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Chapter 11
Un-remembered but Unforgettable: The ‘Spanish
Flu’ Pandemic
Daniel Flecknoe
1 Introduction
In 1918, during the final months of the First World War, an influenza epidemic
swept across the world. This strain of influenza was unusual, in that it was par-
ticularly deadly among 20–40 year olds, the age group typically least at risk
from flu-related mortality. Many victims of the pandemic appear to have died
from respiratory failure due to secondary bacterial infections, which medicine
at the time lacked the antibiotics to treat. Wartime censorship and military
objectives often obstructed the public health response, and troop movements
helped to spread the disease.
Worldwide, during the years 1918–19, the ‘Spanish Flu’ pandemic is estimat-
ed to have killed between 50 and 100 million people. Despite its massive im-
pact on the world, the pandemic was largely written out of early 20th century
history, possibly because of a wish to focus on the more heroic narrative of the
war. The long-term repercussions of the ‘Spanish Flu’ lasted for generations,
and have had both positive and negative impacts on societal resilience. This
chapter discusses the pandemic, its impacts and effects, as well as its implica-
tions for modern public health practice.
The word ‘influenza’ was first coined during an outbreak in Renaissance-era
Italy, in which it was noted that the populace attributed the disease to the ma-
levolent ‘influence’ of the stars.1 Today, influenza still retains some of the mer-
curial and enigmatic character lent to it by this early classification. In abbrevi-
ated lay parlance it is often used to describe a mild cold (“a touch of the ‘flu’”),
or the perceived malingering and tendency to exaggerate trivial symptoms by
men (“don’t mind him, he’s just got man-flu”). And yet, in its pandemic form it
remains at the top of public health risk registers for most developed nations.2
1 Dehner, Influenza – A Century of Science and Public Health Response.
2 nhs England, “Pandemic influenza”: www.england.nhs.uk/wp-content/uploads/2016/04/
pandemic-influenza-brief-apr16.pdf (accessed 31-8-2018); World Health Organisation, “The
ten years of the Global Action Plan for influenza vaccines: report to the director-general from
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These contradictions are embodied in the largest ever recorded influenza epi-
demic, which, despite being one of the single deadliest events in human his-
tory was, and is still, mostly overshadowed by the First World War (which killed
many fewer people).3 Not unlike a solar eclipse, when a vast object (the Sun) is
obscured by a smaller one (the Moon), the explanation for this phenomenon
can be found in their relative proximity to our point of view. In the case of the
‘Spanish Flu’ pandemic, which this chapter will discuss, it appears that the
First World War, with all of its heroic, tragic, and stirring tales of world-changing
but most importantly human agency, has always been much closer to the kind
of narrative that we want to tell about ourselves, and of 20th century history.
But history is not only composed of the stories that people want to tell, and
there is often as much or more to learn from the times when uncaring nature
collaborated with unforeseen consequences in order to humble the best efforts
of medicine and society. This is one of those stories.
2 A Brief History of Infectious Disease Control
Human progress towards understanding and controlling infectious diseases
throughout history has been slow and uneven, with occasional flashes of im-
pressively forward thinking. In the 5th century b.c., for example, the philoso-
pher Empedocles is reported to have successfully rid the city of Selinus of ma-
laria by diverting rivers in order to remove a stagnant swampland.4 Trial and
error over the next two millennia largely established the value of isolating the
sick and enacting quarantines to prevent epidemics from entering uninfected
cities or towns (or confining them in infected ones).5 The famous self-imposed
quarantine of the Derbyshire village of Eyam during the Great Plague of 1665
reinforces the point that knowledge of the causal organism is not always nec-
essary in order to enact successful counter-measures to its spread.6 Nevertheless,
the gap advisory group”: www.who.int/influenza/GAP_AG_report_to_WHO_DG.pdf (ac-
cessed 17-1-2018).
3 Flecknoe, Wakefield, and Simmons, “Plagues and wars: the ‘Spanish Flu’ pandemic as a lesson
from history”: doi.org/10.1080/13623699.2018.1472892 (accessed 31-8-2018).
4 Geroulanos, “Epidemics in antiquity, Byzantium and Renaissance”, p. 19.
5 Dobay, Gall, Rankin, and Bagheri, “Renaissance model of an epidemic with quarantine”,
pp. 348–58; Gall, Lautenschlager, and Bagheri, “Quarantine as a public health measure
against an emerging infectious disease: syphilis in Zurich at the dawn of the modern era
[1496–1585]”, document 13.
6 Whittles and Didelot, “Epidemiological analysis of the Eyam plague outbreak of 1665–1666”:
rspb.royalsocietypublishing.org/content/royprsb/283/1830/20160618.full.pdf (accessed
23-8-2018).
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from the Enlightenment onwards, such knowledge was being sought with in-
creasing energy and technical sophistication.
This trend of historically slow progress towards understanding the true
causes of disease went into abrupt overdrive in the generation prior to the First
World War. Pasteur’s discovery of bacteria in the 1860s gave rise to Germ Theo-
ry, which led to radically beneficial changes in medical practice relating to in-
fectious disease control.7 Vaccines began to be developed, which along with
improvements in clean water and sanitation, meant that many of the major
scourges of the 19th century were dramatically reduced by the onset of war in
1914.8 Disease-causing protozoa and fungi had also been identified, treatments
were becoming more effective, and well-reasoned guesses were beginning to
be made about the existence of tiny ‘filter-passing’ organisms that were too
small to see under a microscope or to be impeded by a standard bacterial filter,
yet nevertheless still had the power to make people ill. These hypothesized
organisms, speculatively called ‘viruses’ (meaning ‘poisons’ in Latin), were
known to be rendered harmless by extremes of temperature, and so were
thought to be alive in some sense, but for now their existence was only a matter
of conjecture.9
Despite the growing ascendency of Germ Theory in the early 1900s, many
senior doctors at the time of the First World War had done their medical
training prior to its discovery, so some older ideas (such as the ‘miasma’ the-
ory of disease) still persisted.10 The disciplines of bacteriology and public
health were still both still in their infancy, but becoming better recognized
(especially in the military) as being important for epidemic control. Pathol-
ogy and laboratory sciences, which could be highly dangerous pursuits in the
absence of modern biohazard precautions,11 were used to good effect in the
Spanish-American war of 1898 and also during the Balkan Wars of 1912–13.12
This represented the beginning of a much needed counter-offensive in the
7 Sihn, “Reorganizing hospital space: the 1894 plague epidemic in Hong Kong and the Germ
Theory”, pp. 59–94.
