The Spanish Influenza Pandemic: As Viewed Then and Now

September 10, 2018 Karie Youngdahl

Newspaper page showing graves being dug in Philadelphia, 1918
The Historical Medical Library of The College of Physicians of Philadelphia. Scrapbook of newspaper clippings (September 14, 1918 to March 1, 1919) concerning the influenza epidemic in Philadelphia, 1918-1919. Z10d.

Today's blog post is by John D.Grabenstein, RPh, PhD, Executive Director, Global Vaccines Medical Affairs, Merck Research Laboratories. He has published widely on the history of vaccine development, immunization policy, and pneumococcal and smallpox vaccination, among other topics.

Trains were the primary mode of transportation; the trains stopped running. So many people died, cities ran out of wood for coffins. Churches cancelled services to slow the contagion. Hospitals across America erected canvas tents to cope with unprecedented numbers of patients. Despite desperate and contradictory advice on how to quell the epidemic, no medical effort existed that could help the people. 

Historians agree that the influenza pandemic of 1918-19 was the greatest loss of life in such a short period at any time in the history of humanity. This pandemic, a very wide-ranging epidemic, easily exceeded the toll of any war or natural disaster. The Eurasian bubonic plague epidemic of the 1300s and the plague of Justinian in the sixth century caused more deaths overall, but those deaths were spread over years and decades, rather than a few months as in 1918-19.[1-4] 

How Bad Was 1918?

The numbers that describe the influenza pandemic of 1918-19 are nothing short of staggering. In the United States, 25 million people fell ill (one-quarter of the nation’s population) and 675,000 people died. These fatalities exceed the combat deaths of American soldiers in every war of the 20th and 21st centuries, combined.[1-6]

In Philadelphia, 7,600 people died within 14 days in 1918. During the week of October 23, 1918, 21,000 deaths due to influenza were reported nationwide, the highest weekly mortality level for any cause at any time in American history. During October 1918, 150,000 people died in Pennsylvania alone. In some Alaskan villages, 50% to 85% of the people died.[1-6] Graphs of American life expectancy show steady improvement, with a clear exception:  the dramatic dip caused by the 1918 influenza pandemic. [See Figure 1.]

Graph, US life expectancy, 1910-1960
US Life Expectancy. 1910-60.  SOURCE:  Lemon SM, Mahmoud A, Mack A, Knobler SL, eds. The threat of pandemic influenza: are we ready? workshop summary. National Academies Press; p. 73. 2005 Apr 9. DATA: U.S. Department of Commerce (1976); Grove and Hetzel (1968); Linder and Grove (1943)

Around the world, the most commonly quoted death toll is 21 million people, about 1% of humanity. Some estimates suggest that 30 million or more people lost their lives. About 500 million became ill. Some communities were stricken especially hard; at least 4% of the population of India are believed to have died. New Zealand was infected by ships from the United States. Australia was protected for several months by a vigorous quarantine that eventually failed.[1-3,7]

It is hard to conceive of human misery on this scale. Healthy streetcar conductors started the day feeling well, then fell dead by lunchtime. Children were found untended, because both parents had succumbed unexpectedly within hours of each other. A San Francisco hospital reported treating more than 1,000 patients with pneumonia simultaneously.[1-3]

Medicine in 1918 and Today

The first indication of the developing American outbreak came in March 1918 at Camp Funston, Kansas, near present-day Fort Riley. By April, cases appeared in most American cities and followed American soldiers deploying to Europe to help General Pershing repel the German Kaiser's army from France. 

The Army hospital commander at Camp Funston reported: “There are 1,440 minutes in a day. When I tell you there were 1,440 admissions in a day, you will realize the strain put on our Nursing and Medical force.”[4] The pandemic weakened German military forces perhaps more than Allied troops, and may have been a precipitating factor in Woodrow Wilson’s physical and mental demise at the end of his presidency.[1-5,7]

During those first few months, the infection was incapacitating, but not exceptionally lethal. By August, however, virulence increased and people were dying in droves. In response to the incapacitation and deaths, theaters, dance halls, bars, schools, and other places of public assembly were closed, including churches. Football games were cancelled and telephone booths were padlocked. 

