3. The flu was unlike any previously seen by medical professionals.
Spanish flu struck quickly. For example, the first outbreak reported in the United States occurred in Fort Riley, Kansas, in the late winter of 1918. On March 4 a company cook reported to sick call with the symptoms associated with the disease. In less than one week 522 soldiers at Fort Riley were stricken. With no quarantine and no restrictions on travel, the disease spread outwards, with America’s excellent railway system carrying many of those exposed but not yet stricken to other locations. The disease was reported in New York City one week later, on March 11, 1918. The symptoms were the usual ones of the flu initially, fever, respiratory difficulties, and aches and pains, including severe headaches. Then they got worse.
Spanish flu victims often hemorrhaged through mucous membranes, leading to the sick spitting and vomiting blood, suffering nose bleeds and often bleeding through the ears. A condition known as petechial hemorrhage – bleeding through the skin causing raised pustules filled with blood – was also not uncommon. Some victims were killed directly by the flu through bleeding through their lungs, literally drowning in their own blood. The virulence of the Spanish flu was such that it led to the death of about 20% of those infected, whereas most flu epidemics have a fatality rate of about 0.1%. Despite its ferocity, the epidemic seemed to be waning in the summer of 1918. Unknown to the medical authorities of the time was that the spring outbreak was only the first wave.
4. August 1918 saw simultaneous outbreaks in Europe, Ireland, North Africa, and the United States
In the late summer of 1918 outbreaks of the Spanish Flu, still not yet known by that name, occurred in Freeport, Sierra Leone, Boston, Massachusetts, Brest, on the coast of France, and throughout Ireland. The locations all had in common the fact that they contained ports visited by the ships of Great Britain; Boston for American provided war materiel and supplies; Freeport to supply the British West African troops against German African colonies; Ireland to supply troops and foodstuffs to the Western Front; and Brest as the main port for providing supplies to the British Army in France. American troops also landed at Brest, many carried by British ships.
The strain which appeared in August was far more virulent than that which had preceded it in the spring, spread more rapidly, and with a strong presence in busy seaports ensured itself the basis for continuing distribution. Seaports were all supported with busy rail networks, allowing the disease to be carried to other destinations before it had even made its appearance in the town supporting the port. Ireland was also connected to Great Britain with ferries, and the disease crossed into Great Britain along with ferry passengers and the returning British seamen and soldiers sent home to convalesce. As the summer of 1918 ebbed into the last autumn of the war, the flu pandemic erupted worldwide, appearing at every place where ships could find ports of call, as well as many where they could not.
5. The disease spread across the globe with astonishing speed
There is little doubt that the disease which came to be known as Spanish Flu was aided in its spread by the First World War, which offered the conditions in Europe which favored the spread of contagious illness of any kind. But its simultaneous eruption across the globe defied explanation other than that it was transmitted by the global shipments of men and materials. The disease would likely have spread with the same speed had the war not been underway, but it may have been less deadly, as it would not have found men massed together in unhealthy environments. Where populations were largest, densely packed, the disease was at its deadliest.
In heavily populated India the Spanish Flu killed up to 17 million people, approximately 5% of the total population of the subcontinent. The areas of the Indian subcontinent under the control of the British Raj – the most densely populated region – saw just under 14 million dead. Throughout the rest of India, the total number of dead can only be estimated, it may have been much higher. It was during the second wave of the pandemic, which began in August 1918 and hit its peak, in terms of fatalities, in October of that year that the flu seemed to differ from other strains of flu. Until then it had followed the usual pattern of most fatalities being the elderly and infirm, and young children. In the autumn of 1918 Spanish Flu began to kill a disproportionate number of young men.
6. The second wave of Spanish Flu did not affect most survivors of the first wave
When the second wave of Spanish Flu hit in the autumn of 1918, in a far more virulent and deadly form of the virus, doctors around the world noted that those who had contracted the disease earlier were not susceptible to the virus. That indicated that the virus was the same which had struck earlier, though it had mutated into a stronger form, and the first wave had in effect inoculated those struck by the disease. Studies conducted since the pandemic demonstrate that the virus was strengthened by the circumstances of the First World War. The theory of natural selection was demonstrated by the spread of the disease during the first wave. At that time soldiers in the camps and trenches which were not severely ill remained where they were, while the very sick were packed together in trains and hospitals.
