I've found information about the first newspaper articles featuring information about the Spanish Flu Pandemic from this link but one of the quotations from the newspaper says:
“The epidemic is of a mild nature; no deaths having been reported”.*
That's from April in 1918.
I'm just wondering when the first report of deaths from the disease happened?
This is impossible to state with any certainty because:
- The exact path of the "Spanish" Flu virus in its early stages is unknown; and
- Early deaths from the virus were not recognised at the time and received little attention.
Available evidence suggests that the Spanish Flu was "seeded" around the world in a number of localised outbreaks well before the mass deaths that occurred in 1918.
Reports of influenza deaths in countries as widely spread as Norway, Sweden, Finland, Canada, Spain, Britain, France, Germany, Senegal, Tanzania, Nigeria, Ghana, Zimbabwe, South Africa, India and Indonesia were recorded. The very wide geographic spread of these deaths in such a short period, in the absence of air travel at the time, suggests that the disease had spread around the globe prior to this time and that 'seeding' had occurred.
Oxford, J. S., et al. "Early herald wave outbreaks of influenza in 1916 prior to the pandemic of 1918." International Congress Series. Vol. 1219. Elsevier, 2001.
Finland recorded unusually high levels of pneumonia deaths in 1917; in Britain the Bochum Administration of Sick Insurance reported a 40% increase in influenza cases in 1916; and a major epidemic of respiratory diseases swept through the United States at the end of 1915.
Although in 1918 influenza was not a nationally reportable disease and diagnostic criteria for influenza and pneumonia were vague, death rates from influenza and pneumonia in the United States had risen sharply in 1915 and 1916 because of a major respiratory disease epidemic beginning in December 1915
Taubenberger JK, Morens DM. 1918 Influenza: the Mother of All Pandemics. Emerging Infectious Diseases. 2006;12(1):15-22.
Therefore, it is possible that the first major outbreak of deaths occurred no later than December 1915. The literal first cases of deaths from when the virus emerged is impossible to determine with any precision, but might have occurred when the virus first made the jump to humans from birds or pigs, possibly from 1913 to 1915.
Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic
The majority of deaths during the influenza pandemic of 1918-1919 were not caused by the influenza virus acting alone, report researchers from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. Instead, most victims succumbed to bacterial pneumonia following influenza virus infection. The pneumonia was caused when bacteria that normally inhabit the nose and throat invaded the lungs along a pathway created when the virus destroyed the cells that line the bronchial tubes and lungs.
A future influenza pandemic may unfold in a similar manner, say the NIAID authors, whose paper in the Oct. 1 issue of The Journal of Infectious Diseases is now available online. Therefore, the authors conclude, comprehensive pandemic preparations should include not only efforts to produce new or improved influenza vaccines and antiviral drugs but also provisions to stockpile antibiotics and bacterial vaccines as well.
The work presents complementary lines of evidence from the fields of pathology and history of medicine to support this conclusion. "The weight of evidence we examined from both historical and modern analyses of the 1918 influenza pandemic favors a scenario in which viral damage followed by bacterial pneumonia led to the vast majority of deaths," says co-author NIAID Director Anthony S. Fauci, M.D. "In essence, the virus landed the first blow while bacteria delivered the knockout punch."
NIAID co-author and pathologist Jeffery Taubenberger, M.D., Ph.D., examined lung tissue samples from 58 soldiers who died of influenza at various U. S. military bases in 1918 and 1919. The samples, preserved in paraffin blocks, were re-cut and stained to allow microscopic evaluation. Examination revealed a spectrum of tissue damage "ranging from changes characteristic of the primary viral pneumonia and evidence of tissue repair to evidence of severe, acute, secondary bacterial pneumonia," says Dr. Taubenberger. In most cases, he adds, the predominant disease at the time of death appeared to have been bacterial pneumonia. There also was evidence that the virus destroyed the cells lining the bronchial tubes, including cells with protective hair-like projections, or cilia. This loss made other kinds of cells throughout the entire respiratory tract — including cells deep in the lungs — vulnerable to attack by bacteria that migrated down the newly created pathway from the nose and throat.
In a quest to obtain all scientific publications reporting on the pathology and bacteriology of the 1918-1919 influenza pandemic, Dr. Taubenberger and NIAID co-author David Morens, M.D., searched bibliography sources for papers in any language. They also reviewed scientific and medical journals published in English, French and German, and located all papers reporting on autopsies conducted on influenza victims. From a pool of more than 2,000 publications that appeared between 1919 and 1929, the researchers identified 118 key autopsy series reports. In total, the autopsy series they reviewed represented 8,398 individual autopsies conducted in 15 countries.
The published reports "clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory flora in most influenza fatalities," says Dr. Morens. Pathologists of the time, he adds, were nearly unanimous in the conviction that deaths were not caused directly by the then-unidentified influenza virus, but rather resulted from severe secondary pneumonia caused by various bacteria. Absent the secondary bacterial infections, many patients might have survived, experts at the time believed. Indeed, the availability of antibiotics during the other influenza pandemics of the 20th century, specifically those of 1957 and 1968, was probably a key factor in the lower number of worldwide deaths during those outbreaks, notes Dr. Morens.
The cause and timing of the next influenza pandemic cannot be predicted with certainty, the authors acknowledge, nor can the virulence of the pandemic influenza virus strain. However, it is possible that — as in 1918 — a similar pattern of viral damage followed by bacterial invasion could unfold, say the authors. Preparations for diagnosing, treating and preventing bacterial pneumonia should be among highest priorities in influenza pandemic planning, they write. "We are encouraged by the fact that pandemic planners are already considering and implementing some of these actions," says Dr. Fauci.
Visit http://www.PandemicFlu.gov for one-stop access to U.S. Government information on avian and pandemic flu.
NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.
About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
NIH&hellipTurning Discovery Into Health ®
DM Morens et al. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: Implications for pandemic influenza preparedness. The Journal of Infectious Diseases DOI: 10.1086/591708 (2008).
What caused the Spanish flu?
The outbreak began in 1918, during the final months of World War I, and historians now believe that the conflict may have been partly responsible for spreading the virus. On the Western Front, soldiers living in cramped, dirty and damp conditions became ill. This was a direct result of weakened immune systems from malnourishment. Their illnesses, which were known as "la grippe," were infectious, and spread among the ranks. Within around three days of becoming ill, many soldiers would start to feel better, but not all would make it.
During the summer of 1918, as troops began to return home on leave, they brought with them the undetected virus that had made them ill. The virus spread across cities, towns and villages in the soldiers' home countries. Many of those infected, both soldiers and civilians, did not recover rapidly. The virus was hardest on young adults between the ages of 20 and 30 who had previously been healthy.
In 2014, a new theory about the origins of the virus suggested that it first emerged in China, National Geographic reported. Previously undiscovered records linked the flu to the transportation of Chinese laborers, the Chinese Labour Corps, across Canada in 1917 and 1918. The laborers were mostly farm workers from remote parts of rural China, according to Mark Humphries' book "The Last Plague" (University of Toronto Press, 2013). They spent six days in sealed train containers as they were transported across the country before continuing to France. There, they were required to dig trenches, unload trains, lay tracks, build roads and repair damaged tanks. In all, over 90,000 workers were mobilized to the Western Front.