Many cities adopted ordinances requiring people to wear gauze face masks in public. Compliance with the regulation was good in some places or at some times, but bad in others. The clinical value of masks in reducing droplet transmission is variable, except in reminding people to reduce close contact. Prescott, Arizona, made shaking hands a jailable offense.[1-4]

Teams with horse-drawn wagons in Philadelphia found 200 abandoned corpses in streets, alleys, and tenements. Morgues were overcrowded when embalmers refused to come to work. In one city, a trainload of coffins passing through was highjacked by a health official for local use.[4]

Recall that this was the pharmacologic era that featured quinine and digitalis. Little was available in the pharmacopeia to prevent or treat this influenza. In the 1910s, scientists had not yet discovered the existence of viruses, much less viewed influenza A virus through a microscope. 

Americans of that era called the 1918 pandemic by the name "Spanish influenza," because early clusters of deaths were reported in Spain while censored elsewhere. People in Spain called it the "Russian flu,” while the French blamed the Chinese. Clinicians of that era called the infection influenza, but they thought it was caused by Bacillus influenzae (Pfeiffer’s bacillus, now known as Haemophilus influenzae). Others blamed Friedlander's bacillus, Klebsiella pneumoniae.[1-4,7]

We know now that influenza pandemics are caused by influenza type A, but not by Haemophilus influenzae type b. Dozens of bacterial vaccines were tried in 1918, but they were ineffective against viruses, naturally. Home remedies included red-pepper sandwiches and various teas. Desperate measures were recommended, including chloroform inhalation, camphor amulets, and removal of tonsils or teeth.[1-4]

What Might a Modern Pandemic Look Like?

What would have happened if the 2009 influenza pandemic had not burned itself out? What will we do when the influenza virus next mutates into a strain as virulent as seen in 1918 or 1957? Without intervention, society would be threatened in an analogous fashion. The toll would be much the same, perhaps worse. 

Airplanes might stop flying for lack of personnel to keep them in the air. Congregation in malls, theaters, arenas, and houses of worship might be banned again. Spread of pandemic influenza in 1918 was aided by the mass movement of troops during World War I. In our modern era, jet airplanes can transport people and viruses far more efficiently.[3,7] Would the public expect or tolerate cessation of commercial airline traffic or closing the Interstate highway system to slow disease transmission?

Commerce and services taken for granted may be disrupted. Telephone service in 1918 failed when switchboard operators succumbed. Telephony services are automated today, but what if computer programmers and utility workers fall ill, or the people who replenish banking machines with $20 bills? Network problems could disrupt services over a wider area than in 1918.

An influenza pandemic differs markedly from more common natural disasters.  The acute phase of hurricanes or earthquakes lasts just a few minutes or hours. Unaffected areas can send assistance during the following weeks and months to help with recovery. Influenza pandemics, on the contrary, are expected to persist for 8 weeks in each locale, striking multiple communities simultaneously, lessening the ability to rally relief from neighboring locations. Competing demands for assistance will be fierce.

We can expect people to misinterpret colds and other viral respiratory infections as cases of pandemic influenza, diverting and diluting health-care resources. Inappropriate or counterproductive responses can be expected. Too stringent quarantine requirements may be imposed, as in 1918. Destruction of property to establish cordons sanitaire is possible, too. We can anticipate quack remedies and talismans reminiscent of 1918, as well as their 21st century counterparts, such as inappropriate serological testing. Objective facts and voices of reason will compete with schemers and the desperate.

Will there be enough trained personnel to operate the hospitals, dispense from pharmacies, and run the ambulances? In the 1918 experience, shortages of people and materiel struck many communities. Contingency plans will be needed.  Simple measures could include suspending vacations, working extra shifts, canceling non-acute care and procedures, and enlisting volunteers. Increased responsibility could be given to nontraditional providers. Training programs could be cut short and graduations accelerated. Retirees could be recalled to duty. National Guard units could be mobilized to help with essential services. 

