1918 flu pandemic: the deadliest influenza

Over one hundred years ago, a viral and dangerous flu swept the world killing more people than the World War that was coming to a close that year. Commonly known as the Spanish Flu, no one is sure where it began, though it certainly wasn’t in Spain. Better described as the 1918 flu pandemic, it was an unusually deadly pandemic caused by the H1N1 influenza and like COVID-19 today it spread quickly across the world.

As Catherine Arnold wrote in Pandemic 1918: The Story of the Deadliest Influenza in History, the most terrifying aspect of H1N1 was its fast-acting and aggressive symptoms. Victims collapsed in the streets haemorrhaging from their lungs and nose. Their skin turned dark blue due to oxygen failure as lungs filled with pus and they gasped for air like landed fish. Others suffered projectile vomiting and explosive diarrhoea and died raving as their brains starved of oxygen. Those who survived were often left with a lifetime of nervous conditions, heart problems, lethargy and depression.

Apart from the enormous death toll, the main memory of the 1918 was the ubiquitous mask, until recently thought to be a freak of history. Masks spread from the medical profession to traffic cops and onto the civilian population. In many places it was an offence to go outside without a mask, though then like now its efficacy was debatable. Writing in 2018 before COVID-19, Arnold likened the mask photos to “scenes from a science fiction movie”.

Like now, there is debate about how the virus started. There are two main candidates for ground zero of the 1918 pandemic, both related to the war. Again like now, there were conspiracy theories related to the 5G scares of the era, such as it was a strain of bubonic plague from China (the yellow peril has a long history), or caused by the effect of rotting corpses and mustard gas in the battlefield, or that it was man-made in Bayer aspirins and distributed by U-boats.

What is true is the war spread the virus quickly across the world with mass troop movements, bond drives, and victory parades. The flu may even have changed the course of the war with the German advance stymied by huge losses to illness. The pandemic was the one enemy that scared both sides.

The earliest known death from H1N1 occurred in February 1917. English Private Harry Underdown, aged 20, died at Étaples field hospital in France officially due to “complications following an attack of influenza”. Underdown was serving in northern France when struck down by “widespread broncho-pneumonia”. As he died, his doctor Lt J.A.B. (initials, not an appropriate nickname!) Hammond noted Underdown’s face was blue due to lack of oxygen. Hammond wrote an article in the Lancet in 1917 about the “small epidemic” at Étaples, the largest field hospital on the western front.

Étaples was chosen for its stragetic location, near Calais and with rail lines to the front. It had port facilities and railway yard, stores, hospitals, prisons and training area. There were also stables for thousands of horses and piggeries and poultry farms to feed the masses – the presence of live animals another portent of the virus which could cross the species boundary via avian faeces eaten by grubbing pigs.

People living close to animals is one of the reasons China is the epicentre of influenza epidemics. In the course of several winters ending in 1917–18, epidemics with afflictions of the lungs were seen in northern China. Chinese labourers were in large numbers at Étaples brought in to support the war effort. Étaples was a bleak spot at the best of times. Poet Wilfred Owen described it as as a “vast, dreadful encampment”. Conditions deteriorated to an extent there was a mutiny in the training camp in September 1917. The revolt was put down with 300 arrests and one soldier sentenced to death.

While the virus was possibly incubating in France, there was another troubling hotspot across the Atlantic Ocean. Doctors in Haskell County, Kansas were seeing strange symptoms of what they called “knock me down” fever. One doctor saw so many cases he wrote to Washington but was ignored because influenza was not a “notifiable disease”.

Some 300km from Haskell was Camp Funston at Fort Riley, where young Americans got basic training before being shipped off to Europe for the war the US entered in 1917. Around four million men, mostly farm boys with little immunity to big city diseases which roamed freely at vast places like Camp Funston (named for Fighting Fred Funston who served in the Spanish wars). Construction began in mid 1917 of 4000 buildings holding 40,000 soldiers.

The air was full of dust and burning ash from the tonnes of horse manure which stung the eyes in the high winds of the Kansas plains, leaving the men prone to respiratory infections. A bad dust storm occurred on March 9, 1918 turning the sun black. Within days a steady stream of soldiers reported sick with high temperatures. By the end of the month a thousand men were stricken and a hangar was used as a ward.

It was diagnosed as the flu with symptoms such as high fever, headache and back pain. Some patients were too weak to stand, others coughed violently or had projectile nose bleeds and some even choked to death. It spread to Camp Dix in New Jersey and other camps across the country and Washington was advised. Again the advice was ignored.

The flu spread back from the camps to the local population. A thousand Ford motor workers in Detroit and Chicago came down with it as did 500 prisoners at San Quentin in California. Schoolboy John Steinbeck also caught it in California and almost died. “I went down and down until the wingtips of angels brushed my eyes,” he wrote. Doctors operated to drain pleural pus from his infected lung and he survived with a profound sense of vulnerability that informed works like The Grapes of Wrath.

