Spanish flu facts for kids
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| Disease | Influenza |
|---|---|
| Virus strain | Strains of A/H1N1 |
| Location | Worldwide |
| Date | February 1918 – April 1920 |
| Suspected cases‡ | 500 million (estimated) |
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Deaths
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25–50 million (generally accepted), other estimates range from 17 to 100 million |
| ‡ Suspected cases have not been confirmed as being due to this strain by laboratory tests, although some other strains may have been ruled out. | |
The 1918–1920 flu pandemic, also known as the Great Influenza epidemic, was a very serious global flu outbreak. It was caused by a type of influenza A virus called H1N1. The first known case was in March 1918 in Kansas, United States. Soon after, cases appeared in France, Germany, and the United Kingdom.
Over two years, about one-third of the world's population, or 500 million people, got sick. The flu spread in four main waves. Experts believe between 17 million and 100 million people died. This makes it one of the deadliest pandemics in history.
The pandemic happened near the end of World War I. Countries fighting in the war often hid bad news to keep people's spirits up. But newspapers in neutral Spain reported the flu freely. This made it seem like Spain was where the flu started, leading to the name "Spanish flu." This name is actually wrong.
Most flu outbreaks usually affect very young children and older adults the most. But this pandemic was different. It caused a lot of deaths among young adults. Scientists have different ideas why this happened. One idea is that the war made people weaker. Another is that a climate event helped the virus spread.
The 1918 Spanish flu was the first of three flu pandemics caused by the H1N1 influenza A virus. The others were the 1977 Russian flu and the 2009 Swine flu.
Contents
Understanding the Flu's Names
This pandemic had many names. Some were old, and some were new. The names often depended on where and when people talked about the flu. People back then did not know that tiny viruses caused the flu. This lack of scientific answers led to many different ideas about the disease.
For example, in July 1918, a newspaper in Sierra Leone wondered what the disease was. They suggested calling it "Man hu," which means "What is it?" in ancient Hebrew.
Descriptive Names for the Flu
Before 1918, flu-like illnesses were seen in British military hospitals. This happened in Étaples, France, and Aldershot, England, in 1916–1917. Doctors noticed that sick people's faces turned a blue-violet color. This symptom led to the name 'purple death'.
Doctors later said that the flu they saw in 1916 and 1917 was similar to the 1918 pandemic flu. In 1918, the flu was also called 'epidemic influenza' or 'the grip'. In Spain, early reports called it 'three-day fever'.
Names Linked to Places
Many names for the flu made it seem like it came from a foreign place. This happened before with the 'Russian flu' in 1889. Back then, Germans called it the 'Russian pest'. Italians called it the 'German disease'. These kinds of names were used again in 1918.
Why it's Called 'Spanish' Influenza
Outside of Spain, the disease was soon called 'Spanish influenza'. This was not because it started in Spain. It was because Spain was a neutral country during World War I. Countries fighting in the war often hid news about the flu to keep their soldiers and citizens strong.
Spain did not have this problem. Its newspapers freely reported on the flu, even when King Alfonso XIII got sick. This made it seem like Spain was the main place where the flu was happening. Spanish health officials did not even know other countries were also affected.
In October 1918, a Spanish official complained about the name. He said the flu did not start in Spain. But the name "Spanish flu" had already stuck.
Other Names from Around the World
The French press first called it 'American flu'. But they soon switched to 'Spanish flu' to avoid upsetting their allies. British soldiers called it 'Flanders flu'. German soldiers called it 'Flemish fever'. Both names came from a famous battlefield in Belgium.
In Senegal, it was called 'Brazilian flu'. In Brazil, it was 'German flu'. In Spain, it was also known as the 'French flu'. Or it was called the 'Naples Soldier', after a popular song.
Other names came from different groups of people. In Poland, it was the 'Bolshevik disease'. In South Africa, some white people called it 'kaffersiekte', which was a very offensive term. Japan blamed sumo wrestlers for bringing the disease from Taiwan. They called it 'sumo flu'.
The World Health Organization now tries to avoid names that link diseases to places or groups of people. This is to prevent social stigma. So, "Spanish flu" is an example of a name to avoid today. Many writers now use names like '1918–19/20 flu pandemic' instead.
Local Names for the Flu
Some names for the flu did not mention specific places. For example, in some African languages, it was called 'Malibuzwe' (let enquiries be made concerning it). In others, it was 'Ugonjo huo kichwa na kukohoa na kiuno' (the disease of head and coughing and spine).