Fortunately, the US government and state governments greatly enhanced their pandemic planning from the mid-2000s onward, prompted by an influenza A/H5N1 pandemic among birds and then the 2009 human influenza A/H1N1 pandemic.[8-10]

A major component of those recent preparedness efforts are focused on vaccines. The US government invested billions of dollars to expand domestic influenza vaccine-manufacturing capacity.[8,10] These efforts were tested in the 2009-10 influenza pandemic, which started out with exceptional pathogenicity, and then fortunately tempered over the course of multiple months. The vaccine supply was inadequate during that early alarming phase.  By the time the vaccine manufacturing pipeline was reliably yielding product, the public recognized the reduction in disease severity and lessened its collective clamor to be vaccinated.[11-14]  Untested was the adequacy of clinic space and supplies to vaccinate hundreds of millions of people in a short period of time.[15] 

The unpredictability of influenza presents many challenges.  Most influenza seasons are not as exceptionally bad as the 1918-19 crisis, but rather closer to the average (substantial) burden of serious disease and death. Understanding the history of extremely lethal influenza pandemics is essential to garner the preparedness and planning resources that will mitigate the next influenza pandemic.[8-13]


Note: This piece was adapted from an earlier publication
Grabenstein JD. Pandemic influenza: Planning now to avoid another tragedy. Hospital Pharmacy 1999;34(Jul):845-6,849-51,855-6.


1. Crosby AW. America's Forgotten Pandemic: The Influenza of 1918. New York: Cambridge University Press, 1989.
2. Collier R. The Plague of the Spanish Lady: The Influenza Pandemic of 1918-1919.  London: Allison & Busby Ltd, 1996. 
3. Fincher J. America's deadly rendezvous with the 'Spanish Lady.' Smithsonian 1989;19(Jan):130-147.
4. Bollet A. President Wilson and the blitzkatarrh. Resid Staff Phys 1988;34:183-187,191.
5. Gladwell M. The dead zone. New Yorker 1997;73(Sep 29):52-65.
6. Larson E. The flu hunters. Time 1998;151(Feb 23):1-5.
7. Patterson KD, Pyle GF. The geography and mortality of the 1918 influenza pandemic. Bull Hist Med 1991;65:4-21.
8. US Homeland Security Council. National Strategy for Pandemic Influenza: Implementation Plan, November 2005.
9. US Department of Health & Human Services. Pandemic Influenza Plan Update, June 2017.
10. US Centers for Disease Control & Prevention. Pandemic Influenza: A Planning Guide for State & Local Officials.
11. National Academies of Sciences, Engineering, and Medicine. Rapid Medical Countermeasure Response to Infectious Diseases: Enabling Sustainable Capabilities Through Ongoing Public- and Private-Sector Partnerships: Workshop Summary. Washington, DC:  National Academies Press, 2016.
12. Hessel L; European Vaccine Manufacturers (EVM) Influenza Working Group. Pandemic influenza vaccines: Meeting the supply, distribution and deployment challenges. Influenza Other Respir Viruses. 2009;3:165-70.
13. World Health Organization. SAGE Working Group on Influenza Vaccines and Immunizations: Influenza A (H5N1) Vaccine Stockpile and Inter-Pandemic Vaccine Use, November 2013.
14. Mei L, Song P, Tang Q, et al. Changes in and shortcomings of control strategies, drug stockpiles, and vaccine development during outbreaks of avian influenza A H5N1, H1N1, and H7N9 among humans. Biosci Trends. 2013; 7: 64-76. 
15. Koonin LM, Beauvais DR, Shimabukuro T, Wortley PM, Palmier JB, Stanley TR, Theofilos J, Merlin TL. CDC's 2009 H1N1 vaccine pharmacy initiative in the United States: Implications for future public health and pharmacy collaborations for emergency response. Disaster Med Public Health Prep. 2011 Dec;5(4):253-5.