Crowding the seriously ill together allowed the virus which had sickened them to strengthen, and when it reappeared in the second wave it was much stronger than that of the first. When the second wave hit it caused the same result in victims as the first, an overly strong response of the body’s autoimmune system to kill the virus. Since the virus was stronger than its predecessor the response was as well. Young, previously healthy men with healthy immune systems were thus more susceptible to both contracting the virus and experiencing an aggressive autoimmune response (a cytokine storm), which led to their deaths from the direct consequences of the flu, or secondary causes such as pneumonia.
7. Aspirin overdoses were responsible for thousands of deaths
The Spanish Flu pandemic coincided with the patents on aspirin held by Bayer expiring. Scores of pharmaceutical manufacturers began making and marketing the drug, which was widely prescribed by doctors for relieving the symptoms of the illness. The severity of the symptoms led some doctors to prescribe huge doses of aspirin. The American Medical Association in its Journal recommended doses of between 8 and 31 grams of aspirin, a suggestion which was backed by the Surgeon General of the United States. A normal dose of two aspirin is 650 milligrams. The massive doses administered by physicians, or self-administered by their patients, led to often fatal consequences.
The consequences of an aspirin overdose were little understood by the physicians of the day. It later became understood that a dose at the levels being recommended in 1918 could cause hyperventilation in about one-third of all patients. It could also cause congestion to build up in the lungs, leading to congestive heart failure. The death rate from Spanish Flu spiked in October, 1918, coincident with the recommendations to use massive doses of aspirin to treat the symptoms of the illness. How many died of aspirin overdoses has never been accurately determined, since aspirin killed in much the same manner as the flu itself, and the consequences of aspirin overdose were masked by the same symptoms it was prescribed to treat.
Several islands of the western Pacific had been German territories prior to World War One, occupied by New Zealand during the war. Ships from New Zealand traded with the islands of the Dutch West Indies (today’s Indonesia) as well as several other islands of the South and Western Pacific. When the pandemic broke out in Australia and New Zealand, the government of the former imposed strict policies to prevent the Spanish Flu from being carried across the sea. New Zealand did not. Ships from New Zealand carried the Spanish Flu to the islands, with often devastating results, as most did not have adequate medical care facilities, nor doctors with the knowledge and training to deal with the illness.
Formerly German Samoa was particularly hard hit, and saw 52% of its adult population which contracted the flu succumb. Just over 90% of the entire population of Samoa contracted the disease. As occurred elsewhere, the majority of the dead had been previously healthy young men. American Samoa was largely spared from the disease thanks to the imposition of a blockade of all shipping by its forward-thinking governor, John Martin Poyer, a naval officer who was awarded the Navy Cross for his action. Although his action drew the ire of the New Zealanders because of the restriction of trade, Poyer ensured that American Samoa was one of the very few areas across the world which incurred no deaths as a result of the pandemic.
9. Japan implemented trade restrictions to quarantine its home islands
Across the Pacific, the death toll from the flu mounted. New Zealand saw about 8,500 deaths, with the native Maori population much harder hit than those of European descent, largely due to their more crowded living conditions. Tonga, a British possession, saw about 8,000 fatalities. Nauru was captured by the Germans during the war by Australian troops, and a ship from New Zealand brought the flu to the island near the end of the pandemic, in 1920, resulting in a death rate of almost 20%. Fiji, also under British control, lost about 9,000 of its native population to the disease, a fatality rate of approximately 5%. British authorities implemented strict quarantines of the ill, isolating them from the Europeans on the island.