8 Cox, “The First World War: disease, the only victor”, www.youtube.com/watch?v=x70gZ
jugLRM (accessed 13-12-2019).
9 Gordon, “The filter passer of influenza”, pp. 1–13; Dehner, Influenza.
10 Cox, “The First World War”.
11 Wever, Hodges, “The First World War years of Sydney Domville Rowland: an early case of
possible laboratory-acquired meningococcal disease”, pp. 310–15.
12 Flamm, “The Austrian Red Cross and Austrian bacteriologists in the Balkan wars 1912/13 –
centenary of the first application of bacteriology in theatres of war”, pp. 132–47; Wright
and Baskin, “Pathology and laboratory medicine support”, pp. 1161–172.
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battle between armies and communicable diseases, in which the microbes
had previously held a decisive advantage. The number of recorded deaths
from infectious disease in the Peninsula, Crimean, and South African Wars,
and the American Civil War (all of which occurred in the century prior to
the First World War) each exceeded the recorded deaths from combat in
those conflicts by a wide margin.13 The First World War would bring about
some major victories for the human side of this inter-species conflict,14 and
also some significant defeats, the most devastating of which is the subject of
this chapter.
Influenza was a disease that both gratified and frustrated practitioners of the
science of medicine during this period. In its habit of mostly killing the elderly
or infirm it was sometimes regarded as a merciful disease, and also a relatively
congenial one for doctors who were paid per visit and could expect a bonus if
their patient recovered. An illness of which many suffered but relatively few
died, was therefore good for business. However, its causal organism still eluded
scientific enquiry. A bacterium, now known as Haemophilus influenzae,15 had
been identified as being so commonly found in the lungs of autopsied influ-
enza victims that some scientists thought it was the illness’ cause, while others
suggested that one of the hypothesized ‘viruses’ was a more likely candidate.16
There had been an influenza pandemic in the late 1880s, which killed roughly
1 million people around the world, and which was observed at the time to dis-
proportionately affect soldiers in crowded barracks.17 At the outbreak of the
war in 1914, medical personnel on all sides of the conflict were mobilized in
large numbers to fight the familiar military diseases of typhus, measles, and
cholera.18 No one was prepared for what they actually faced.
13 Cox, “The First World War”.
14 Such as the standardized use of anti-tetanus serums for the wounded, who were at signifi-
cant risk of developing this frequently fatal disease due to the deep traumatic injuries
that the newer battlefield weaponry of the First World War could inflict. Many lives were
undoubtedly saved by this innovation: Wever and Van Bergen, “Prevention of tetanus dur-
ing the First World War”, pp. 78–82.
15 Known at the time as ‘Pfeiffer’s bacillus’ after the scientist who first identified it. Bresalier,
“’A most protean disease’: aligning medical knowledge of modern influenza, 1890–1914”,
pp. 481–510.
16 Bresalier, “A most protean disease”.
17 [Anon.], “The epidemic of influenza in St. Petersburg” [letter]; Vallerona, Coria, Valtata,
Meurissec, Carrata, and Boëlle, “Transmissibility and geographic spread of the 1889 influ-
enza pandemic”, pp. 8778–781.
18 Shanks, “How World War 1 changed global attitudes to war and infectious diseases: legacy
of the 1914–18 war”, pp. 1699–1707.
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3 The Pandemic
The precise beginning and end of the ‘Spanish Flu’ pandemic – so called be-
cause neutral Spain actually reported on the disease, while belligerent nations
officially suppressed the news19 – is difficult to cleanly define.20 The gener-
ally agreed epidemiological pattern is of three sequential waves of varying se-
verity: in the spring of 1918 (low fatality), autumn of 1918 (high fatality) and
spring-summer of 1919 (moderate fatality) (Fig. 11.1).21 However, some research-
ers have drawn attention to earlier outbreaks of atypical respiratory disease in
British army barracks and French military camps in 1916–17.22 Under-reporting
in the chaos of the First World War was a significant problem, and influenza
was easily mistaken for some of the other febrile and debilitating illnesses
caused by the unhygienic conditions that soldiers lived in, such as Trench Fe-
ver (now known to be caused by Bartonella Quintana infection transmitted by
lice).23 Indeed, it is not completely certain that all three waves were caused by
the same disease. Genetic testing has thus far only been possible on samples
taken from victims of the second wave, and some people at the time thought
that this must be a wholly new disease due to its unprecedented virulence.24
However, the working assumption among most scientists and historians is that
the H1N1 influenza virus, identified in the lungs of permafrost-frozen corpses
in the Arctic, was responsible for all three peaks of the pandemic.25 We will
proceed upon that assumption.
19 For this reason, the inaccurate but widely accepted term ‘Spanish Flu’ will be used in
quotation marks throughout this chapter.
20 Witte, “The plague that was not allowed to happen: German medicine and the influenza
epidemic of 1918–19 in Baden”; Flecknoe et al., “Plagues and wars”.
21 Taubenberger and Morens, “1918 influenza: the mother of all pandemics”, pp. 15–22.
22 Oxford, Sefton, Jackson, Johnson, and Daniels, “Who’s that lady? An analysis of scientific
and social literature suggests that army bases located in France and the UK may be re-
sponsible for the worldwide distribution of the ‘Spanish lady’ influenza pandemic of
1918”, pp. 1351–352.
