although the moves in that direction weren’t universal or, at first, complete. Public health embraced the idea of not just treating disease but preventing it. Epidemiology–the study of diseases’ patterns, causes, and effects–came into its own, and epidemiology demands data, which governments, or some of them anyway, began to gather. One of the problems that article after article mentions about the flu pandemic is that it wasn’t a reportable disease, so doctors weren’t required to report cases to the government and wouldn’t have had a bureau to report them to if they’d been inclined that way. That meant no one knew the size or shape of the crisis.

In 1919, the forerunner of the World Health Organization was founded–an international bureau to fight pandemics.