Other Common Names
This outbreak was also known as the 'great influenza epidemic'. This name came from the 'great war', which was what World War I was called before World War II. German doctors called it 'pseudo influenza' (false influenza). In Africa, doctors called it 'influenza vera' (true influenza) to make people take it seriously.
A children's song from an earlier flu pandemic was changed for 1918. It became a skipping-rope rhyme:
I had a little bird,
its name was Enza.
I opened the window,
and in-flu-enza.
History of the Pandemic
Timeline of the Flu's Spread
First Wave in Early 1918
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The pandemic is often said to have started on March 4, 1918. This was when Albert Gitchell, an army cook, got sick at Camp Funston in Kansas, USA. But there might have been cases even earlier in Haskell County, Kansas. A local doctor warned health officials about it in January 1918.
Within days of the first case at Camp Funston, 522 soldiers there were sick. By March 11, 1918, the virus reached Queens, New York. Many people later criticized that not enough was done to stop it early on.
The U.S. had just joined World War I. So, the disease quickly spread from Camp Funston to other army camps. It also reached Europe with American troops. By April 1918, it was an epidemic in the Midwest and East Coast of the U.S. It reached the Western Front in Europe by mid-April.
Then, it quickly spread to France, Great Britain, Italy, and Spain. In May, it reached Poland and Ukraine. After a peace treaty was signed, German soldiers returning from Russia also brought the disease home. It reached North Africa, India, and Japan in May. By June, it was reported in China. This first wave started to slow down after reaching Australia in July.
The first wave of the flu was from early 1918 and was not very severe. The number of deaths was not much higher than normal. In the U.S., about 75,000 flu-related deaths were reported in the first six months of 1918. This was similar to 63,000 deaths in the same period in 1915. There were no quarantines during this time. However, the first wave did affect World War I. Three-quarters of French troops, half of British forces, and over 900,000 German soldiers got sick.
Deadly Second Wave in Late 1918
The second wave started in late August 1918. It likely spread to Boston, Massachusetts, and Freetown, Sierra Leone. Ships from Brest, France, probably carried the virus. It likely arrived there with American troops. From Boston, it quickly spread to other U.S. military bases. It also affected troops going to Europe.
Troop movements helped the flu spread quickly. Over the next two months, it reached all of North America. Then it went to Central and South America. It also reached Brazil and the Caribbean by ship. In July 1918, the Ottoman Empire saw its first cases.
From Freetown, the pandemic spread through West Africa. It followed the coast, rivers, and railways. South Africa got the flu in September from ships bringing soldiers back from France. From there, it spread across southern Africa. It reached Ethiopia in November.
On September 15, New York City had its first flu death. A large parade in Philadelphia, Pennsylvania, on September 28, 1918, caused a huge outbreak. About 12,000 people died after attending the parade.
From Europe, the second wave swept through Russia. It also reached Iran and India in September. China and Japan were affected in October. Celebrations for the end of World War I on November 11, 1918, also caused outbreaks. But by December, this deadly wave was mostly over.
The second wave was much more deadly than the first. The first wave was like a typical flu. The sick and elderly were most at risk. But the second wave was different. October 1918 had the highest death rate of the whole pandemic. In the U.S., about 292,000 deaths were reported from September to December 1918. This was much higher than the 26,000 deaths in the same period in 1915. India was hit especially hard. An estimated 12.5–20 million people died there in late 1918 alone.
Third Wave in 1919
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The pandemic continued into 1919 in many places. This might have been because it was winter in the Northern Hemisphere. Winter is usually when the flu is most active. But the pandemic continued regardless of the season or location.
Cases started to rise again in some parts of the U.S. in late November 1918. Health officials reported a return of the disease in early December. This varied across the country. For example, Michigan saw a quick return of the flu in December. This might have been because rules about public gatherings were lifted.
Many places brought back rules like closing schools and banning public gatherings. This was to try and stop the flu from spreading. In January 1919, there was a sudden rise in deaths in most cities. Almost all cities saw some return of the flu in January and February.
Big outbreaks happened in cities like Los Angeles, New York City, and San Francisco. By late February, flu activity was going down in most parts of the country. But nearly 160,000 deaths were still caused by the flu in the first six months of 1919.
A clear return of the flu appeared in Europe later in the winter and spring. A big third wave hit England and Wales by mid-February. It peaked in early March and did not fully go away until May. France and the Netherlands also had a big wave that peaked in February. Norway, Finland, and Switzerland saw the flu return in March. Sweden saw it in April.
Much of Spain was affected by a "substantial" wave of flu from January to April 1919. Portugal had a return of the flu from March to September 1919. The west coast and north of the country were hit hardest.