23 Atenstaedt, “Trench fever: the British medical response in the Great War”, pp. 564–68.
24 Newsholme, “A discussion on influenza”, pp. 1–18; Jivraj and Butler, “The 1918–19 influenza
pandemic revisited”, pp. 347–52.
25 Davis, Heginbottom, Annan et al., “Ground penetrating radar surveys to locate 1918 Span-
ish Flu victims in permafrost”, pp. 68–76; Steele and Collins, “La grippe and World War i:
conflict participation and pandemic confrontation”, pp. 183–204; Morens, Taubenberger,
Harvey, and Memoli, “The 1918 influenza pandemic: lessons for 2009 and the future”,
e10–e20.
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30
25
Deaths per 1,000 persons
20
15
10
5
0
6/29 7/27 8/24 9/21 10/18 11/18 12/14 1/11 2/8 3/8 4/5
1918 1919
Illustration 11.1 Three pandemic waves. Weekly combined influenza and pneumonia
mortality, United Kingdom, 1918–1919
The disease, which at the time was known variously as ‘Spanish Lady’,26 ‘French
Flu’ (in Spain),27 and the ‘Purple Death’28 may have had both avian and swine
elements to its genetic make-up.29 Its origins have been variously suggested to
have been Europe, Southern China, or the Midwest of America.30 Wherever it
originally came from, it detonated in early 1918 at the epidemiological Ground
Zero of the Western Front – an area that had already been the setting for some
of the most profound, noble, and yet ultimately futile human suffering in re-
corded history31 – and promptly made conditions there a good deal worse.
What were described at the time as the “relentless needs of warfare”,32 swept
virtually all public health considerations aside and created the perfect storm of
overcrowding and forced troop movements across and between continents to
spread the disease far and wide.33 This novel strain of H1N1 successfully ex-
ploited a man-made ecological niche created by the greatest mass population
movements in history; to take the most unambiguous example, during the last
six months of the war, an estimated 1.5 million American soldiers crossed the
26 Oxford et al., “Who’s that lady?”.
27 Trilla, Trilla, and Daer, “The 1918 ‘Spanish Flu’ in Spain”, pp. 668–73.
28 Radusin, “The Spanish Flu – Part 1: the first wave”, pp. 812–17.
29 Shortridge, “The 1918 ‘Spanish’ Flu: pearls from swine?”, pp. 384–85.
30 Oxford et al., “Who’s that lady?”; Shortridge, “The 1918 ‘Spanish’ Flu”.
31 Hart, The Somme.
32 Newsholme, “A discussion on influenza”, p. 13.
33 Barry, The Great Influenza: The Story of the Deadliest Pandemic in History.
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40.0 1.1
1.0
35.0
0.9
30.0 0.8
0.7
25.0
0.6
20.0
0.5
Birth: 1897–1900
15.0 18–42 years old in 1918
0.4
0.3
10.0
Birth: 1900 >42 years old in 1918
0.1
0.0 0.0Un-remembered but Unforgettable 221
ship outbreak observed that “[t]he strange thing about this sickness is that the
big strong men seem to get it the worst and are the ones that die”.37 Mortality
was largely attributable to secondary bacterial pneumonia, which created the
cyanotic ‘heliotrope’ discoloration on the faces of the dying, from which the
ominous nickname ‘Purple Death’ was derived.38
Years later, medical personnel who saw the disease first-hand still marvelled
at the “furious speed” with which it spread, not only through communities
(military and civilian) but across continents.39 Historical conspiracy theorists
would find great scope in the contemporary and modern reports that the pan-
demic seemed to appear in many parts of the world simultaneously, so rapidly
did it travel.40 Patriotic fervour and demonization of the enemy gave traction
to Allied rumours that the Germans were engaging in biological warfare, pos-
sibly through gases released from U-boats.41 Some also observed that the
symptoms of ‘Spanish Flu’ closely resembled those of phosgene gas poison-
ing.42 With the benefit of access to the historical records of both sides in the
conflict, and a clear understanding of scientific progress at the time, we can
safely dismiss these speculations while still being awed by the speed with
which a pandemic could spread around the world even at the very beginning
of the era of globalisation.43
‘Spanish Flu’ appears (no doubt there is some reporting bias here) to have
engulfed almost the entire world in a matter of weeks.44 From the Allied side
of the Western Front it leapt across No Mans’ Land to the German side, likely
by way of captured enemy prisoners,45 and thereafter was quickly spread to
37 Summers, “Pandemic influenza outbreak on a troop ship – diary of a soldier in 1918”,
pp. 1900–903.
38 Hunt, “Notes on the symptomatology and morbid anatomy of so-called ‘Spanish influen-
za’ with special reference to its diagnosis from other forms of ‘p.u.o’”., pp. 356–60; Shanks,
“Insights from unusual aspects of the 1918 influenza pandemic”, pp. 217–22.
39 Editorial, “The Australian Army Medical Services in the War of 1914–1918. Vol. 3”, p. 240.
40 Newsholme, “A discussion on influenza”; Oxford et al., “Who’s that lady?”.
41 Crosby Jr, Epidemic and Peace; Honigsbaum, “Regulating the 1918–19 pandemic: flu, sto-
icism and the Northcliffe Press”, pp. 165–85.
42 Editorial, “The Australian Army Medical Services in the War of 1914–1918. Vol. 3”, p. 240.
43 The First World War has been succinctly described as a ‘chemists’ war’, because of the
amount of novel chemical compounds (from medicines to weapons) that were used dur-
ing it for the first time. In order for the ‘Spanish Flu’ to have been the deliberate weapon
that some observers at the time suspected, it would have had to have been a microbiolo-
gists’ war as well, but the deliberate and scientific weaponization of that particular sci-
ence was still (thankfully) some years away.