As the disease ravaged the Pacific islands, the Japanese government returned to the policy of isolation which they had followed in the 19th century. Japanese ports were closed to foreign ships and even interaction between the home islands was curtailed. Although more than a quarter of a million Japanese died from the flu during the pandemic, their death rate was nonetheless considerably lower than the other countries of Asia and the western Pacific. After July 1919, when shipping to and from the islands was curtailed, the rate dropped dramatically. The territories of the British Empire protested the financial losses due to the restriction of trade, but the Japanese actions protected most of its population from the worst of the pandemic, and Japanese deaths were well under 1% of the total population.
10. The Spanish Flu pandemic may have had its source in China
Although China possessed a large population, with much of it contained in crowded cities and villages, its mortality rate was lower than most other nations. China was hit during the first wave of the pandemic, and according to scholars in the 21st century may have been the source of the worldwide plague of flu. The disease first appeared in China in the early winter of 1917-18, and was identified by officials as a pneumonic plague. British officials at the legation in Beijing reported that the illness which swept across northern China was actually a virulent form of influenza. The outbreak occurred at the same time that British and French emissaries were gathering Chinese laborers for transportation to the Western Front in Europe.
The workers were shipped to Canada via the port of Vancouver, where they were kept in isolation, not for health reasons, but instead because of the racist attitudes towards the Chinese prevalent in Canada. The workers were kept aboard the trains as they traveled eastward, and at longer stops were quarantined in secure compounds. When several reported sore throats and other symptoms, they were treated by Canadian doctors with various nostrums, but not isolated from their fellow Chinese. Shortly after their arrival in Europe, the flu appeared among the troops on the Western Front, leading scholars to attribute the epicenter of the pandemic as the provinces of northern China, though the theory is disputed by historians and epidemiologists.
11. The symptoms of Spanish Flu were exceptionally severe
During the first wave of Spanish Flu in Europe and in the United States and Canada, the symptoms were of a severe case of the flu, but as has been seen, not alarmingly so among the young, previously healthy adults. It was the second wave, which almost appeared to target a healthy immune system to overreact, which became deadly. Both waves presented an illness which was highly contagious, but the second wave was both highly contagious and highly dangerous. Within a few hours of exposure, a healthy young adult felt extreme fatigue of muscle and mind. Fever followed, often dangerously high, along with severe headache, muscle aches, stiffness in the neck, and a developing deep cough, often coughing so violently as to tear abdominal muscles or suffer injury to the rib cage.
The victims of the disease developed a bluish tint to the skin, across the entire body, sometimes to such a deep shade of blue that it was no longer possible to identify the original skin color. The color indicated a lack of oxygen. The cough soon produced blood, foaming from the mouth and through the nose and sometimes the ears. Some died within hours of first exhibiting symptoms, others lingered for several days before succumbing to secondary infections, others died from the ministrations of ill-informed physicians or medics. Others survived. The severity of the symptoms, the number of deaths, and the virulence of the flu’s contagion led to disruptions of society which went beyond the treatment of the sick.
12. Spanish Flu caused societal changes due to its virulence
As Spanish flu raged across the United States during its deadly second wave it inflicted problems on the social fabric of American towns and cities. The first was the impact on the medical community, which was already short-handed with so many doctors and nurses serving in the military as a result of the World War. Morgues were overwhelmed with the number of dead, and many were forced to leave bodies of the flu’s victims in hallways, stacked like piles of firewood. In some communities, isolation wards were established for the victims of the flu. Necessity led to the establishment of mass graves for many of the victims, due to the lack of enough grave diggers to prepare individual resting places.
Communities closed their theaters, parks, schools, and other areas where the public gathered. Some communities passed laws making it illegal to expectorate and in some cases even to sneeze or cough in public, though few policemen were willing to approach someone who did so. Folk remedies, such as carrying a potato in one’s pocket, or swabbing one’s neck with garlic or camphor, were believed by some to be effective against contracting the flu. The second wave of the Spanish Flu hit its peak before the Armistice which ended the fighting during the Great War, as it was then called, but the illness did not fully disappear, and following the end of the fighting and beginning with the return of the troops from the front, a third wave of Spanish Flu appeared worldwide.