The flu entered Australia for the first time in January 1919. Strict rules had kept it out in late 1918. It became an epidemic in Melbourne first, peaking in mid-February. The flu then spread to New South Wales and South Australia. It continued to spread across the country throughout the year.
Land quarantine rules helped slow the spread of the disease. This meant different states had different experiences. Queensland was not infected until late April. Western Australia avoided the disease until early June. Tasmania stayed free of it until mid-August. Victoria and New South Wales had the biggest epidemics. Both had another big wave of illness in the winter.
The disease also reached other parts of the world for the first time in 1919. Madagascar saw its first cases in April. The outbreak had spread across the island by June. In other places, the flu returned as a true "third wave." Hong Kong had another outbreak in June. South Africa also had one during its fall and winter months. New Zealand also saw some cases in May.
Parts of South America had a return of the flu throughout 1919. A third wave hit Brazil from January to June. Chile had a severe second wave from July 1919 to February 1920. Deaths peaked in August 1919. Montevideo also had a second outbreak from July to September.
The third wave hit Spain, Serbia, Mexico, and Great Britain especially hard. It caused hundreds of thousands of deaths. It was generally less severe than the second wave. But it was still much deadlier than the first wave.
Fourth Wave in 1920
In the Northern Hemisphere, people worried about the flu returning as fall came. Experts looked at past flu epidemics, like the one in 1889–1890. They thought the flu might return a year later. In September 1919, U.S. Surgeon General Rupert Blue said the flu would "probably" return. France prepared a public information campaign. Britain started making vaccines in the fall.
In Japan, the flu broke out again in December. It spread quickly across the country. People thought this was because of the cold weather. Rules to stop the flu were brought back. Health officials told people to wear masks. The epidemic got worse in late December. It quickly peaked in January.
Between October 1919 and January 23, 1920, 780,000 cases were reported in Japan. At least 20,000 people had died by that date. This seemed three times worse than Japan's first epidemic in 1918–1919. But the disease was thought to be milder than the year before, even if it spread more easily. It lasted through the winter before fading in the spring.
In the United States, there were "isolated" cases of flu throughout the spring and summer of 1919. Cases started to increase in September. Chicago had one of the first big outbreaks in mid-January. Health officials said they would try to "localize the epidemic." But the disease was already spreading in Kansas City. It quickly spread from the center of the country.
Within days, it was clear the flu was spreading faster in Chicago than in winter 1919. But fewer people were dying. New cases in Chicago passed the peak of the 1919 wave within a week. Around the same time, New York City saw a sudden increase in cases. Other cities across the country soon followed.
Some rules, like closing schools and theaters, were brought back. Businesses were told to open and close at different times to avoid crowds. This happened in cities like Chicago, Memphis, and New York City. Schools in New York City stayed open, but those in Memphis closed.
The fourth wave in the U.S. ended as quickly as it started. It peaked in early February. This epidemic in early 1920 caused about one-third as many deaths as the 1918–1919 wave. New York City alone reported 6,374 deaths from December 1919 to April 1920. This was almost twice the number of deaths in the first wave in spring 1918. Other U.S. cities like Detroit and Milwaukee were hit very hard. Their death rates were higher than all of 1918. Hawaii had its peak in early 1920. It recorded 1,489 flu-related deaths.
Poland had a very bad outbreak during the winter. Its capital, Warsaw, had 158 deaths in one week. This was higher than the peak of 92 deaths in December 1918. But the 1920 epidemic lasted only a few weeks. In contrast, the outbreak in western Europe was considered "mild." The age of people dying started to look like a normal seasonal flu. Five European countries had a late peak between January and April 1920.
Mexico had a fourth wave in February and March. In South America, Peru had waves of the flu throughout the year. A severe third wave hit Lima from January to March. This caused about four times more deaths than the 1918–1919 wave. Ica also had another severe wave in 1920. A fourth wave also happened in Brazil in February.
Korea and Taiwan also had big outbreaks in late 1919 and early 1920.
After the Pandemic Ended
By mid-1920, most people and governments thought the pandemic was "over." Some parts of Chile had a milder third wave from November 1920 to March 1921. But the flu seemed mostly gone through the winter of 1920–1921. In the U.S., deaths from pneumonia and flu were "very much lower than for many years."