Humphries explains that in one count of 25,000 Chinese laborers in 1918, some 3,000 ended their Canadian journey in medical quarantine. At the time, because of racial stereotypes, their illness was blamed on "Chinese laziness" and Canadian doctors did not take the workers' symptoms seriously. By the time the laborers arrived in northern France in early 1918, many were sick, and hundreds were soon dying.
What the Pandemic Wrought
The Spanish Flu got its name through a strange confluence of war restrictions. The governments of warring countries did not want enemy nations to know their forces were being weakened by the fast-moving disease, nor did they want morale to deteriorate.
Spain was neutral during World War I and its newspapers were not censored. They published stories about the deadly influenza and so the "Spanish Flu" became a moniker that stuck. It was also called the "Purple Death" because sufferers sometimes turned a frightening shade of indigo from lack of oxygen in their bloodstreams. It was also called the "Chinese Flu" and the "Russian Pest."
In the U.S., children skipped rope to this rhyme: "I had a little bird, its name was Enza, I opened up the window and in flew Enza."
Masks were crude. They consisted of cheesecloth and gauze, said historian Kenneth Davis, which would be roughly akin to holding a piece of a screen window to one's face and hoping it would stop the bacteria.
There were no federal guidelines about anything. "There was no CDC. There was no National Institutes of Health. There was no Department of Health and Human Services," Davis said.
Society and families were collapsing. From major cities and rural areas came reports of people starving "because no one had the courage to bring them food, even other members of their own family," said author John Barry.
Hundreds of thousands of children became orphans when their parents died from the horrid flu.
Families were larger then, and siblings found themselves being separated and sent off to relatives or orphanages. Some would not see their brothers and sisters for decades, or ever again. Worse, some were put up for adoption and handed out like door prizes, with no one to oversee their welfare because social government agencies didn't exist at the time.
"They would put the kids who lost their parents on a train, and just go from depot to depot and anybody who wanted to adopt a kid would just show up," Barry said, "and walk away with them."
"So, there was a whole generation of Spanish flu orphans."
The flu raged in three waves beginning in 1918, with the last ebbing around the summer of 1919. "The first phase, the least deadly, at least in the United States, went from March into the spring time," said Davis. "But then flu season returned in September, October. More troops on the move once again, and a real explosion. And that second wave was the most deadly" in America.
The final wave stretched from the winter of 1919 until the summer months, when cases began declining.
The war ended Nov. 11, 1918. The survivors &mdash soldiers, battlefield nurses and doctors &mdash walked or limped back into day-to-day life, and more than anything, they wanted simply to move on.
In 1920, "Warren G. Harding campaigns for president on the idea of a return to normality, and that was a winning slogan," said Davis. "He came in as (the) Republican president, and he said, 'We're going to return to normal.'''
One late sufferer of the virus was reportedly Woodrow Wilson, who was in Paris in 1920 to help negotiate the Treaty of Versailles. The French city was battling a high number of influenza cases at the time.
Wilson became seriously ill. He recovered, "but many people who knew him, including the White House valet who knew him for a long time, said he was never the same," Davis said.
His judgment and reasoning may have been affected, not unlike coronavirus sufferers who complain of brain fog and debilitating mental setbacks.
"He did relent and concede some very, very important points," Davis said of Wilson's negotiations, including "much more punishing aspects of the retribution given to Germany in terms of the reparations that they would have to pay."
That, in turn, "certainly contributed to the rise of Hitler and the Nazis," the historian said.
In America, moving on from World War I included changes at every level of society.
Hemlines went up and social mores went down. Women got the vote in 1920, and many smoked openly in public, bobbed their hair and became "flappers." Businesses boomed, as did speakeasies, despite the new Prohibition against the production and distribution of alcohol.
"We tend not to think about history in terms of disease," Davis said. "This was an important part of history that we don't always teach or talk about."
People just wanted to forget. They wanted to get back to their lives.
"It was really something that was so terrible that nobody wanted to think or talk or write about it," Davis said.
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The misnamed "Spanish Flu" pandemic peaked in late 1918 and remains the most widespread and lethal outbreak of disease to afflict humankind worldwide in recorded history. Small mutations in a flu virus created an extraordinarily lethal variant that killed healthy young adults as readily it did more vulnerable age groups. The pathogen's place of origin is still debated, but the role of World War I in its rapid spread is undisputed. Even so Washington, despite a heavy military presence, fared better than any other state in the union except Oregon. While the death toll was highest in the state's most populous cities, the pandemic touched nearly every community. Attempts to control the outbreak were largely futile, and from late September 1918 through the end of that year it killed nearly 5,000 Washingtonians. More than half the victims were between the ages of 20 and 49.
An Ancient Scourge
Influenza viruses probably first sickened humans 6,000 to 7,000 years ago, corresponding with the early domestication of pigs and cattle. Increased human mobility facilitated epidemics and pandemics that could affect vast areas. Until the early 1930s influenza was thought by most scientists to be a bacterial rather than a viral disease. In fact both were often involved those weakened by an influenza virus were left more vulnerable to bacterial pneumonia. Still, during flu's annual visitations it usually caused only moderate illness. But now and then something different and far more lethal came along.
The first recorded pandemic likely caused by an influenza virus came in 1580 and ravaged an area stretching from Asia Minor to as far north as today's Netherlands. There were frequent large outbreaks thereafter, but relatively few deaths. A more lethal virus struck Europe and the Russian empire in 1781-1782, and in 1889 and 1890 more than a million people died when a deadly variant burst from China, spread to Russia and throughout Europe, and made its way to North America and Latin America before sputtering out in Japan. Next came the pandemic of 1918, by far the most widespread and deadly, a dismal distinction that stands to the present day.
American Samoa was the only organized society on the planet to entirely escape the 1918 pandemic, thanks to an early, rigorous, and lengthy quarantine. In Western Samoa, barely 50 miles distant, 20 percent of the population died in a matter of months. Flu girdled the globe from east to west and from north of the Arctic Circle to the southern tip of Chile, leaving in its wake shattered societies and tens of millions dead.
A Different Disease Entirely
Before 1918 the average mortality rate for most influenza was only about one-tenth of 1 percent, or approximately one fatality for every 1,000 infections. The 1918 flu killed more than 2.5 percent of those afflicted, almost always within days of the first symptoms and often within hours. Some died from acute respiratory distress (a direct effect of the flu virus) and others fell prey to opportunistic bacterial pneumonia. And unlike almost any previous known infectious disease, this virus hit adults between ages 20 and 40 particularly hard.
World War I was in its final months when the worst of the pandemic hit. Approximately 53,500 Americans lost their lives in combat and a nearly equal number died of influenza while serving in Europe. The number of Americans, military and civilian alike, killed by the virus back home was estimated to be in excess of 650,000. The most conservative (and perhaps least accurate) estimate of the death toll worldwide is more than 20 million, and as many as 100 million may have died (many governments kept few or no accurate records, making even rough estimates highly problematic).