44 Phillips and Killingray, “Introduction”.
45 Radusin, “The Spanish flu – Part 1”.
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other theatres of war.46 Away from the battlefield it typically appeared first in
port cities, where soldiers, sailors, and cargo ships were arriving from other
parts of the world, and then radiated out via rail networks.47 Isolated island
nations were sometimes hit hardest by the second, more deadly wave, espe-
cially if they had missed out on the immunity conferred by the milder first
wave.48 Western Samoa, where 25 per cent of the population died from the
pandemic in the autumn of 1918, is a good example of this phenomenon.49
Some cultures were also particularly vulnerable because of social customs that
enhanced house-to-house disease transmission, such as the practice of visiting
bereaved neighbours in order to pay respect to the dead.50
Public health response to the pandemic was patchy, due in part to incom-
plete knowledge and in part to the greater priority assigned by most decision
makers to military objectives. In some areas, such as Australia, successful
quarantine measures were enacted once news of the second wave began to
arrive, and this may well account for their proportionally low (although still
significant) mortality figures.51 In other parts of the world, especially those
most befuddled by the fog of war, folk remedies and quack cures abounded in
the absence of a well-organized state response.52 The civilian populations of
belligerent nations were left especially unprotected against disease outbreaks,
not only by the nutritional austerity of wartime, but also because a large per-
centage of their trained medical and nursing staff were overseas, seconded to
the military.53 And the military, for their part, were too often living in over-
crowded, poorly-ventilated quarters, which dramatically enhanced the spread
of disease within the ranks of those fighting the optimistically named ‘war to
end all wars’.54
Isolation of the infected, one of the tried-and-tested methods of infec-
tious disease control, was frequently made impossible by the unwillingness
of military leaders to prioritize public health over war-winning objectives
46 Shanks, “Formation of medical units in response to epidemics in the Australian imperial
force in Palestine 1918”, pp. 14–9.
47 Palmer, Rice, “A Japanese physician’s response to pandemic influenza: Ijiro Gomibuchi
and the ‘Spanish flu’ in Yaita-cho, 1918–1919”, pp. 560–77.
48 These observations lend credence to the assumption that at least the first and second
waves of the “Spanish flu” were definitely caused by the same viral pathogen.
49 Radusin, “The Spanish flu – Part 2: the second and third wave”, pp. 917–27.
50 Palmer and Rice, “A Japanese physician’s response to pandemic influenza”.
51 Crosby Jr, America’s Forgotten Pandemic: The Influenza of 1918; Oxford et al., “World War i
may have allowed the emergence of ‘Spanish’ influenza”.
52 Witte, “The plague that was not allowed to happen”.
53 Steele and Collins, “La grippe and World War i”.
54 Aligne, “Overcrowding and mortality”.
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Illustration 11.3 Warning sign posted at a Philadelphia Naval property in 1918
(ill. 11.3).55 Patriotic parades and other ceremonial military-civilian gatherings
went ahead in cities across America during the second wave, despite medical
advice that this would only facilitate the spread of this newly-lethal disease.56
The troop ships continued to set sail. Since many doctors still believed that
influenza had a bacterial cause, vaccines against what were thought to be the
likely candidate micro-organisms were widely used, to little or no avail.57 Mis-
information was sown, as the failure to locate Pfeiffer’s bacillus in the lungs of
some of the deceased was proclaimed as conclusive evidence that the disease
was not influenza.58 Gauze facemasks were used in many parts of the world,
which may have offered some slight protection, as although they were not fine
enough to stop viruses they could block the larger dust motes and particulates
upon which viruses could be riding. In San Francisco, where the failure to wear a
mask in public was made illegal, there was considerable libertarian resistance
55 Barry, The Great Influenza.
56 Crosby Jr, Epidemic and Peace.
57 Palmer and Rice, “A Japanese physician’s response to pandemic influenza”.
58 Dehner, Influenza. Pfeiffer’s bacillus, now known as ‘Haemophilus influenza’, is the bacte-
rium sometimes thought to be the causal organism of influenza at the time because it was
frequently present (as a secondary infection) in the lungs of autopsied influenza victims.
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against what was perceived to be an unconstitutional interference with personal
liberty.59
The war, and (by modern standards) very poor data collection systems, frus-
trated contemporary efforts to both measure the true scale of the catastrophe
and to effectively combat it at the time.60 The estimated number of deaths
worldwide, from all three known waves of the pandemic, has been gradually
revised upwards over the last 100 years as better information has become avail-
able. The consensus view over the last decade has been that the ‘Spanish Flu’
killed between 50–100 million people.61
4 How did the Pandemic Affect the War?
The First World War has often been cited as a turning point in the history of
warfare. In wars prior to 1914 it was almost invariably the case that deaths from
infectious diseases would exceed the deaths caused by combat.62 The scales
were being tipped from both directions by the start of the 20th century, with
increasing medical knowledge successfully reducing outbreaks of disease, as
well as curing those who contracted them, and also by the increasing efficiency
of battlefield weaponry, killing the enemy in far greater numbers than ever was
possible before. However, whether you consider the First World War to be in
fact the tipping point, or merely the last triumph of disease’s long ascendancy
in wartime deaths, very much depends upon how you factor in the ‘Spanish
Flu’.63 If civilian casualties of the pandemic are included in the calculation
then diseases could have killed up to ten times as many as were killed by com-
bat between 1914 and 1918.
In terms of the effect of the pandemic on the course of the war, there is nec-
essarily some uncertainty about this. The opinions of observers at the time,
and those of historians up to the present, can provide us with probabilities and
informed opinion, but since it is not possible to know what would have hap-
pened if the ‘Spanish Flu’ had not emerged when it did, there will always be
an element of speculation. Other infectious diseases that were prevalent in
sections of the military during the First World War are generally thought to
59 Crosby Jr, Epidemic and Peace.
60 Steele and Collins, “La grippe and World War i”.
61 Morens et al., “The 1918 influenza pandemic”.
62 Kiss, “Contagious diseases in the Austro-Hungarian Army during the First World War”,
pp. 197–203; Pages, Faulde, Orlandi-Pradines, and Parola, “The past and present threat of
vector-borne diseases in deployed troops”, pp. 209–24.