The flu started to be reported again in many places in 1921. Chile had a fourth wave that affected seven of its provinces from June to December 1921. The winter of 1921–1922 was the first big return of seasonal flu in the Northern Hemisphere. It was the most significant flu activity since the main pandemic in late 1918. Northwestern Europe was especially affected. Deaths in the Netherlands almost doubled in January 1922. In Helsinki, a major epidemic happened from November to December 1921. The flu was also widespread in the U.S.
After 1920, the disease became more familiar. It was like the "seasonal flu" we know today. The H1N1 virus stayed around. It sometimes caused more severe outbreaks as it slowly changed over the years. The time since 1918 has been called a "pandemic era." All flu pandemics since then have been caused by viruses related to the 1918 flu.
In 1957, a new virus, H2N2, replaced the H1N1 virus. This new virus was a mix of human H1N1 and a bird flu virus. In 1977, an H1N1 virus very similar to the old one reappeared in Russia. This caused a "technical" pandemic that mostly affected people aged 26 and younger. After this, H1N1 became common again. But it did not replace the other flu virus, H3N2. For the first time, two flu A viruses were circulating at the same time. This is still true today. In 2009, a new H1N1 virus caused another pandemic. It then took the place of the seasonal H1N1 and now circulates alongside H3N2.
Where Did the Flu Start?
Even though it's called the Spanish flu, no one knows for sure where it started. Scientists have different ideas.
United States Theory
The first confirmed cases were in the United States. Historian Alfred W. Crosby said in 2003 that the flu started in Kansas. Author John M. Barry also pointed to an outbreak in Haskell County, Kansas, in January 1918 as the starting point.
A 2018 study looked at old tissue samples. It found that the cases in Kansas were milder. This suggests the disease might not have started there. But the study did find evidence that the virus likely came from North America. Other studies suggest the H1N1 virus might have changed into its deadly form around 1915.
Europe Theory
Some scientists think the flu started at a large British military camp in Étaples, France. Virologist John Oxford believes this. His study found that in late 1916, the Étaples camp had a new disease with many deaths. Its symptoms were like the flu. A similar outbreak happened in March 1917 in England. Doctors later said these early outbreaks were the same disease as the Spanish flu.
The camp at Étaples was very crowded. It was a perfect place for a breathing virus to spread. The hospital treated thousands of soldiers injured by poison gas. About 100,000 soldiers passed through the camp every day. There were also pigs and chickens nearby. Oxford and his team think a bird flu virus changed and then spread to pigs. Then it jumped to humans.
A 2016 study found evidence that the 1918 virus was already spreading in European armies months or even years before 1918. Another study from 2009 found that flu deaths peaked at the same time in 14 European countries. This does not fit the idea that the virus started in one place in Europe and then spread out.
China Theory
In 1993, Claude Hannoun, a flu expert, thought the virus likely came from China. He believed it then changed in the U.S. near Boston. From there, it spread to France, Europe's battlefields, and the rest of the world. Allied soldiers and sailors were the main carriers.
In 2014, historian Mark Humphries suggested that Chinese laborers might have brought the pandemic. About 96,000 Chinese laborers worked behind British and French lines. Humphries found old records showing a breathing illness in northern China in November 1917. Chinese health officials later said it was the same as the Spanish flu.
China was one of the few places that seemed less affected by the Spanish flu. Some studies show a milder flu season there in 1918. This led some to think the flu started in China. If it did, the Chinese people might have had some protection from it already.
However, a 2016 study found no evidence that Chinese workers brought the virus to Europe. It suggested the virus was already in Europe. The low death rate among Chinese workers in Europe also suggests they were not the source of a new deadly virus.
How the Flu Spread and Changed
Transmission and Virus Changes
The flu virus could infect between 2 and 3 other people on average. The crowded conditions and huge movement of soldiers during World War I helped the pandemic spread quickly. The war might have also made the virus change and become more deadly. It might have also made people weaker. Some think soldiers' bodies were weakened by poor food, stress from fighting, and chemical attacks. This made them more likely to get sick.
Modern travel systems also helped the flu spread worldwide. Soldiers, sailors, and travelers easily carried the disease. Governments also hid information and denied how serious it was. This left people unprepared.
The second wave was so deadly because of World War I. In normal life, a mild flu strain spreads more easily. Sick people stay home, but mildly sick people go out. In the trenches, this was reversed. Soldiers with a mild flu stayed in the trenches. But very sick soldiers were sent on crowded trains to crowded hospitals. This spread the deadlier virus.
The second wave started, and the flu quickly spread around the world again. Doctors now look for deadlier virus strains in places with big social problems. People who recovered from the first wave were immune. This showed it was the same flu strain. This was seen in Copenhagen. It had a very low death rate because people were exposed to the less deadly first wave. For others, the second wave was much deadlier. Young, healthy adults were the most vulnerable.