It's unknown where the pandemic originated. It was commonly called the "Spanish flu," probably because Spain, which didn't participate in World War I, freely reported illnesses and deaths caused by the disease, information that was censored by the combatant nations. The prejudiced suspicion that deadly infectious diseases spring from rural pig sties in Asia or the steamy jungles of sub-Saharan Africa probably was not true in 1918. One supportable theory holds that the "Spanish" flu originated in Haskell County, Kansas, where in February 1918 a local doctor was overwhelmed by a number of cases of a particularly virulent and deadly illness, unlike anything he had seen in long years of practice. During the outbreak a local man came home on leave from the army, then returned to Camp Funston in the sprawling Fort Riley complex 300 miles away. Within three weeks, more than 1,100 soldiers at the camp were hospitalized with the flu and 28 did not survive, an unusually high mortality.
By early April significant outbreaks of a milder flu were reported, including in Detroit, where as many as 2,000 workers at the Ford automobile plant were stricken. The deadly variant hit Spain in late May. The mystery remains today -- it is uncertain where the "normal" flu virus mutated into an efficient killer. Competing theories range from Kansas to Norway to English Channel ports to the usual suspect, China. It is unlikely that this question can ever be conclusively resolved, and it hardly matters.
One fact is undisputed: War and disease went hand in hand. During the spring of 1918, convoys were carrying American troops to fight in World War I and returning with wounded, ill, and demobilized soldiers. While the conflict apparently had no direct link to the origins of the virus, it had everything to do with its spread.
Hints of a Coming Cataclysm
Many of the cases reported in the middle months of 1918 were relatively mild and localized, but in late August events took a dire turn when the deadly variant broke loose:
"It occurred in three major parts of the North Atlantic almost simultaneously: Freetown, Sierra Leone, where local West Africans were brought together with British, South African, East African, and Australian soldiers and sailors Brest, France, which was the chief port for Allied troops and Boston, Massachusetts, one of America’s busiest embarkation ports and a major crossroads for military and civilian personnel of every nation involved with the Allied war effort. Massive troop movements and the disruption of significant segments of the population during World War I played an important role in the transmission of the disease" ("Influenza," Medical Ecology website).
In Washington the first eight months of 1918 seemed similar to most years, and newspapers in the state apparently took no notice of spring outbreaks of flu in Detroit and a few other American cities. On April 15, however, it was reported that at the army's Camp Lewis south of Tacoma, "Pneumonia has slightly increased during the week, most of the cases follow influenza, which was at its maximum two weeks ago" ("Civilian Workers Fast Being Eliminated . "). In late May The Seattle Times carried a brief wire-service report stating that "a mysterious epidemic" had sickened at least 40 percent of Spain's population, and that although the symptoms "resemble influenza . many persons afflicted with it have fallen in the streets in a fit" ("Unknown Disease . "). One week later, the paper said of the Spanish outbreak, "The rapidity of its spread is comparable only to the great plague of 1889," a reference to the flu pandemic of nearly 30 years before ("King Visited by Strange Illness"). In June there were gleeful reports of a flu epidemic among enemy German soldiers, but early that month Camp Lewis reported just 39 cases.
Things seemed more ominous by early July. On July 9, The Seattle Times reported that the influenza in Spain had "spread over other parts of Europe" ("A Puzzling Epidemic"). On July 28 the newspaper noted that Camp Lewis had 327 cases of flu, but a week later the number had fallen to below 100. As late as mid-August there were reassuring reports that the count of flu cases at the army base continued to decrease, and no indication of any special concern. Even into September, the general mood was one of confidence. An optimistic commentator enthused, "It is a marvel, due to the perfection of our medical science, that there has been no widespread epidemic this summer of a more serious character than 'flu,' as the Spanish influenza and other allied fevers are called" ("Heavy Rain and Mud . ").
As the month wore on, a tone of modest alarm began to creep into some accounts. A Times article on September 22 referred to a "mild epidemic" at Camp Lewis, with 173 new cases reported ("Camp Lewis Reports . "). On the same page, mention was made of two serious cases of influenza reported in Bellingham. Still, two days later army medical sources were quoted in the newspaper as saying, with some jocularity, "There may have been a Spaniard with influenza at Camp Lewis, but there is no Spanish influenza here" ("Say Camp Lewis . ")..
This could have been whistling past the graveyard, but in truth no one had any understanding of the tsunami that was building. What was happening was not remotely within the knowledge of the brightest scientists and doctors of the era. The virus that caused influenza had mutated, and in ways that would make it one of the most deadly pathogens to ever afflict the human race. When it fully hit America it moved with breathtaking speed through the entire country, helped at every turn by a war-mobilized military.
Spreading Like Wildfire
Between September 1918 and the war's end in November, up to 40 percent of American army and navy personnel were infected with influenza. The nexus between the military and the rapid spread of the pandemic was starkly clear. State health officials were aware of the danger. The minutes of a state Board of Health meeting in Spokane on September 28, 1918, noted, "The probability of an outbreak of influenza in the State was extensively discussed and ways and means of attempting its prevention were considered" (Twelfth Biennial Report, 6).
It would prove to be both unpreventable and essentially untreatable. Just two days later, on September 30, at the University of Washington Naval Training Station on Seattle's Portage Bay (the current site of the university's Health Sciences complex), more than 650 cases of "mild influenza" were reported ("Navy Camp at 'U' . "). In the first week of October more than 100 cases of "severe influenza" were documented at Camp Lewis. Cases were also found at the Puget Sound Naval Shipyard in Bremerton, and on October 4 it was reported that 14 naval recruits had died there and "between 200 and 400" civilian workers at the navy yard had become ill ("Bremerton Hit . "). These reports were harbingers of much worse to come as the deadly virus spread with amazing speed.
A Dearth of Data
For several reasons, tracking the progress of the pandemic in the state with much accuracy is impossible. First, influenza was not a disease that had to be reported to state health authorities, at least not during its most virulent phase in the fall of 1918. Voluntary reporting was extremely sporadic, as will be seen. Deaths needed no diagnosis and were faithfully recorded, but overall tallies of the infected must be considered rough estimates, even when impressively specific.
Second, the flu in 1918 and early 1919 came in three distinct waves -- a usually mild form in the spring and summer of 1918, followed by the deadly strain in the closing months of that year, and ending with a return of usually (but not always) milder disease in the early months of 1919 , not fully tapering off until 1920. Not everyone who became ill was infected with the virulent "Spanish" flu some had a more mild form, which still could be lethal to the very young and the elderly.
To further frustrate public-health authorities, the Spanish flu killed both directly and by leaving victims vulnerable to secondary infections with bacterial pneumonia, which was often fatal even in the absence of the flu, particularly in the elderly or infirm. This muddled the causality picture. But because the Spanish flu had proven so stunningly contagious and pneumonia was so often found during autopsies of flu victims, the federal Census Bureau decided to use a single category in its mortality statistics for 1918: "deaths from influenza and pneumonia (all forms)" (Mortality Statistics, 1918). As frustrating as it is to epidemiologists and life-insurance actuaries, all statistical studies of the effects of the 1918 pandemic are riddled with uncertainty and approximations.