63 Cox, “The First World War”.
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have had the effect of prolonging it. Some of these diseases were due to the
abysmal conditions that men were fighting in (such as Trench Fever), and oth-
ers due to unfamiliar pathogens endemic to the theatres of war that soldiers
were travelling to fight in (e.g. malaria).64 They took a severe toll on the fighting
strength of the belligerent nations, and as such are considered likely to have
delayed any possible military victory by either side.65
‘Spanish Flu’ certainly sapped the strength of all sides in a similar way. By
July of 1918 there were widespread outbreaks on both sides of the conflict,
causing significant morbidity and mortality among the soldiers who would
otherwise have been mustering for last ditch strikes against the enemy.66 Those
victims that ‘Spanish Flu’ did not kill, it temporarily incapacitated, and the ill
were (in some ways) more of a burden to the military than the dead, in that
they needed caring for, thereby diverting resources from the fighting.67 Also, at
a time when both sides were relying more and more heavily on reserve troops
to relieve the exhausted frontline divisions, the pandemic frequently picked
them off as they arrived; new recruits, lacking any partial immunity from expo-
sure to previous waves of the disease along the Western Front, had by far the
highest mortality.68 The U.S. military, entering the war in 1917 on the Allied
side, were heavily affected, by some estimates losing at least as many soldiers
to ‘Spanish Flu’ as they did in combat.69 All of this would argue for the pan-
demic having probably lengthened the war.
However, the alternative possibility is also worth considering. The ‘Spanish
Flu’ struck in the final year of the war, at a moment when Germany was close
to defeat but still had some important cards left to play. In the spring of 1918,
German forces on the Western Front launched the Kaiserschlacht (Kaiser’s
Battle), intended to be a series of decisive blows that would drive the Allied
forces back across France until their backs were against the English Channel.
They were strengthened by large numbers of troops and resources from the
Eastern Front, redeployed following the withdrawal of Russia from the war.
64 Marc Ho, Jeff Hwang, Vernon Lee, “Emerging and re-emerging infectious diseases: chal-
lenges and opportunities for militaries”: mmrjournal.biomedcentral.com/articles/10.1186/
2054-9369-1-21 (accessed 31-8-2018); Newman, Johnstone, Bridge et al., “Seroconversion
for infectious pathogens among UK military personnel deployed to Afghanistan, 2008–
2011”, pp. 2015–022.
65 Cox, “The First World War”.
66 Newsholme, “A discussion on influenza”; Shanks, “Formation of medical units”.
67 Crosby Jr, Epidemic and Peace.
68 Shanks, MacKenzie, Mclaughlin et al., “Mortality risk factors during the 1918–1919 influ-
enza pandemic in the Australian army”, pp. 1880–889.
69 Dehner, Influenza; Wever and Van Bergen, “Death from 1918 pandemic influenza during
the First World War: a perspective from personal and anecdotal evidence”, pp. 538–46.
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American troops were streaming across the Atlantic to bolster Allied forces,
but for the moment, the Germans held the numerical advantage. The early of-
fensives of the Kaiserschlacht were successful, and the Allies were forced to
retreat. However, a combination of factors prevented the German forces from
consolidating their early gains, and the momentum faltered, bringing to an
end their final realistic hope for victory. One of those factors was the first wave
of the ‘Spanish Flu’.70
Other factors included exhaustion, low morale, and political upheavals
within the German army. The German High Command had been successful
in fomenting a rebellion in Russia that removed their eastern enemy from the
war, but the same anti-war sentiments which had animated the revolutionary
workers’ councils (or ‘Soviets’) were also spreading through their own ranks.
However, General Erich von Ludendorff, commander of the German forces,
wrote after the war that the pandemic had been a significant factor preventing
the success of the Kaiserschlacht.71 Without that victory, Germany was no lon-
ger in a position to win the war, and was consequently forced to begin consid-
ering the terms of surrender.72 It could be argued that von Ludendorff would
have had a bias in favour of attributing the Kaiserschlacht’s failure to the pan-
demic, since he could hardly be blamed for it. However, it is also plausible that
without the impact of the ‘Spanish Flu’ on what could have been a decisive
turning of the tide against the Allies, the war could have gone on much longer.
Although the historical connection is now well established, popular narra-
tives of war do not tend to prominently feature the role that infectious diseases
can play in bringing about either victory or defeat. During the American War of
Independence, George Washington had his soldiers vaccinated against small-
pox, which was then endemic in North America. As a result, the Continental
Army lost many fewer men to the disease than the British and Loyalist forces,
which is now considered by historians to have been a significant factor in en-
suring victory for what later became the United States.73 As with the impact of
‘Spanish Flu’ on the outcome of the First World War, this interpretation rarely
prevails over the more nationalistically affirming ‘superior tactics, valour and
force of arms’ explanation for military outcomes. As the anthropologist Jared
70 Crosby Jr, Epidemic and Peace; Zabecki, The German 1918 Offensives. A Case Study in the
Operational Level of War.
71 Wever and Van Bergen, “Death from 1918 pandemic influenza”.
72 Zabecki, The German 1918 Offensives; Herwig, The First World War: Germany and Austria-
Hungary 1914–1918.
73 Geroulanos, “Epidemics in antiquity”; Ratto-Kim, Yoon, Paris et al., “The US military com-
mitment to vaccine development: a century of successes and challenges”: www.ncbi.nlm
.nih.gov/pmc/articles/PMC6021486/ (accessed 31-8-2018).