13. The third wave of Spanish Flu was less severe than the second wave
As troops began to return from the horrors of the First World War and the world breathed a collective sigh of relief in early 1919, Spanish Flu returned in a third wave across the globe. It was not as devastating as the second wave – which had been the most deadly of them all – but it was still more severe than the first appearance in Europe and the United States, as well as in the rest of the world. Those who had already had the flu and survived appeared to be immune to the third appearance, and it took on the indications of most forms of influenza, in that it was more dangerous for the elderly and children younger than the age of two or three. Healthy adults were more likely to survive than during the second wave.
The third wave lasted longer than its predecessors, appearing in late 1918 or early 1919, depending on the source, and lasting until late 1920, when it finally disappeared. As with the previous waves it was most virulent in areas of overcrowding, and it is likely that it was less deadly due to the previous experience of the earlier outbreaks. There was also the return of medical personnel from the war zones, which eased the shortage of professionals able to treat those stricken with the flu. By the time of the third wave, many treated the flu as a horror to be scoffed at, with children creating nursery rhymes about the illness to which they could skip rope; “I had a little bird, its name was Enza, I opened a window, and In-flu-enza”.
14. The Spanish Flu differed from most forms of influenza in several ways
As has been seen, during the deadliest period of the Spanish Flu pandemic, its second wave, it differed from most outbreaks of influenza in many ways. All forms of the flu are highly contagious, but the Spanish Flu was exceedingly so. It killed previously healthy young adults at a higher rate than it did elderly victims and young children, the latter two being much more susceptible during most flu outbreaks. Curiously, it also was at its height during the summer and early fall of 1918, while most flu outbreaks are at their peak during the months of late autumn and the depth of winter. It struck worldwide simultaneously when it was winter in the Southern Hemisphere, but summer in the Northern climes.
The Spanish Flu was also linked to lower educational achievement in children of the survivors in the years which followed the pandemic. Of all the statistical categories of people who were stricken with the flu during the pandemic, the highest mortality rate overall was with women who were pregnant at the time they contracted the flu. Of those who did survive, over a quarter miscarried. The death rate for pregnant women was as high as 71% in some areas, and possibly even higher, as most studies are based on those who were hospitalized. In many areas, particularly small towns and rural communities, pregnancy and childbirth were still the realm of midwives, and statistics of deaths attributed to the flu in such areas are unobtainable.
15. The flu attacked communities for a relatively short time.
Although the pandemic lasted from 1918-1920 around the world, including in the United States, it did not ravage individual communities for that entire period, including during the deadliest period of the pandemic, the second wave. In most areas, the flu struck with ferocious speed, remained virulent in the area for about a month or so, and moved on, leaving the survivors to deal with the damage that it had done. The months in which it was at its peak in the United States were the months when epidemics were still fairly common in the larger cities and towns, particularly along the East Coast, including cholera and typhoid fever, which led the flu to draw little media attention.
In the United States and especially in war ravaged Europe, the flu was often considered to be a consequence of the ongoing war when it struck. Even in neutral Spain, which inadvertently gave the flu its name, it was considered to be a by-product of the global disaster of the Great War. Its economic impact was limited due to the overall impact of the war. Although individual communities suffered temporary losses, especially in service industries, they were limited by the short duration of the illness within their own areas, while the long-term economic impact of the war continued, masking much of the losses caused by the pandemic. The health care industry, and the pharmaceutical companies which made and sold aspirin, profited from the Spanish Flu.
16. The Spanish Flu was contracted by many noted leaders of the day
The Spanish Flu was first reported worldwide when it struck Alfonso XIII, the King of Spain, in 1918. His illness, which was grave and reported around the world, gave the impression that the flu originated in Spain and thus bestowed the name Spanish Flu on the pandemic. He survived. He was far from the only notable to contract the illness. In the United States, President Woodrow Wilson contracted the disease, and some believe its ravages contributed to his suffering a stroke later. Walt Disney contracted the flu while in training to serve in the Ambulance Corps at an Army camp outside of Chicago. Artist Edvard Munch suffered through the flu, survived, and later painted Self-Portrait with the Spanish Flu.