What the Record Shows
Washington was one of 30 "registration states" deemed by the U.S. Census Bureau to have reasonably reliable recordkeeping in 1918, but the state's epidemiologist, in a January 1919 Board of Health biennial report to Governor Ernest Lister (1870-1919), emphasized the unprecedented nature of the pandemic and the difficulty of gathering accurate information:
"This pandemic made its appearance in Washington in the first week of October. In the history of the State Board of Health no such calamity has afflicted the State nor has so serious an emergency ever arisen. In the five years 1913-1917 inclusive, from the five most common contagious diseases . there have been 1768 deaths. From influenza alone we have had to date well over 2000 deaths and the end is not yet. The toll will probably be double or triple 1768 . .
"City health officers, except in Seattle, Tacoma, Spokane and Yakima, are part-time men. Their salary is often nothing or five dollars a month. They are appointed by their mayors and change frequently. They are not of our making and do not feel as if they have much responsibility to us. Their jobs pay little and their policy is to do as much as the pay justifies" (Twelfth Biennial Report, 34-35).
The report was prepared in December 1918, when the full extent of the catastrophe was unknown. The health board's next biennial report was not issued until January 1921 and was almost silent on the 1918 pandemic. There appears to be no available compilation, state or federal, of infection rates or deaths on a county-by-county basis, much less for individual communities, although census data does exist for Washington's two largest cities, Seattle and Spokane, and Yakima's experience is relatively well documented.
In its Mortality Statistics 1918 the U.S. Census Bureau compared the state's total 1918 flu deaths with those from 1915, contrasting the first eight months of each year with the last four. Between January and August of 1915, 605 Washington residents died of influenza and pneumonia in the first eight months of 1918, 838 Washingtonians died, a sizable but not shocking increase.
In the last four months of 1915, only 381 people in Washington succumbed to the flu, but in the last four months of 1918, the pandemic killed 4,041 in the state, 10.6 times the 1915 count for the same period. The state epidemiologist's pessimism about the final toll proved fairly accurate.
Other facts from the mortality tables demonstrate the unprecedented nature of the Spanish flu. Perhaps most surprising, slightly more than half, or 2,461 of the 4,879 flu fatalities in Washington in calendar year 1918, were men and women between the ages of 20 and 39, the demographic group that normally enjoyed the highest disease survivability. The same rough proportions held true in the state's two largest cities. In Seattle 708 of 1,441 flu deaths recorded between October 12, 1918, and March 15, 1919, fell into that age range, while in Spokane the count was 252 of the 428 flu deaths. These numbers alone illustrate just how unique this pandemic was in comparison to any other disease outbreaks for which records exist. This mystery has never been fully resolved, but the leading theory is that the 1918 virus triggered catastrophic immune reactions in young adults with robust immune systems.
Comparative numbers were not calculated for Yakima, but roughly one-third of the population, or about 6,000 people, were infected there. Of these, 120 died -- 32 percent of the city's total 1918 death toll from all causes. So contagious was the disease that Yakima's only hospital, St. Elizabeth, run by the Sisters of Providence, for a time refused to admit influenza patients.
There is only one statistic in the 1918 mortality tables from which some comfort may be taken. Of the 30 registration states relied upon by the Census Bureau, with the single exception of Oregon, Washington by a significant margin had the lowest number of influenza/pneumonia deaths per 1,000 residents. Nevertheless, 4.1 of every 1,000 Washingtonians were killed by influenza/pneumonia in 1918 (more than five times normal) and 1.9 of every 1,000 in 1919 (more than twice normal). In contrast, the state's mortality rate from those causes in each of the three preceding years was less than one per 1,000.
Doing Their Best
The health board's Twelfth Biennial Report documented both a realistic apprehension of the danger Spanish influenza presented and a recognition of the futility of efforts to prevent it. It recounted the efforts of Dr. Thomas D. Tuttle, the state's health commissioner and the report's lead author, to get advice from the federal government:
"This epidemic was very prevalent in the Eastern states during the month of September, and, realizing that in all human probability it would rapidly spread over the entire country, your commissioner of health took up with the United States Public Health Service the question of the advisability of quarantining individual cases" (Twelfth Biennial Report, 22-23).
Specifically, the board reported, Tuttle sent a telegram to U.S. Surgeon General Rupert Blue asking "Intrastate quarantine Spanish influenza under consideration. What period of quarantine if any do you recommend?" and Blue relied "Service does not recommend quarantine against influenza" (Twelfth Biennial Report, 22-23).
In the report Tuttle provided the health board's opinion on how the Spanish flu came to Washington. It is but one theory among several, but as credible as any:
"The epidemic struck our state in the early part of October. The immediate introduction of the disease was through a shipment from Pennsylvania to the United States Naval Training Station at Bremerton of about 1500 men, a large percentage of whom were afflicted with influenza when they reached their destination. From this location the disease spread widely [but] many outbreaks were not directly traceable to the infection at or near Seattle" (Twelfth Biennial Report, 23).
Tuttle's account of a Chicago meeting of state health authorities could not conceal a tone of desperation:
"The outstanding feature of the discussion of the subject at this conference was the evidence that whatever efforts were made the spread of the disease was only retarded and not prevented. As one health officer very aptly expressed the situation: 'One can avoid contracting the disease if he will go into a hole and stay there, but the question is how long he would he have to stay there? The indications are that it would be at least for a year or longer'" (Twelfth Biennial Report, 23).
Desperate Measures, Mostly Futile
Despite its early concerns, the Washington State Board of Health did not impose statewide measures to combat the pandemic until it was well under way, probably because it had very limited resources and little or no control over local health authorities. The only preventive regulation of statewide application that the board issued came on November 3, 1918, when it required that surgical masks of a specified size and thickness "entirely covering the nose and mouth" be worn in virtually all public places where people came into close contact with one another the order also required that the proprietors of stores, restaurants, and cafes "keep their doors open and their places well ventilated" and that one-third of the windows in streetcars be opened when in use by the public ("Special Order and Regulation . ").
Vancouver in Clark County was one of the first cities in the state to aggressively address the pandemic. On October 7, 1918, acting on a report from the chief health officer, the city council ordered that "all places of public gathering, such as schools, churches, dances etc." be closed (Vancouver City Council minutes). Two days later the town council of Monroe in Snohomish County approved a similar measure, as did Yakima, which later joined with Yakima County to lease a building owned by St. Michael's Parish "for the purpose of establishing same as an Isolation Hospital" (Yakima City Commission minutes, October 21). On October 31 the ban on gatherings in Yakima was widened even further to include "all places where any kind of business is transacted . with the exception of drug stores, meat markets, restaurants, eating places, hotels and fruit ware-houses," the last an apparent concession to the town's leading industry (Yakima City Commission Minutes, October 31).
Similar bans on public assembly were imposed in counties, cities, and towns across the state. A small sample would include Seattle (October 6) Spokane (October 8) Pullman (October 10) Anacortes in Skagit County (October 15) Ferry County in Northeast Washington (November 17) tiny Wilson Creek in Grant County, where all children under age 16 were ordered confined to their homes (December 7) and Chelan, although it exempted schools (December 10). No corner of the state was spared, nor did the ordeal end with the new year. The Cowlitz County Council did not even impose similar restrictions until January 16, 1919, and White Salmon to the east was at that time still under siege.
These and similar measures probably helped to limit the spread to some extent, but perhaps the most telling reason for the eventual ebbing of the pandemic was that it simply ran out of vulnerable victims. In this regard it is important to remember that most people did not become infected, despite nearly universal exposure, nor did it kill but a fraction of those it did infect.