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Diamond has observed, “The winners of past wars were not always the armies
with the best generals and weapons, but were merely those bearing the nasti-
est germs to transmit to their enemies”.74
It scarcely needs to be said that the ‘Spanish Flu’ had enormous impacts
beyond any effect that it may have exerted upon the outcome of the First World
War. Around the world, 500 million people are thought to have been infected
over the course of the pandemic, which continued well into 1919.75 In the post-
war years, while millions of civilians were dying of typhus, tuberculosis, and
other diseases associated with the malnutrition, overcrowding and poor sani-
tation in refugee camps, bombed cities, or devastated farming communities,
‘Spanish Flu’ was also quietly taking its toll.76 The global social and economic
impacts were exacerbated because the dead were so often those of productive
working age, causing labour shortages in cities77 and famines in rural areas.78
It took as many as 100 million lives and immiserated many times that number,
and then, seemingly, it vanished from the public memory. Histories of the pe-
riod published in the first half of the 20th century rarely mentioned it, and
popular culture gave it little or no attention.79 But forgotten or not, it contin-
ued to have an impact on society, medicine, and resilience.
5 Longer Term Impacts
The most truly awful, yet plausible, long-term impact of the ‘Spanish Flu’ pan-
demic is that it may have contributed to setting the scene for the Second World
War. In April 1919, evidence suggests that US President Woodrow Wilson be-
came a victim of the third wave of the pandemic. He collapsed during peace
talks at the conference of Versailles, suffering from a high fever, cough, and
confusion, all symptoms consistent with influenza. Wilson had expressed a de-
sire for a peace agreement that did not excessively punish the German people
for their country’s actions during the war, and in earlier negotiations he had
74 Diamond, Guns, Germs and Steel: A Short History of Everybody for the Last 13,000 Years.
75 Radusin, “The Spanish flu – Part 2”.
76 Cox, “The First World War”.
77 Chowell, Viboud, Simonsen et al., “Mortality patterns associated with the 1918 influenza
pandemic in Mexico: evidence for a spring herald wave and lack of pre-existing immunity
in older populations”, pp. 567–75.
78 Dehner, Influenza.
79 Crosby Jr, Epidemic and Peace.
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strongly argued, against his European counterparts, for a leniency that they
were not otherwise inclined to bestow. His temporary removal from the nego-
tiations, and the weakness and inattention to detail that he reportedly showed
when he recovered enough to return, may well have caused the sanctions even-
tually levied against the defeated German nation to be harsher than they might
otherwise have been.80 Given the extent to which the provisions contained
within the Treaty of Versailles contributed to the rise of extremist politics in
interwar Germany, that one single case of ‘Spanish Flu’ could indeed have been
an indirect cause of the Second World War.81
Although the pandemic does not appear to have lingered in the collective
consciousness, just like the war the resultant social changes would not be
quick to fade away. Millions of volunteers had mobilized to care for the sick,
putting their own lives at risk to deal with a national and international emer-
gency. In Britain, the phlegmatic ‘keep calm and carry on’ spirit, later made fa-
mous by Second World War propaganda posters, was invoked as a duty by se-
nior doctors with regards to the ‘flu’.82 However, it would be frivolous to suggest
that any benefits in terms of community cohesion or stoicism could possibly
outweigh the societal burden created by the loss of so many people in the mid-
dle generation, at a time when so many others had already been taken by the
war.83 The pandemic cast a long shadow over the communities it touched for
generations to come, even if its name was lost to memory.
The question of exactly how and why the ‘Spanish Flu’ came to be so ne-
glected in the histories, narratives, and memories of the 20th century is an
interesting one. From a medical point of view, there is no doubt that the
sense of collective failure which was attached to the experience could have
influenced many doctors to want to wash it from their minds. The triumpha-
lism of the previous generation’s rapid progress in gaining ascendancy over
hitherto ungovernable infectious diseases came down to earth with an ego-
jolting thump when confronted by a worldwide plague, which the science of
the time was powerless to either understand or treat. It was an aberration in
80 Barry, “How the horrific 1918 flu spread across America”: www.smithsonianmag.com/his
tory/journal-plague-year-180965222/#jVOUoKVpWQwsH9QE.99 (accessed 27-12-2017).
81 Colonel Mark Sykes, one of the authors of the Sykes-Picot Agreement, died of the ‘Span-
ish Flu’ in early 1919 during the postwar peace negotiations. However, the impact of his
death on the modern Middle East, which the agreement played a major part in shaping,
is much harder to estimate: Barr, A Line in the Sand: Britain, France, and the Struggle that
Shaped the Middle East.
82 Newsholme, “A discussion on influenza”; Honigsbaum, “Regulating the 1918–19 pandemic”.
83 Phillips and Killingray, “Introduction”.
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the a nthropocentrically-anticipated course of events – that of human science
steadily and irrevocably mastering nature – and which was therefore compla-
cently categorized as an ‘isolated’ throwback that could be safely stricken from
the record.84 It had no comfortable place within the heroic narrative of the
First World War, in which the densely-populated cemeteries of the Western
Front were named after the battlefields, rather than the causes of death of
those that populated them. Extraordinarily, even in the immediate aftermath
of the war, historians were recording that armies practically decimated by the
pandemic suffered from “no major epidemic problems”.85
While the pandemic represented a defeat for medicine, both in terms of its
public and self-image, it could be considered a relative success for the profes-
sion of nursing. The medical treatments and prophylaxis available were largely
ineffective, and in fact some of them may have actively made the situation
worse. The use of high doses of salicylates (aspirin) to control fevers has been
suggested as a possible contributor to high mortality during the pandemic, as
they are now known to have a detrimental effect on lung function when ad-
ministered in large quantities.86 The only truly effective treatment was the old
nursing standard of ‘tlc’ (tender loving care), which was administered in large
measure by the millions of mostly-female volunteers who rallied to care for the
sick across the world.87 Public recognition of the value and importance of
nursing care, especially by those millions for whom it had been life-saving in
the absence of effective medical interventions, was undoubtedly enhanced by
the ‘Spanish Flu’ experience (Fig. 11.4).88 Although the pandemic was not ex-
plicitly mentioned in the relevant parliamentary discussions, it seems unlikely
to be a coincidence that the first British legislation to create a professional
framework for nurses was passed in November 1919.89
84 Byerly, Fever of War: The Influenza Epidemic in the U.S. Army during World War i; Shanks,
“How World War i changed global attitudes”.
