In times of COVID-19, let’s take a look at the 1918 pandemic, and compare that to the current situation. Perhaps, the world is very different now, but the pandemic was deadly then, and is deadly now. Almost two years into the current pandemic, and the world is still battling COVID-19 and the health systems are still struggling to manage it.

Spanish Flu – Initial start and spread

The world in 1918 was very different from what it is today. Cities were smaller, commercial air travel by plane was still science fiction, messaging still meant sending written letters by post, and horse-drawn carriage was still the mode of transport for many. It had been over three years since World War I had started, and the US had only recently entered the war and was mobilizing and training people fast for it. That meant millions of new recruits would be crammed in barracks and millions of new workers would enter cities and factories to manufacture both, bullets and bandages, for the war, overcrowding cities that didn’t have sufficient housing. Beds would sleep two people, and when they were vacated, two new people would cram into the same uncleaned space. During the winter, new recruits would huddle together around a heat source often in closed spaces to preserve the warmth. There was an unusual level of mobility due to the war which meant people were moving from place to place more frequently, in steamships and trains, much like in the globalized world of today.

Against this backdrop, during the frigid winter months at the start of 1918, a rural village in Kansas, Haskell County, became the starting point of a truly devastating pandemic. People suffering from influenza usually shed virus and infect others no more than seven days after infection. The virus would have stayed in the isolated corner of Kansas but for the fact that a large army base was not far from there and every now and again people travelled from this isolated corner to the army base, Camp Funston, which was the second-largest cantonment in the country and held on average 50,000 new young troops. And there was a constant stream of soldiers and personnel that moved from Funston to other army bases around the country. Two weeks after the first case in Funston, influenza surfaced at two army bases in Georgia over 1500km away. What started as a drizzle here and there, turned into a torrential downpour soon after. By the end of spring, 24 of the 36 largest army bases in the US experienced an influenza outbreak. And 30 of the 50 largest US cities in the country also experienced “excess mortality” from influenza and most of these cities were adjacent to military facilities.

Influenza virus is like a black cloud in the sky. Sometimes, the black cloud just drizzles a few drops on a high population region and moves on. Sometimes it can cause a rather heavy downpour and result in disruptions lasting a few hours.

 Then there is that rarest of rare events when so much rain falls in such a short amount of time, it causes flash floods and widespread damage. That cloud has burst, and the water just falls onto the city below like a waterfall, causing lasting devastation. That influenza virus results in a pandemic.

By April, the larger outbreaks had started to happen in Europe, starting from France where American troops had disembarked for the war. The first wave of the virus was not as deadly but was debilitating enough that it interfered with the war and slowed the movement of troops. By May the virus had reached Spain, which was neutral during the war. Because of this, the press was not censored, unlike in France, UK and Germany, and the newspapers freely reported on the disease, especially when the Spanish king fell seriously ill. So even though the origin of the virus was in the US, it came to be known as the Spanish flu because only the Spanish reporting was being picked up by other countries.

Spanish Flu – Deaths

The 1918 influenza virus resulted in more deaths than the total deaths, military and civilian, resulting from World War 1. Moreover, it killed more people than any other pandemic in human history in raw numbers, although the plague in the 1300s had killed a larger proportion of the population in Europe.

Epidemiological estimates put deaths due to the virus between 50 and 100 million. The Spanish flu was unusual because it killed people in the prime of their life more often than the elderly and infants. In fact, nearly half of those that died were people in their 20s and 30s. Upper estimates put the death rate in young adults at almost 10%. The virus killed with great intensity and speed. Two-thirds of all that died, died in only 6 months. It killed more people in 24 weeks than AIDS has killed in 24 years.

COVID-19 in comparison has so far reported 5.2 million deaths worldwide, as of December 2021. Actual estimates may be more. The world population in 2021 is 7.75 billion while in 1918 was 1.8 billion, giving a sense of ferocity and lethality of the 1918 pandemic. Also, the majority of deaths due to COVID-19 are in people who are older or immunocompromised with 93% of the deaths among people older than 50 and 75% of the deaths in people older than 65 in the US.

How was the 1918 pandemic similar to the COVID-19 pandemic?

Like COVID-19, the 1918 pandemic also saw a shortage of nurses. Most nurses were called for the war effort. Approximately 80% of nurses from the east coast cities of the US were abroad during the war. Most countries reported a shortage of nurses, doctors, and hospital beds. But unlike COVID-19 where treatment and care is being provided in hospitals for moderate to severe cases, in the 1918 pandemic, most victims received care at home. Regardless, each pandemic overwhelmed the healthcare system. 

There was no vaccine available to prevent the spread then. Only non-pharmaceutical interventions- handwashing, wearing face masks, quarantine, restricting social gathering, were used. And because of quarantines, restrictions on using public transport, and general fear in the public, the economy suffered.

Since N95 masks were only invented in the 1990s, nurses in 1918 relied on cloth/gauze masks. During COVID-19, the shortage of PPE equipment, including N95 masks, was a major concern for many health care providers around the world.

The field of medicine has come a long way since 1918. Apart from greater understanding and effectiveness of non-pharmaceutical interventions, antiviral drugs are now available to treat some flu illnesses and strong antibiotics can treat secondary bacterial infections like pneumonia. WHO, which was only founded in 1948 also has a global influenza surveillance system that gives scientists better insight into the spread of the virus and its variants, providing lawmakers with crucial insights that have allowed some countries to prevent overloading their health care systems and given them better knowledge of the course that the virus would take.
Better research capabilities and the internet has allowed faster dissemination of research in almost “real-time” that has enabled health care providers to adapt faster to combat the symptoms and give them more ability to prevent deaths.

Where are we now in terms of COVID-19 ….

Having said that, have we really come a long way? Two years into the COVID-19 pandemic and we are still not very safe. Most scientists and public health experts will agree that no one is safe from the pandemic until everyone is.
Even though the current pandemic has brought about many conversations around health equity and fighting the pandemic together, a lot of it only seems to be talk. The global effort to help those with the least resources is not very evident.

Yes, we have vaccines and treatment regimens to tackle COVID-19, but until everyone has equal access to those, we will only be going in circles.

The current Omicron variant may appear to be less severe, but its fast spread can potentially have an impact, especially amongst those that lack immunity. Furthermore, the newer variants that may emerge may act differently and vaccines will have to be tailored accordingly. Hence, until the virus spread is controlled everywhere, the cycle will continue and we will be left at the mercy of the virus. The only way to fight this pandemic and go back to the normal world is by thinking about everyone.

Hence, I say it again ….. No one is safe, until everyone is safe.

Author – Radha Shukla


The Great Influenza: The Story of the Deadliest Pandemic in History by John M. Barry
Comparing the Spanish flu and COVID19 pandemics: Lessons to carry forward by Karen R. Robinson PhD, RN, FAAN