After the deadly second wave in late 1918, new cases dropped fast. In Philadelphia, over 4,500 people died in one week in October. But by November 11, the flu had almost disappeared. One idea is that doctors got better at treating pneumonia, which often followed the flu. But some experts say there is no proof for this.
Another idea is that the 1918 virus quickly changed into a less deadly strain. Viruses often become less deadly over time. This is because very dangerous strains kill their hosts too quickly to spread well. But deaths continued into 1919. For example, ice hockey player Joe Hall died from the flu in April 1919. This led to the cancellation of the 1919 Stanley Cup Finals.
Symptoms of the Spanish Flu
Most infected people only had typical flu symptoms. These included a sore throat, headache, and fever. This was especially true during the first wave. But during the second wave, the disease was much more serious. It often led to bacterial pneumonia, which was a common cause of death.
In serious cases, people's skin would turn blue. This was called heliotrope cyanosis. First, two spots would appear on the cheekbones. Then the whole face would turn blue. After that, the hands and feet would turn black. Then the black color would spread to the arms, legs, and body. Death would follow within hours or days. This happened because the lungs filled with fluid.
Other symptoms included bleeding from the mouth and nose. Pregnant women often had miscarriages. People reported a strange smell, teeth and hair falling out, and confusion. They also had dizziness, trouble sleeping, and loss of hearing or smell. Some had blurry vision. One person wrote that bleeding from the nose, stomach, and intestines was common. Bleeding from the ears and small red spots on the skin also happened.
Most deaths were from bacterial pneumonia. This is a common infection that happens after the flu. Bacteria from the upper breathing tubes could get into the damaged lungs. The virus also killed people directly. It caused a lot of bleeding and swelling in the lungs.
Scientists now think the virus was very deadly because it made the body's immune system overreact. This is called a cytokine storm. The strong immune reactions of young adults might have harmed their bodies. Children and middle-aged adults had weaker immune reactions. This might be why fewer of them died.
Mistakes in Diagnosis
Doctors at the time could not see the virus under a microscope. This made it hard to diagnose correctly. They mistakenly thought a bacterium called Haemophilus influenzae was the cause. This bacterium was big enough to see. It was also found in many sick people. So, a vaccine was made against this bacterium. It did not stop people from getting infected. But it did lower the death rate.
During the deadly second wave, people also feared it was plague, dengue fever, or cholera. Another common wrong diagnosis was typhus. Typhus was common when society was in chaos. So it was also affecting Russia after the October Revolution. In Chile, leaders thought the country was in decline. Doctors thought the disease was typhus caused by poor hygiene. They did not think it was infectious. This led to a bad response. They did not ban large gatherings.
Role of Weather Conditions
Studies show that the immune systems of Spanish flu victims might have been weakened by bad weather. It was very cold and wet for long periods during the pandemic. This especially affected World War I troops. They were exposed to constant rain and cold temperatures. This was true during the second wave of the pandemic.
Detailed climate data shows a severe weather event in Europe from 1914 to 1919. This directly affected how severe and widespread the Spanish flu was. There was a big increase in rain across Europe during the second wave, from September to December 1918. Deaths increased as rain increased and temperatures dropped.
Scientists have ideas why this happened. Colder temperatures and more rain might have been good for the virus to grow and spread. They also might have weakened people's immune systems. This made people more likely to get sick. This is especially true for soldiers and others exposed to bad weather. This factor is known to increase the chance of getting both viruses and bacterial infections.
A six-year climate event brought cold, ocean air to Europe. This changed the weather a lot. This weather might have also affected how bird flu viruses spread. These viruses can contaminate water with their droppings. The climate event might have also led to more dust in the air from constant bombing. This dust could have caused more rain.
How People Responded
Public Health Actions
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In 1918, there were ways to tell health officials about infectious diseases. But they usually did not include the flu. This led to a slow response. Still, actions were taken. Islands like Iceland, Australia, and American Samoa set up rules to stop ships from bringing the flu. This saved many lives.
Rules about social distancing were put in place. Schools, theaters, and churches were closed. Public transportation was limited. Large gatherings were banned. Wearing face masks became common in some places, like Japan. But people argued about if they worked. Some people, like the Anti-Mask League of San Francisco, did not want to wear them.
Vaccines were also made. But these were based on bacteria, not the actual virus. So, they could only help with other infections that came after the flu. How well these rules were enforced varied. In New York City, the health commissioner told businesses to open and close at different times. This was to avoid crowded subways.