What Was It? Where Did It Go?
In the 1990s researchers, using archived autopsy samples from 1918, mapped the virus's genome and determined it to be Type A, the most common, which can infect both humans and some animals. More specifically, the investigation revealed that the virus was a strain of Type A known as H1N1. The "H" represents a protein molecule on the surface of a virus that is the usual target for the immune system. When random mutations alter that molecule, the virus can become virtually invisible to the body's defenses. As researchers explained in 2006, "Recently published . analyses suggest that the genes encoding surface proteins of the 1918 virus were derived from an avianlike influenza virus shortly before the start of the pandemic and that the precursor virus had not circulated widely in humans or swine in the few decades before" (Taubenberger and Morens, 16). Because it had not circulated widely, humanity had developed no "herd immunity" to it. This explains its rapid spread but not its lethality, which remains a mystery.
As to where it went, the answer is that it went nowhere. Almost all cases of type A influenza since 1918 have been caused by less-dangerous descendants of that lethal virus. Viruses do not have intentions, only random mutations. Some mutations will enable them to sicken birds, pigs, people, or other animals. Some will make them unusually lethal, others will render them totally harmless to humans. But inevitably a strain will emerge that is as infectious and deadly as the 1918 variety. Viral mutation is ongoing, endless, and unpredictable. In any new flu pandemic the toll will likely be lower due to advances in immunology and other countermeasures, but as with death itself, the question is not whether it will come, but rather when.
Announcement closing public places during flu pandemic, The Pullman Herald, October 11, 1918
Policemen wearing gauze masks during influenza epidemic, Seattle, December 1918
Courtesy National Archives (Record No. 165-WW-269B-25)
Stewart and Holmes employees wearing masks, 3rd Avenue, Seattle, 1918
Photo by Max Loudon, Courtesy UW Special Collections (UW1538)
Front page, The Seattle Times, October 5, 1918
Streetcar conductor blocking entry of unmasked man during flu pandemic, Seattle, 1918
Courtesy National Archives (Record No. 165-WW-269B-11)
Masked elevator attendant during flu pandemic, Seattle, 1918
Historical accounts detail wave of flu deaths in Oklahoma during 1918 pandemic
Those chilling first-person accounts don’t describe some modern-day disease outbreak occurring half a world away. Instead, they’re words that Oklahomans in the last century used to describe what is believed to be the deadliest epidemic in human history: the 1918 flu pandemic.
The video-taped interviews, recorded in the 1980s and included in the Oklahoma History Center archives, offer chilling descriptions of those dark days: whole towns sickened, healthy people dead within hours, mothers and children dying on the same day.
This year, with 82 fatalities reported since September, Oklahoma has recorded the largest number of annual flu deaths since the state began tracking the number in 2009. But those numbers pale in comparison to the tide of death that swept across Oklahoma and much of the world in 1918 when experts estimate as many as 100 million perished from the virus, 675,000 of them in the United States.
According to some experts, the 1918 pandemic may have gotten its start just 40 miles north of the Kansas-Oklahoma line.
“There are other theories about other sites,” said John M. Barry, a New Orleans-based author of a 2004 book on the 1918 outbreak. “I think the evidence for Haskell is probably roughly as good as it is for any other site, but we’ll probably never know.”
In January and February, 1918, an eruption of influenza in Haskell County, Kan., struck down some of the strongest, healthiest people “as if they had been shot,” Barry wrote in “The Great Influenza: The Epic Story of the Deadliest Pandemic in History.”
At a time when public health agencies had yet to begin tracking such outbreaks, the Kansas cases were severe enough to prompt a local doctor to warn national public health officials about the virulent strain.
From there, the disease is believed to have spread when Haskell County men reported to an Army camp at Fort Riley, Kansas. That spring, at least 1,100 of the fort’s 56,000 troops required hospitalization. Those soldiers then fanned out to Army posts throughout the U.S. and then to France, transporting the flu to the trenches of World War I. In Europe, the outbreak received prominent coverage from Spanish media outlets while those in Germany, France and Britain avoided such coverage, fearing reports would hurt morale, Barry said. As a result, the outbreak got a nickname: The Spanish flu.
In August 1918, the epidemic hit America’s East Coast like a bomb. At Camp Devens, in Boston, 1,543 soldiers reported ill with influenza in a single day. In a letter to a colleague, a doctor at the post described how the flu turned into the most vicious type of pneumonia he had ever seen the faces and bodies of dying victims turned blue from the lack of oxygen, sparking rumors that the Black Death, a terrifying plague from the Middle Ages, had returned. Healthy men dropped dead within a matter of hours, hundreds in a day, some of them bleeding from the eyes.
Sooner state ravaged
In Oklahoma, state officials reported the first cases of influenza in Tulsa and Clinton on Sept. 26 by Oct. 4, 1,249 cases had been reported in 24 counties. After that, the spread became so difficult to track that officials made reports in generalities, according to a history of the epidemic on the U.S. Department of Health and Human Services’ website flu.gov.
“People died like flies,” Jim W. Smith, recalled in one of the archived interviews. Smith, of Washington, OK, who would have been 22 in the fall of 1918 and going to school in Durant for his teaching certificate, said most people died when, while on the mend, they went back to work and relapsed.
Ralph Norman was 21 when he fell ill while at a military training camp. In an archived interview, the Woodward resident remembered one hospital room filled with the corpses of soldiers who had died from the flu.
Fern Behrendt recalled the flu’s beginnings in the Oklahoma panhandle. Then 19, she remembered a family who lived about six miles north of Boise City being the first to contract the virus and then watching it quickly spread.
“Quite a few people died,” Behrendt told her interviewers.
Behrendt said she helped a local family until she caught the flu. After she recovered, she continued to help area families by doing chores while they were sick.
C.L. Alley said he was the first of 600 Woodward men drafted for World War I but was sent home because he was a farmer and rancher and received a deferment. Soon after, “the whole neighborhood came down with the flu,” he reported. The only doctor’s orders, he said, were “just go to bed and rest.”
On Sunday, Oct. 13, 1918, church bells stayed silent in Oklahoma City as every house of worship canceled services “due to the city commissioners’ drastic order closing all schools, churches and other public places in an effort to stay the spread of the Spanish influenza. . ”
Seeking a cure
Newspaper ads from that period hawked quack cures, everything from whiskey to mouth gargle Vicks reported a shortage of VapoRub and those in rural areas turned to home remedies, like rock candy in whiskey and cloverleaf salve.
The flu outbreak caused a run on whiskey, which jumped to $18 a quart in Oklahoma City, according to an Oct. 15, 1918, article in The Daily Oklahoman.
But the epidemic also brought out the best in some people.
A Feb. 8, 1919, story described how a destitute 35-year-old father arrived in Enid with thinly clad and barefoot children, two boys, 8 and 6, and a 4-year-old girl. The children’s mother had died from the flu and the father had lost his job while battling his own sickness. He traveled by train from Oklahoma City to Enid in search of work. En route, passengers collected $15 for the family and local residents purchased clothes for the children and helped get the man a job.