85 Wever and Van Bergen, “Death from 1918 pandemic influenza”.
86 Starko, “Salicylates and pandemic influenza mortality, 1918–1919 pharmacology, patholo-
gy, and historic evidence”, pp. 1405–410.
87 Crosby Jr, Epidemic and Peace; Bristow, “‘You can’t do anything for influenza’: doctors,
nurses and the power of gender during the influenza pandemic in the United States”,
pp. 58–69.
88 Groft, “‘Everything depends on good nursing’”, pp. 19–22.
89 Hansard, “Nurses registration (No. 2) Bill. 18th November 1919, vol. 121 cc864-80”: api.
parliament.uk/historic-hansard/commons/1919/nov/18/nurses-registration-no-2-bill (ac-
cessed 27-8-2018).
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Illustration 11.4 Spanish Flu patients receiving nursing care
6 Communication and Conscience
Another long term effect of the pandemic was to shine a light on the subject of
wartime propaganda: its uses and abuses. Even before the pandemic, the First
World War was spawning hysterical ‘end times’ movements who saw signs of
Armageddon in the unprecedented scale of the conflict. The advent of a mys-
terious plague sweeping across the world lent even greater fervour to these
theological convulsions.90 These reactions emphasize the need for clear and
open public communication during such crises in order to gain the public
trust, to inform and reassure them as appropriate.91 At a time when the public
communication tools of many governments were fully mobilized to the goal
of providing deliberate misinformation in the service of the war effort –
demonising the enemy and exaggerating military victories – this was always
going to be a significant challenge. European newspapers were often forced by
90 Phillips and Killingray, “Introduction”; Stuckert, “Strategic implications of American mil-
lennialism”: www.dtic.mil/dtic/tr/fulltext/u2/a485511.pdf (accessed 25-8-2018).
91 Reynolds, Crouse, “Effective communication during an influenza pandemic: the value of
using a crisis and emergency risk communication framework”, pp. 13s–17s.
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authorities to either not report on the ‘Spanish Flu’, or to say that the disease
was far milder than was in fact the case, because of the effect it was feared the
truth would have upon public morale.92 Wartime propaganda unquestionably
hampered public health efforts, as rudimentary as they were in the early 20th
century, to control the pandemic. In the era of ‘fake news’, very similar barriers
of deliberate misinformation are likely to be encountered by those attempting
to transparently inform or educate the public about how to protect themselves
from any future pandemic.
Another still-relevant issue which the ‘Spanish Flu’ threw into sharp focus is
the balance between protecting the health of the public and preserving the
right of individual liberty. The enforcement of quarantine, isolation, or the
wearing of protective clothing, while it may sometimes be necessary to pre-
vent the spread of disease, is always likely to meet with resistance from people
who lack the information, public-spiritedness or trust in government institu-
tions to wish to comply. The San Francisco example of mandatory facemasks
has already been mentioned, and there were demonstrations and arrests as a
result.93 Even in wartime, when populations tend to be more willing to cede
control to the government, authoritarian impositions (however well inten-
tioned) can often cause resentment and widespread non-compliance.94 In at-
tempting to control infectious disease outbreaks, public health professionals
still have to balance the safety of the many against the rights and liberties of
the few.95 The fact that those most severely affected by communicable disease
outbreaks tend to come from the poorest sections of society – as also seems to
have been true during the ‘Spanish Flu’ pandemic – while libertarian resis-
tance is more characteristic of wealthier, less-affected populations, only com-
plicates matters further.96
7 Why was the ‘Spanish Flu’ Forgotten?
The gradient of inequality in the impact of ‘Spanish Flu’ has been posited as a
reason for the relative lack of attention that historians paid to it for most of the
92 Honigsbaum, “Regulating the 1918–19 pandemic”; Tognotti, “Lessons from the history of
quarantine, from plague to influenza A”, pp. 254–59.
93 Crosby Jr, Epidemic and Peace; Palmer and Rice, “A Japanese physician’s response to pan-
demic influenza”.
94 Steele and Collins, “La grippe and World War i”.
95 Selgelid, McLean, Arinaminpathy, and Savulescu, “Infectious disease ethics: limiting lib-
erty in contexts of contagion”, pp. 149–52.
96 Selgelid, “Ethics and infectious disease”, pp. 272–89.
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20th century. Most historians of the last hundred years have lived in the west-
ern world and been writing for western audiences, and there are several factors
which may have decreased the importance of the pandemic from their (collec-
tive) point of view. Firstly, western nations had been the primary antagonists
and combatants in the First World War, which was therefore likely to be more
prominent in their narratives of the period. Secondly, mortality appears to
have been significantly higher in many non-belligerent nations of the global
south, where medical infrastructure was weak and death registration systems
were generally lacking.97 The huge death tolls in these impoverished nations
mostly escaped the attention of chroniclers of the pandemic until relatively
recently, out of a mixture of cultural chauvinism and less easily accessible
data. It is worth noting that a 21st century variant of the 1918–19 pandemic
would be likely to exhibit an even steeper global inequality gradient in terms of
mortality.98
For all of these reasons and more, the ‘Spanish Flu’ pandemic remained
under-recognized and poorly studied by the medical and scientific community
for much of the 20th century. Perhaps this is not surprising. It should be re-
membered that, although the First World War was, in many of its technologies
and tactics, a ‘modern’ war, the medicine of the day was anything but. Doctors
of 1914–18 were still operating, and certainly had mostly trained, in a transi-
tional period before the full acceptance of Germ Theory.99 In 1890, during the
Russian influenza pandemic, less than 30 years before the ‘Spanish Flu’
emerged, it was unremarkable for qualified doctors to write to The Lancet that
“it must not be forgotten that many unusual earthquakes have occurred during
the past year in Eastern Europe. Why should not this troublesome complaint
have been produced by injurious emanations from the earth?”.100 The ‘Spanish
Flu’ did little to settle the controversies that were then raging in medical and
scientific fields, being enigmatic enough to function as something like a Ror-
schach Inkblot test, with almost everyone involved in such debates being able
to discern support for their own position in its outlines. Arguments over influ-
enza’s causal organism continued largely unaffected and uninformed by the
catastrophe.101
However, some changes for the better were instituted by those who elect-
ed not to deposit the pandemic into the medical memory hole. Legislation
97 Johnson and Mueller, “Updating the accounts: global mortality of the 1918–1920 ‘Spanish’
influenza pandemic”, pp. 105–15.