A later study found that banning large gatherings and requiring masks could cut the death rate by up to 50 percent. But this only worked if the rules were put in place early and not lifted too soon.
Medical Treatments Used
There were no antiviral drugs to treat the virus. And there were no antibiotics to treat the bacterial infections that followed. So, doctors used many different medicines. Some worked, some did not. These included aspirin, quinine, and arsenic. They also used digitalis, strychnine, epsom salts, castor oil, and iodine.
Traditional medicines were also used. These included bloodletting, ayurveda, and kampo.
Sharing Information During the Pandemic
Because of World War I, many countries censored news. They did not allow reports about the pandemic. For example, an Italian newspaper was not allowed to report daily death tolls. Newspapers often tried to protect people from panic.
Wrong information also spread with the disease. In Ireland, some believed that bad gases were rising from war graves in France. They thought these gases were being "blown all over the world by winds." There were also rumors that Germans were behind it. Some thought they poisoned aspirin or released poison gas from submarines.
How Many People Died?
Deaths Around the World
The Spanish flu infected about 500 million people. This was about one-third of the world's population. Estimates of how many died vary a lot. But it is still considered one of the deadliest pandemics in history. Early estimates in 1927 said 21.6 million died. A 1991 estimate said between 25 and 39 million. A 2005 estimate put the death toll at 50 million, possibly as high as 100 million. This was about 3% to over 5% of the global population. However, a 2018 study estimated about 17 million deaths.
With a world population of 1.8 to 1.9 billion, these numbers mean between 1% and 6% of people died. A 2021 estimate by John M. Barry suggests the total death toll was well over 100 million.
A 2009 study looked at 14 European countries. It estimated 2.64 million extra deaths in Europe from the Spanish flu in 1918–1919. This was about 1.1% of Europe's population. This rate was higher than in the U.S. This might be because of the severe effects of the war in Europe.
About 12–17 million people died in India. This was about 5% of the population. In British-ruled India, 13.88 million died. The years between 1911 and 1921 were the only time India's population fell. This was mostly due to the Spanish flu.
In Finland, 20,000 died out of 210,000 infected. In Sweden, 34,000 died. In Japan, nearly 500,000 people died over two waves between 1918 and 1920.
In the Dutch East Indies (now Indonesia), 1.5 million people were thought to have died. In Tahiti, 13% of the population died in one month. In Western Samoa, 22% of the 38,000 people died in two months.
In Istanbul, the capital of the Ottoman Empire, 6,403 to 10,000 people died. This was at least 0.56% of the city's population.
In New Zealand, the flu killed about 6,400 Pākehā (people of European descent) and 2,500 indigenous Māori in six weeks. Māori died at eight times the rate of Pākehā.
In Australia, the flu killed about 12,000 to 20,000 people. Its death rate was one of the lowest at 2.7 deaths per 1,000 people. But up to 40% of the population got infected. Some Aboriginal communities had a death rate of 50%.
In the U.S., about 28% of the 105 million people got infected. Between 500,000 and 850,000 people died. Native American tribes were hit very hard. Entire Inuit and Alaskan Native villages in Alaska died. In Canada, 50,000 people died.
In Brazil, 300,000 people died, including President Rodrigues Alves. In the UK, up to 250,000 died. In France, over 400,000 died.
In Ghana, the flu killed at least 100,000 people. Haile Selassie, who later became Emperor of Ethiopia, got the flu but survived. Many of his people did not. In Addis Ababa, the capital, estimates for deaths range from 5,000 to 10,000 or higher.
The death toll in Russia is estimated at 450,000. But this number is uncertain. If correct, Russia had one of the lowest death rates in Europe. Another study thinks this number is too low. It suggests Russia's death toll was closer to 2.7 million people. This is because the country was in a civil war, and daily life had broken down.
Communities Hit Hard
Even where deaths were low, so many adults got sick that daily life stopped. Some stores closed. Others asked customers to leave orders outside. Healthcare workers and gravediggers also got sick. Mass graves were dug by machines. Bodies were buried without coffins in many places.
Bristol Bay, Alaska, had a death rate of 40% of its total population. Some villages disappeared completely. Nenana, Alaska, avoided the flu for a while. But it reached the town in spring 1920. Reports said most of the town got sick in the first two weeks of May. About 10% of the people died, mostly Alaska Natives.
Several Pacific islands were hit very hard. The flu reached them from New Zealand. New Zealand was too slow to stop ships carrying the flu from leaving its ports. From New Zealand, the flu reached Tonga (killing 8% of people), Nauru (16%), and Fiji (5%, or 9,000 people).