Avoiding another pandemic
Ultimately, the Spanish flu is estimated to have killed at least 7,500 people in Oklahoma and sickened an estimated 100,000 more.
Today, public officials aren’t sitting around waiting for the next pandemic.
The World Health Organization established a formal monitoring system for flu viruses in 1948, with scientists around the world collaborating to track virus mutations and adjust each year’s vaccine.
Health experts say that in addition to getting a flu shot, two of the best ways to keep from getting or spreading the flu are to wash your hands frequently and cover your mouth with your inner elbow when you cough.
Could a pandemic like this one resurface?
“It’s inevitable,” Barry said.
“Any infectious disease expert will tell you (their) biggest nightmare is another serious influenza pandemic.”
There are other theories about other sites. I think the evidence for Haskell is probably roughly as good as it is for any other site, but we’ll probably never know.”
Author John M. Barry,
Patients and workers fill an emergency hospital at Camp Funston, Kan., during the 1918 influenza epidemic. PHOTO PROVIDED BY NATIONAL MUSEUM OF HEALTH AND MEDICINE COURTESY OF THE NATIONAL MUSEUMPatients and workers fill an emergency hospital at Camp Funston, Kan., during the 1918 influenza epidemic. PHOTO PROVIDED BY NATIONAL MUSEUM OF HEALTH AND MEDICINE COURTESY OF THE NATIONAL MUSEUM
The forgotten agony - the Spanish Flu pandemic of 1918-19
The World Health Organisation has recently released a plan designed to meet ‘the greatest threat to global public health.’ The report describes the threat as neither predictable nor preventable, and not a question of if it will strike the world, but when. The Global Influenza Strategy 2019-2030 aims to enable the world to better coordinate and respond to the threat posed by a potential influenza pandemic. In our increasingly globalised and interconnected world the threats posed by such pandemics are taken extremely seriously. This is due, in part, to the experiences of a previous pandemic, when global movements saw a virus emerge that would devastate a worldwide population already scarred by the carnage of war.
Although a number of pandemics have occurred in previous decades, the most deadly was the Spanish Flu pandemic of 1918-1919. The Spanish Flu has been described by the author Laura Spinney as ‘the greatest tidal wave of death since the Black Death, perhaps in the whole of human history.’ This pandemic is estimated to have caused the deaths of between 50-100 million people and infected one-third of the human population, around 500 million people. The flu killed far more than either the First or Second World Wars, and may even have killed more than the death tolls from both conflicts combined. The flu forced fundamental changes to public heath care systems across the globe and its severity and impact is still felt today.
The flu that most people are aware of is a seasonal virus that circulates across the globe in the colder months. Although the flu virus can effect humans, it is also prevalent in birds and mammals. Sometime in late 1917 or early 1918 a strain of avian flu managed to make the transition from birds to humans. Historians still debate the exact location of ‘patient zero,’ the very first human to become infected with this deadly new strain. Some scientists such as British virologist Professor John Oxford argue that the outbreak began in a hospital camp in Etaples, France, whilst others suggest that it began in a US Army camp in Kansas.
"We are facing a health threat unlike any other in our lifetimes."
A message from @antonioguterres, Secretary-General of @UN. #CoronavirusOutbreak pic.twitter.com/Zhs8o0iLUP
— HISTORY UK (@HISTORYUK) March 16, 2020
Spain was immune from the censorship that limited the wartime nations press. When the Spanish King was struck down many newspapers were finally able to report on the outbreak that was sweeping across the world. These press reports then led to a mistaken belief that the outbreak had started in Spain.
The unusual circumstances of 1918 helped the virus to travel further and faster than in any previous event in human history. The First World War resulted in the largest global migration of humans yet seen. This enabled the virus to spread, on troopships and transports, to every corner of the globe. Furthermore, the large concentrations of people, especially in the military, enabled the virus to infect individuals with lightning speed.
Although the study of bacteria was well known, the presence of viruses had been postulated but never proven because no equipment then existed to observe something so small. This meant that when the outbreak occurred there was no way of studying the virus effectively or developing a cure.
The Spanish Flu instead appeared to target young men and women between the ages of 18-35
A further terrifying feature of the outbreak that was apparent from its onset was the main age group of its victims. Seasonal influenza normally targets children under the age of 4 or elderly grandparents over the age of 65. The Spanish Flu instead appeared to target young men and women between the ages of 18-35. This age group normally has the strongest and healthiest immune systems, able to fight off any illnesses. However the Spanish Flu turned its victims own immune systems against them. The virus would trigger a Cytokine Storm, an autoimmune response whereby the victims immune system goes into overdrive, attacking and causing significant damage to lung tissue. This damage would cause the victims to turn blue as their bodies battled for oxygen. Victims would then eventually drown as their lungs filled with fluid.
The first wave of the outbreak in early 1918 was mild by comparison, but by August a second far deadlier strain was sweeping the world.
The devastating impact of the virus is illustrated in the ways it affected local communities. The first reports of the virus hitting the town of Crewe in the North West of England occurs in June of 1918. It reportedly laid low many of its residents, especially in its large railway works which would prove the perfect breeding ground for the virus. By November the virus had claimed 60 lives in just a 10 day period and resulted in 115 internments in Crewe’s cemetery, the highest in any month since the cemetery opened. In November 1918 of the 38 men killed on active service 18 are confirmed to have died of an influenza related illness.
The influenza virus is a parasite that can only live in an infected host. The most successful strain would be the one in which the host stayed alive, enabling the virus to be passed on. If the virus killed the host its chances of being passed on become limited. This helps to explain the spikes in death rates, and why the virus came and went so quickly. The virus became a victim of its own success, its deadly nature resulted in victims failing to pass on more deadly strains, which eventually led to the virus appearing to seemingly vanish after the end of the third wave in 1919.
The virus caused worldwide devastation to communities ravaged by the effects of war. The world of 1920 wanted to forget the terrible experiences of the war years, and so the Spanish Flu was confined to memory. In the years that have followed however, scientists have studied its devastating effects, using the outbreak as a model in how to cope with future pandemics. The virus is still around today, although in a less deadly form than when ‘the Spanish Lady’ first struck one hundred years ago.
Are Covid Fatalities Comparable with the 1918 Spanish Flu?
On April 23, 2021 The New York Times published an article titled “How Covid Upended a Century of Patterns in U.S. Deaths.” The article lays out some data regarding the unprecedented uptick in the US death rate that occured in 2020.
As shown in the graph provided by the New York Times, US death rates have been steadily declining over the past century, likely due to advances in technology and living standards. Last year certainly signaled a noticeable break from this trend with a sizable increase in deaths, but not nearly the same as the 1918 Flu which is a universal benchmark for a killer influenza virus.
This graph provided by the New York Times indicates the spike in excess deaths in 2020, which is the number of deaths that have occured exceeding the predictions of standard death trends. This is of course all important information. Last year was certainly a horrific year with the outbreak of Covid-19, the lockdowns, and all the chaos that followed. It was a year of death and despair which should not be taken lightly.