98 Ferguson, “Poverty, death, and a future influenza pandemic”, pp. 2187–88.
99 Shanks, “How World War i changed global attitudes”.
100 Weekes et al., “The influenza epidemic”.
101 Dehner, Influenza.
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e nacted in the postwar years added influenza to the growing list of notifiable
diseases in many western countries, and also instituted widespread infectious
disease monitoring through the International Office of Public Health.102 Al-
though there was a lack of organized governmental research during the inter-
war years, private enterprise accomplished a great deal, with the definite iden-
tification of the influenza virus finally occurring in the early 1930s.103 Earlier
experimentation with influenza samples had actually been the context in
which Alexander Fleming stumbled upon the antibiotic penicillin, a crucial
weapon in humanity’s ongoing war against infectious disease.104 Then, in a dis-
tressingly short interval following the so-called ‘war to end all wars’, the poi-
soned political atmosphere of Europe dragged the continent down into an
even greater epoch of bloodshed.105 And, as is paradoxically but surprisingly
often the case, the imperatives of warfare proved to be the spur for scientific
developments which would ultimately benefit all of humanity, even though
the motive force behind their discoveries was anti-humanitarian by its very
nature.
8 Does War Reduce Resilience?
Despite some positive longer-term outcomes from military interventions
(which will be discussed below), war remains a huge challenge to both public
health and civil resilience. The technological fruits of armed conflict generally
benefit only military personnel during the conflict in which they are invented,
and their subsequent usefulness in protecting the health of civilians is always
vulnerable to negation by any subsequent war. If the Second World War gave us
a mass-produced influenza vaccine then the Syrian Civil War (to take just one
example) has prevented it from being used within that conflict zone, as it pre-
vents virtually any systematic vaccination programme from taking place. De-
spite the massive amount of progress that has been made in the fight against
102 Phillips and Killingray, “Introduction”.
103 Smith, Manch, Andrewes, and Laidlaw, “A virus obtained from influenza patients”.
104 Fleming, “On the antibacterial action of cultures of a Penicillium, with special reference
to their use in the isolation of B. influenza”: www.asm.org/ccLibraryFiles/Filename/0000
000264/1929p185.pdf (accessed 1-9-2018).
105 Ferdinand Foch, the Supreme Allied Commander on the Western Front is said to have
remarked at the signing of the Treaty of Versailles: “This is not a peace. It is an armistice
for twenty years”. Although his specific complaints were that the treaty was too lenient on
Germany, rather than too harsh, he was prophetic nonetheless, and the Second World
War started almost exactly twenty years later.
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infectious disease over the last century, war remains a significant barrier to the
full control of some key diseases, most notably polio.106 The fact that the risk of
a new global pandemic arising from any modern war zone seems to so rarely
feature in the political decision-making which determines whether or not na-
tions go to war in the first place, indicates that the lessons of 1918 have not all
been well learned. Wars weaken the ability of a country to prevent, detect, or
fight outbreaks of infectious disease, and leave the civilian population incred-
ibly vulnerable.107 The modern ‘failed state’ or warzone remains the most likely
crucible from which a new global pandemic might spread.108
9 Does War Improve Resilience?
It was during the Second World War that serious attention began to be paid
to the role of the First in causing the greatest pandemic of all time, perhaps
for obvious reasons. There was suddenly a pressing need to learn from what
was then described as “one of the darkest pages in our medical annals”,109 and
to improve the effectiveness by which the military protected its personnel
against infectious diseases, and thereby preserved their fighting strength.110
Hard lessons learned in military medical units during the First World War111
were applied and extrapolated, slowly during the interwar years and then rap-
idly during the Second World War.112 In 1943, an effective influenza vaccine was
finally developed by the U.S. military,113 which enabled them to dramatically
reduce the toll of morbidity and mortality among soldiers living in crowded
barracks, which otherwise provide ideal conditions for the spread of respira-
tory infections.114
While warfare in the 20th century killed, disfigured, disabled, and psycho-
logically scarred hundreds of millions of people, it has also been the driver for
some of the most valuable medical advancements from which we in the 21st
106 Piot, “Old and new global challenges in infectious diseases”, p. 37.
107 Steele and Collins, “La grippe and World War i”.
108 Hirschfeld, “Failing states as epidemiologic risk zones: implications for global health se-
curity”, pp. 288–95; Flecknoe et al., “Plagues and wars”.
109 Editorial. “The Australian Army Medical Services in the War of 1914–1918”, p. 240.
110 Stuart-Harris, “Epidemic influenza”, pp. 270–76.
111 Shanks, “Formation of medical units”.
112 Bailey, “A brief history of British military experiences with infectious and tropical diseas-
es”, pp. 150–57; Wright and Baskin, “Pathology and laboratory medicine support”.
113 Dehner, Influenza.
114 Shanks, “How World War 1 changed global attitudes”.
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