The worst affected was Western Samoa. It had been taken over by New Zealand in 1914. 90% of the people got infected. 30% of adult men, 22% of adult women, and 10% of children died. In contrast, the Governor of American Samoa, John Martin Poyer, stopped the flu from reaching American Samoa. He did this by blocking ships.
The disease spread fastest among higher social classes of native peoples. This was because of their custom of gathering stories from chiefs on their deathbeds. Many elders got infected this way.
In Iran, many people died. Estimates say between 902,400 and 2,431,000 people died. This was 8% to 22% of the total population. The country was also going through a severe famine at the time.
In Ireland, the Spanish flu caused one-third of all deaths during its worst 12 months.
In South Africa, about 300,000 people died in six weeks. This was 6% of the population. Government actions early on might have accidentally helped the flu spread. Almost a quarter of the workers in the diamond mines of Kimberley died. In British Somaliland, an official estimated that 7% of the native population died. This high death toll was due to many people getting infected and very severe symptoms.
Other Areas with Low Deaths
In the Pacific, American Samoa and the French colony of New Caledonia stopped any deaths from the flu. They used strong quarantines. However, the outbreak was only delayed. American Samoa had an outbreak in 1926, and New Caledonia in 1921. Australia also avoided the first two waves with a quarantine. Iceland protected one-third of its people by blocking the main road. By the end of the pandemic, the isolated island of Marajó in Brazil had no reported outbreak. Saint Helena also reported no deaths.
Estimates for deaths in China vary a lot. This is because there was no central way to collect health data during the Warlord period. China might have had a milder flu season in 1918. But some reports from inside China suggest that death rates were higher in some places. Overall, there is little evidence that China was as badly affected as other countries.
Early estimates in 1991 said between 5 and 9 million Chinese died. But later studies criticized this. Newer studies suggest a much lower death rate in China. For example, a 1998 estimate said between 1 and 1.28 million deaths. These lower estimates are based on low death rates in Chinese port cities. They also assume that poor communication stopped the flu from reaching inland China.
However, some old newspaper reports and missionary doctors' reports suggest the flu did reach inland China. They also say the flu was severe in some rural areas. Medical records from Chinese port cities like Hong Kong and Shanghai show low death rates. For example, Hong Kong reported a death rate of 0.25%. This was much lower than cities like Calcutta or Bombay. In Shanghai, with over 2 million people, only 266 flu deaths were recorded among Chinese people in 1918.
If these numbers are true for all of China, the death rate would be less than 1%. This is much lower than the world average of 3–5%. Japan and Taiwan had higher death rates than Chinese port cities. But it is noted that deaths in Hong Kong and Canton might have been undercounted. This is because only deaths in colony hospitals were counted. Also, Shanghai's numbers were only for a small part of the city. Actual deaths were likely much higher. Records from inland China show that rural areas had much higher death rates than cities.
Who Was Most Affected?
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The pandemic mostly killed young adults. In 1918–1919, 99% of flu deaths in the U.S. were in people under 65. Nearly half of all deaths were in young adults aged 20 to 40. This is unusual. Flu is usually most deadly for very young children, adults over 70, and people with weak immune systems. In 1918, older adults might have had some protection. This could be from being exposed to the 1889–1890 "Russian flu."
According to historian John M. Barry, pregnant women were the most vulnerable. In 13 studies of pregnant women in hospitals, the death rate was 23% to 71%. Of those who gave birth and survived, over a quarter (26%) lost their baby. Another strange thing was that the outbreak was widespread in summer and autumn. Flu is usually worse in winter.
The death rate also varied by location. Some parts of Asia had 30 times higher death rates than parts of Europe. Africa and Asia generally had higher rates. Europe and North America had lower ones. There were also big differences within continents. Cities were affected more than rural areas. Differences between cities might be due to exposure to the milder first wave, which gave some immunity. Also, social distancing rules helped.
Another pattern was differences between social classes. In Oslo, poorer people living in smaller apartments died at a higher rate. Immigrant communities, like Italian Americans, also had higher death rates. This was due to worse diets, crowded living conditions, and problems getting healthcare. However, African Americans were surprisingly less affected.
More men than women died from the flu. Men were more likely to go out and be exposed. Women tended to stay at home. Men were also more likely to have tuberculosis, which made recovery harder. But in India, the opposite was true. This might be because Indian women had poorer nutrition and were expected to care for the sick.