Important Discussion: Deaths and Victims
It is common to invoke comparisons with the 1918 Flu Pandemic, as that was an extremely devastating virus that rocked the world. The article makes multiple references to the 1918 pandemic but there are a couple that raise interesting questions for further investigation. The first point is as follows,
“Combined with deaths in the first few months of this year, Covid-19 has now claimed more than half a million lives in the United States. The total number of Covid-19 deaths so far is on track to surpass the toll of the 1918 pandemic, which killed an estimated 675,000 nationwide.”
Comparing the death counts between the 1918 Flu and Covid-19 without adjusting for population growth is extremely misleading. In 1918 the population of the United States was roughly 103 million, while near the end of 2020 it stood at roughly 330 million. According to CDC statistics compiled by a study in JAMA Covid-19 killed 345,000 people in 2020 and now stands at around half a million as stated by the New York Times. Adjusted for the population growth of over 200 million people and holding the death rates constant, the 1918 Flu would have killed over 2 million people if it occured today, which is more than four times greater than Covid-19.
Furthermore, the two diseases are vastly different in terms of who is vulnerable. Covid-19’s severe outcomes almost exclusively affect the elderly and the immunocompromised, particularly those over the age of 65, which is also approaching the life expectancy of a human. Furthermore 94 percent of Covid deaths occurred with preexisting conditions. It poses virtually no risk to children, minimal risk to young adults, and only seems to kill more than 1 percent of victims with those over the age of 65.
On the other hand the Spanish Flu was devastating to virtually all age groups and did not discriminate between the healthy and the unwell. The CDC writes the following about the 1918 Flu:
“Mortality was high in people younger than 5 years old, 20-40 years old, and 65 years and older. The high mortality in healthy people, including those in the 20-40 year age group, was a unique feature of this pandemic.”
It is clear that the comparison is flawed between the 1918 Flu and Covid-19, as the former was a devastating killer virus whereas the latter only poses a threat to vulnerable populations.
Too Much Statistical Noise
It is certainly worth investigating the noted increase in excess deaths in 2020 as that is obviously a problem. However, the article seems to suggest that Covid-19 was the main causal factor driving increases in death. Although that is certainly a reasonable intuition given that it is a novel virus, clearly there is far more at play.
The main issue to point out is that there were two health crises, not one. Covid-19 is certainly one but we cannot simply ignore the absolutely devastating and unprecedented use of lockdown policies that drastically upended all of society in a way that a virus could never accomplish.
The effects of lockdowns have been thoroughly studied by AIER and in a series of articles I noted just some of the damage to the economy, young people, and the normal functioning of society. All these disruptions led to adverse outcomes whether it be mental health issues, decline in living standards, or even disrupted healthcare procedures. In a press release the CDC noted that in May 2020, it recorded the highest number of drug overdoses ever recorded in a 12-month period.
A study in JAMA notes that although there was a substantial increase in overall deaths in 2020, Covid-19 was only one part of the problem, assuming all Covid deaths are directly attributable to Covid and not a comorbidity.
Some statistics of note are an increase in deaths due to heart disease, unintentional injuries, stroke, and diabetes. Although more investigation would be needed to understand how all of this comes together, it wouldn’t be absurd to believe that lockdown policies led to an increase in deaths due to their many disruptions to normal societal functions.
To cite one example of many, the Mackinac Center Legal Foundation recounts on one of its clients by writing,
“One of the affected medical practices, Grand Health Partners, operates in the Grand Rapids area. It performs endoscopies and other elective surgeries, many of which were deemed nonessential by executive order. Due to the shutdown, many of their patients were not able to receive treatment and have suffered because of it.”
Alongside exploring and cutting through the statistical noise posed by increases in death plausibly related to lockdowns, there still needs to be a discussion on quantifying the Covid-19 death count. Genevieve Briand, an economist at John Hopkins University, was subject to a massive degree of controversy for putting out a flawed but important lecture – later expanded into a research paper – that pointed out among other things that Covid-19 deaths may be inappropriately reclassified as deaths from other leading causes.
This is especially worthy of discussion given that the overwhelming majority of Covid deaths occur with comorbidities amongst eldery populations often nearing or exceeding life expectancy.
The data is clear 2020 was a horrific year full of death and despair. The New York Times’ article certainly does a great job at starting a conversation about this topic. However, its comparisons of Covid-19 and the 1918 Flu raises more questions than answers. Furthermore its presentation of data regarding increases in deaths requires more context.
Upon further investigation, it is clear that Covid-19 claimed many lives. However, it is also clear that there is a substantial presence of statistical noise from comorbidities and increases in death from other causes. This raises many questions not just about the collateral damage of our policy response, but also about whether we are even operating with the appropriate information to be making such decisions with people’s lives in the first place.
Vaccine Development Across the United States
At the Naval Hospital on League Island, Pennsylvania (the Philadelphia Naval Shipyard), physicians described their approach to a vaccine: “After the nature of a drowning person grasping at a straw, a stock influenza vaccine was used as a preventive in fifty individual cases and as a curative agent in fifty other uncomplicated cases” (Dever 1919). They made the vaccine made from B. influenzae and strains of pneumococcus, streptococcus, staphylococcus, and Micrococcus catarrhalis (now Moraxella catarrhalis). Each dose contained between 100,000,000 and 200,000,000 bacteria per cubic centimeter, in a four-dose regimen. The investigators reported that no vaccinated individuals (who were hospital workers) became sick, but also noted that strict preventive measures were taken, such as the use of masks, gloves, and so on. In a group of ill patients treated therapeutically with the vaccine, none developed pneumonia but one developed pleurisy (infection of the lining of the lungs). They noted, “The course of the disease [in those treated therapeutically]…was definitely shortened, and prostration seemed less severe. The patients apparently not benefitted were those admitted from four to seven days after the onset of their illness. These were out of all proportion to the number of pneumonias that developed and the severity of the infection of the control cases. The effects were always more striking, the earlier the vaccine was administered.” Finally, they concluded that, “The number of patients treated with vaccines and the number immunized with it is entirely too small to allow of any certain deductions but so far as no untoward results accompany their use, it would seem unquestionably safe and even advisable to recommend their employment.”
Another group of investigators described the use of vaccines at the Naval Training Station in San Francisco. They relate that Spanish influenza did not reach San Francisco until October 1, 1918, and that that staff at the training station therefore had time to prepare preventive measures (Minaker 1919). Isolation was easy, due to the location of the base on Alameda Island, reachable only by boat from San Francisco and Oakland. Naval Yard personnel were required to use an antiseptic throat spray daily. Beyond these measures, the authors noted that “steps were taken to produce a prophylactic vaccine,” even though there was a “great diversity of opinion as to the exciting cause” of the pandemic. In general pneumococcus and streptococcus were seen as the cause of the most severe complications. Additionally, and amid dissent, they decided to obtain a culture of B. influenzae from a fatal case at the Rockefeller Institute to include in the vaccine. In all, the vaccine contained B. influenzae, 5 billion bacteria pneumococcus Types I and II, 3 billion each pneumococcus Type III, 1 billion and Streptococcus hemolyticus (S. pyogenes), 100 million.