Troops from Camp Funston and elsewhere brought the virus with them on the troopships as the ‘doughboys’ were shipped out to Flanders. The British first noticed a small outbreak in the already unhealthy Ypres Salient in April 1918 and a second wave in June was deadlier still. By then the virus had crossed no-mans-land and German commander Eric von Ludendorff estimated 2000 men in each division had the flu, a huge problem as he struggled to replace a million casualties despite the end of the war on the Russian front. “It was a grievous business to hear the chief of staff’s recital of the influenza cases and the weakness of the troops if the English attacked again,” he complained.

In late May the disease hit Spain and king Alfonso XIII and several government ministers fell sick. Because Spain was neutral, Spanish censorship was not as strict as elsewhere and it was the first press to report on the crisis, calling it the French flu. But when international papers picked up on the news from Madrid, the pandemic was immortalised as the Spanish flu. Cartoonists depicted it as the ghoulish Spanish Lady, her skull dancing in a black flamenco dress.

In the months to come the Spanish Lady’s deadly dance crossed Europe. Convalescing troops brought it home to Britain, the northern industrial cities hit hardest. Miners were particularly prone and the coal, iron and munitions industry was crippled as people collapsed and died in the streets. “If you try to shake it off it becomes much worse,” a Manchester paper reported.

In London the theatres full of service personnel from every nation helped spread disease. Many victims were young, rich and healthy. Virginia Woolf in Richmond noted it had “come next door”. Fellow writer and socialite Cynthia Asquith wrote how it was the worst illness of her life, “bursting head, painful pulses, aching legs, sick, burning with cold shivers. I tossed and groaned.” Over 70,000 Britons were dead by November but the war effort demanded the flu be ignored. Britain’s chief medical officer admitted it could not be controlled and refused to take public health measures. The nation’s “sacred duty”, he said, was to carry on working and it was unpatriotic to even worry about it.

The pandemic meanwhile, spread across the world from port cities such as Bombay (Mumbai). It then spread east back to Baghdad and Shiraz where the bazaars and shops were closed as there was no doctors, nurses or drugs to offer help. More ports spread it in Africa; Mombasa, Freetown, and Cape Town. Injured men on troopships brought it back to North America creating another wave in August, overwhelming the east coast naval hospitals.

Boston schools shut down in October 1918 which schoolboy Francis Russell remembered at first with delight in great weather. That changed the day he stumbled upon a funeral where he saw gravediggers dump the bodies out of the coffins to reuse them. The memory scarred Russell for life.

Philadelphia was the worst hit city after an outbreak at the naval yard. A massive parade in September, the Fourth Liberty Loan Drive, attracted 200,000 people and a massive epidemic began a day later, with 75,000 cases in October. Over 700 died in a week and numbers increased in the following weeks, overwhelming understaffed hospitals. Services collapsed and Bell Co shut down the phones to all but essential calls. The undertaking business was overrun and coffin theft was rife with 500 bodies at the morgue and demand growing daily. Bodies piled up in the streets and the Highways Bureau loaned steam shovels to dig trenches in Potter’s Field for the burial of the poor and unknown.

Mask wearing became compulsory across America. The San Francisco Chronicle reported a range of masks which started with standard surgical gauze and went from elaborate Turkish muslin yashmak veils to flimsy chiffon coverings. “Some wore fearsome looking machines like extended muzzles,” the paper reported. Commuters on the ferries found it a nuisance and were caught with masks dangling from chins while they enjoyed a morning pipe in the sea air.

The pandemic got to Australia in early 1919, brought back by returning soldiers to Sydney, and gradually spreading out. The Queensland government closed its borders and established quarantine camps along its southern boundary at Wallangarra and Coolangatta. Travellers had to remain in the camps for seven days before being allowed to enter the state and strict inspection of all ships was carried out.

Nevertheless on May 3 laundresses at Kangaroo Point Hospital in Brisbane caught it. It then spread throughout the state and defied all attempts to control it, including isolation, closure of public places, and inoculation. Many of the 830 deaths in Queensland were young adults with Aboriginal populations particularly vulnerable – the epidemic caused 69 deaths among the 596 residents of the Barambah Aboriginal Settlement (now Cherbourg).

By mid 1919, the Spanish Lady had mostly finished her exhausting dance across the world. Some 500 million people were infected, around a third of the world’s population, and up to 50 million were dead. It wasn’t until the 1990s when the genome from a defrosted flu victim from the Tundra showed it was a bird virus adapted to humans. The virus provoked an auto-immune response called a cytokine storm with a marked inflammatory response, causing secondary damage to lungs. This secondary response caused the deaths, not the virus itself.

Writing a century later, Arnold said we had not since seen a pandemic on the scale of 1918. But she acknowledged the Hong Kong H5N1 outbreak in 1997 was a ‘wake up call for epidemiologists and public health authorities” and the threat of another pandemic was real. She finished with prophetic words from English virologist John Oxford back in 2000 who compared their work to vulcanologists. “We are sitting on our volcano, and we don’t know when it is going to erupt”.

Twenty years later, seems to be the answer.

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