Franklin Delano Roosevelt, at the time the Assistant Secretary of the Navy, contracted the flu while returning from France aboard USS Leviathan. The flu led to pneumonia, and Roosevelt was carried off the ship on a stretcher upon arrival in the United States (he was not yet confined to a wheelchair). Some who did not survive the flu were artist Gustav Klimt, Frederick Trump (grandfather of US President Donald Trump), Bill Yawkey (owner of the Detroit Tigers Baseball Club), and Edmond Rostand, whose most famed work was the play Cyrano de Bergerac. Some sources claim the Dodge Brothers, John and Horace, who founded the Dodge Automobile Company, died of Spanish Flu, though others state that Horace died of cirrhosis of the liver.
17. The Spanish Flu pandemic was truly global in its scope
Of the areas of the world which were populated at the time of the pandemic only one – an island in the delta of the Amazon River near Brazil known as Marajo – did not report an outbreak of the Spanish Flu. Even the remote South Atlantic island of St. Helena, where Napoleon had spent his last years of exile a century earlier, was stricken by the Spanish Flu, though no deaths were reported there. The French colony of New Caledonia, similarly to American Samoa, imposed a blockade of its shores and prevented any deaths to the flu. Other areas seemed to be particularly vulnerable despite efforts to prevent the spread of the flu. Casualties around the world were staggering.
In the United States alone up to 675,000 fatalities were attributed to Spanish Flu and the secondary infections it caused, more than died in the four years of the American Civil War a half-century earlier. Native American tribes suffered a disproportionate number of deaths, and in Alaska entire communities of Inuit natives were wiped out. Great Britain suffered 228,000 dead. Brazil lost its President, Francisco de Paula Rodrigues Alves, and over 300,000 of its citizens. Iran lost almost 22% of its total population during the pandemic. Even the tropical paradise of Tahiti was stricken, so severely that it was estimated to have lost up to a quarter of its population when the pandemic struck there, as with so many locations, brought to the isolated island by a visiting ship.
By the end of the year 1920, the Spanish Flu pandemic appeared to have finally faded away. Memory of the global disaster faded with it. During its height, media coverage was limited and what was present was for the most part localized, rather than covering the disease as it spread around the globe. With the end of the World War, once the flu had passed through one’s community, citizens wanted to get on with their normal lives. In the United States, the issue of Prohibition and the decade which became known as the Roaring Twenties moved to the fore. The flu which had ravaged the country became just another of the epidemics which were at the time a part of life. The world merely shrugged it off and moved forward.
Because of its coinciding with the Great War, as it was known at the time (it wouldn’t become known as World War I until the name World War II was coined), the overall impact on the public psyche in most countries was limited. With the majority of its fatalities among healthy young men, as with the war, it came to be considered a part of the war, a view especially prevalent in Europe. Its impact in Asia and the Pacific was relatively unknown to the great majority of people who were not in some manner connected to those regions. The same can be said about its impact in Africa. Not until the late 20th century, when public awareness of bird flu and other forms of influenza virus increased, was the Spanish Flu Pandemic brought to the public consciousness.
The origins of Spanish Flu remain debated among medical professionals, scientists, epidemiologists, historians, and others. Some postulate that the virus originated in birds and hogs, was transmitted to humans, and then transferred around the world. A leading theory for years was that the epicenter for the virus was Fort Riley, Kansas, among the animals bred to feed American troops. Others postulate that the virus originated in birds as a type of avian flu and transferred directly to humans, with humans passing the virus on to swine. Still, others suggest that the virus originated in China, supporting the belief that it was passed to the troops in the trenches of Europe by Chinese laborers brought to the battlefront to build infrastructure.
In the 21st century efforts to understand how the virus developed, what caused it to mutate into the deadlier virus of the second wave, and how it spread, continue to produce often conflicting theories. The fact is though efforts to understand what the virus was continuing, a definitive answer remains elusive. The pandemic which killed so many people that it was compared to the Black Death of the Middle Ages – and may well have killed a greater percentage of the population of Europe than its predecessor – remains a mystery, even as its history becomes more widely known.
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