Guinea pigs were first injected with the vaccine to assess toxicity, and then five lab worker volunteers were inoculated. Lab tests determined that their white cell count increased and their sera agglutinated B. influenzae (meaning that they had antibodies in their blood that reacted to the bacteria). Side effects from the injection included local swelling and pain but no abscesses. Given permission to proceed, more vaccine was prepared and 11,179 military and civilians were inoculated, including some at Mare Island (Vallejo, CA) and San Pedro as well as San Francisco civilians associated with the Naval Training station. In most experimental groups, the rate of influenza cases was lower than in the uninoculated groups (though no information is given on how the statistics for the uninoculated groups were gathered, nor is there information on how a case was defined). Moreover, people who were inoculated received the injections about three weeks after influenza appeared in California, so it’s impossible to tell whether they had already been exposed and infected. The percent of influenza cases in control groups ranged from 1.5% to 33.8% (the latter being nurses in San Francisco hospitals), whereas between 1.4% and 3.5% (the latter being hospital corpsmen on duty in an influenza ward) of those in the inoculation group became ill with influenza.
Another use of vaccine was documented in Washington State at the Puget Sound Navy Yard (Ely 1919). Investigators claim that influenza invaded the Navy Yard when a group of sailors arrived from Philadelphia (it’s unclear exactly when they arrived, but the paper states that “the period of observation was from September 17 to October 18, 1918”). In all, 4,212 people were vaccinated with a streptococcal vaccine. The investigators reported that the influenza attack rate in the vaccinated ranged from 2% to 57% and in the unvaccinated from 1.8% to 19.6%. However, they noted that no deaths occurred in the vaccinated men. They stated “We believe that the use of killed cultures as described prevented the development of the disease in many of our personnel and modified its course favorable in others.” The investigators concluded that B. influenzae played no role in the outbreak.
E. C. Rosenow (Mayo Clinic) reported on the use of a mixed bacterial vaccine in Rochester, Minnesota, where about 21,000 people received three doses of vaccine in his initial study. He concluded that “The total incidence of recognizable influenza, pneumonia, and encephalitis in the inoculated is approximately one-third as great as in the control uninoculated. The total death rate from influenza or pneumonia is only one-fourth as great in the inoculated as in the uninoculated.” He would go on to test his vaccine in nearly 100,000 people.
In an editorial entitled “Prophylactic Inoculation Against Influenza,” Journal of the American Association of Medicine editors warned that, “the data presented are simply too inadequate to permit a competent judgment” of whether the vaccines were effective. In particular, they addressed Rosenow’s paper:
“To specify only one case: The experience at a Rochester hospital—where fourteen nurses (out of how many?) developed influenza within two days (how many earlier?) prior to the first inoculation (at what period in the epidemic?), and only one case (out of how many possibilities?) developed subsequently during a period of six weeks—might be duplicated, so far as the facts given are concerned, in the experience of other observers using no vaccines whatever. In other words, unless all the cards are on the table, unless we know so far as possible all the factors that may conceivably influence the results, we cannot have a satisfactory basis for determining whether or not the results of prophylactic inoculation against influenza justify the interpretation they have received in some quarters.”
St. Louis took action early
St. Louis was the sixth-largest city in the USA with a population of about 756,000. News of the flu spreading through Boston, Philadelphia and other cities provided early warnings, and officials took notice.
"St. Louis had an energetic and visionary health official in Dr. Max Starkloff," Navarro says. The city's health commissioner "immediately started warning the public and told physicians to report influenza cases."
Starkloff, fully supported by the city's mayor, "was very quick to implement city closures," Navarro says. He closed public places such as schools, theaters, playgrounds, city courts and churches and banned gatherings of more than 20 people.
He canceled the city's Liberty Bonds parade. "They recognized that crowds were a danger," McKinsey says.
Businesses protested closings. "They were upset because they were losing revenue," McKinsey says. "It was a constant conflict between them and the city."
How many more deaths did Philadelphia have?
Estimated total deaths from influenza and pneumonia, September-December 1918:
SOURCE University Archives and Records Center, University of Pennsylvania Research Medical Center, Kansas City, Missouri
Though "Starkloff listened to business pleas to reopen, he didn't reopen the city all at once," Navarro said. "He did it in a step-wise fashion."
Starkloff reimposed restrictions as infection cases rose again in November 1918. Infections subsided, and restrictions ended in December. St. Louis fared better than other cities.
Which cities had highest peak death rates?
Estimated peak death rate per 100,000 population in 16 weeks for 1918 flu:
NOTE Excess pneumonia and influenza mortality rate, Sept. 14-Dec. 14, 1918, from 1913-17 baseline peak is the day with the highest number of cases SOURCE Proceedings of the National Academy of Sciences
Post-pandemic analyses revealed "social distancing was highly effective against virus transmission," McKinsey says.
"We also found volunteers had a great impact in dealing with the epidemic, especially the Red Cross, which did an excellent job in making masks, training nurse assistants and distributing medical information pamphlets to the public. It really made a difference," McKinsey says.
Total death rates of cities compared
Estimated overall death rate per 100,000 population for 1918 flu:
NOTE Excess pneumonia and influenza mortality rate, Sept. 14, 1918-May 31, 1919, from 1913-17 baseline SOURCE Proceedings of the National Academy of Sciences
Except for a minor fourth wave early in 1920, U.S. pandemic fatalities dwindled and virtually ended in the summer of 1919.
In the pandemic's aftermath, "we see a change in efforts for better public health," says Deanne Stephens, professor of history at the University of Southern Mississippi.
"It ranged from a greater emphasis on clean drinking water to the recognition that nursing was a critical service," Stephens says. "There was also the realization that government could take a stronger role in disease prevention."
Beyond that, Americans turned their attention elsewhere. Perhaps that was to be expected.
"There was a different mentality then," Stephens says. "The U.S. was used to epidemics. So in urban areas, there was an attitude of 'we're going to plow through this.' "
And finally, there was the shadow of World War I itself. Americans "may have thought of the flu as simply a subdivision of the war," historian Alfred Crosby wrote in "The Forgotten Pandemic."
Horror of 1918 flu faded
Subjects of stories in American periodicals after the flu (in inches of column space):
NOTE Prohibition was the ban on sale of alcoholic beverages in the U.S. Bolsheviks were far-left Marxist revolutionaries who killed the czar in 1917 and started a communist regime in Russia SOURCE The Readers Guide to Periodical Literature, 1919-1921, as cited in "America's Forgotten Pandemic: The Influenza of 1918" by Alfred Crosby.
SOURCES Centers for Disease Control and Prevention University of Pennsylvania, Archives and Records Center National Institutes of Health National Endowment for the Humanities Library of Congress Federal Reserve History Museum of American Finance National Bureau of Economic Research "When We Have a Few More Epidemics, the City Officials Will Awake," published master's thesis of historian Jeffery Anderson, Rutgers, 1997 "The Great Influenza: The Story of the Deadliest Pandemic in History" by John M. Barry, 2004 "Pale Rider: The Spanish Flu of 1918 and How It Changed the World" by Laura Spinney, 2017 "America's Forgotten Pandemic: The Influenza of 1918" by Alfred W. Crosby, 1989 "Pandemic 1918: Eyewitness Accounts from the Greatest Medical Holocaust in Modern History" by Catherine Arnold, 2018 "Influenza: The Hundred-Year Hunt to Cure the Deadliest Disease in History" by Dr. Jeremy Brown, 2018
USA TODAY research by George Petras illustrations and graphics by Karl Gelles