Studies suggest that changes in how the virus spread caused the three waves. Human behavior, like school openings and closings, and temperature changes also played a role. Human behavior had the biggest effect.
Effects of the Pandemic
Impact on World War I
Academic Andrew Price-Smith argues that the virus helped the Allies win World War I. He says the flu hit the Central Powers (Germany and Austria) before the Allies (Britain and France). Deaths and sickness were much higher in Germany and Austria. A 2006 study supports this.
Kenneth Kahn at Oxford University Computing Services says that the war conditions helped the disease spread. He also believes the flu influenced the war's outcome and the peace treaty. He has created a computer model to test these ideas.
Economic Effects
Many businesses in entertainment and services lost money. But the healthcare industry made more money. Historian Nancy Bristow says the pandemic helped women in nursing. This was partly because male doctors often failed to control the illness. Female nurses were proud of their patient care. They did not link the spread of the disease to their work.
A 2020 study found that U.S. cities that used early and strong non-medical rules (like quarantine) did not suffer extra economic harm. However, this study has been questioned. This is because it happened during World War I, and there were other data problems.
Long-Term Effects
A 2006 study found that people who were in the womb during the pandemic had problems later in life. They had less education, more physical disabilities, lower income, and needed more government help. A 2018 study also found that the pandemic reduced how much education people got. The flu has also been linked to an outbreak of encephalitis lethargica (a sleeping sickness) in the 1920s.
Survivors faced a higher risk of death later on. Some never fully recovered from the physical problems caused by the infection.
Legacy of the Pandemic
Even though many people got sick and died, the Spanish flu was largely forgotten for decades. This changed when news about bird flu and other pandemics came out in the 1990s and 2000s. Some historians call the Spanish flu a "forgotten pandemic." But historian Guy Beiner disagrees. He says it was remembered in private and local ways, even if it was overshadowed by World War I.
There are different ideas why the Spanish flu was "forgotten." It spread very quickly. Most victims in the U.S. died in less than nine months. This meant limited media coverage. People were also used to other diseases like typhoid and cholera. So, the flu might not have seemed as important. In some areas, the flu was not even reported. Only ads for medicines claiming to cure it were seen.
The outbreak also happened at the same time as World War I. The war got most of the media's attention. Another reason is who the disease affected. Most deaths from both the war and the flu were young adults. The high number of war deaths might have overshadowed the flu deaths.
When people read obituaries, they saw war deaths and flu deaths side by side. Especially in Europe, where the war took a huge toll, the flu might have seemed like another tragedy of the war. The length of the pandemic and the war might have also played a role. The war was expected to end quickly but lasted four years when the pandemic hit.
In Books and Movies
Despite the pandemic's impact, it was not a big theme in American literature. Alfred Crosby thinks this is because it happened after World War I. The war was the most important event for that generation. Katherine Anne Porter's 1939 book Pale Horse, Pale Rider is one of the most famous stories about the pandemic. The 2006 novel The Last Town on Earth is about a town that tries to stop the flu by not letting people in or out. The Pull of the Stars is a 2020 novel by Emma Donoghue. It is set in Dublin during the Spanish flu. It was published quickly because of the COVID-19 pandemic happening at the time.
Comparing to Other Pandemics
The Spanish flu killed a much smaller percentage of the world's population than the Black Death. The Black Death lasted for many more years. The recent COVID-19 pandemic is estimated to have killed between 17.5 and 31.4 million people.
Research on the Spanish Flu
The origin of the Spanish flu and its link to flu in pigs has been debated. One idea is that the virus started at Fort Riley, Kansas. It might have come from poultry and pigs raised there for food. Soldiers then spread the disease worldwide. Similarities between the reconstructed virus and bird flu viruses suggest it jumped directly from birds to humans. Pigs then caught it from humans.
Others disagree. Newer research suggests the virus might have come from a non-human mammal. It might have appeared in mammals between 1882 and 1913. This ancestor virus then split into two groups around 1913–1915. These groups led to the flu in pigs and humans. The most recent common ancestor of human strains is from February 1917 to April 1918. Pigs are more easily infected by bird flu than humans. So, pigs were suggested as the first animals to get the virus. They then passed it to humans between 1913 and 1918.
Scientists worked together to recreate the Spanish flu strain. This was done by the Armed Forces Institute of Pathology, the USDA ARS Southeast Poultry Research Laboratory, and Mount Sinai School of Medicine. On October 5, 2005, they announced they had found the virus's genetic sequence. They used tissue samples from an Inuit woman buried in Alaskan permafrost. They also used samples from American soldiers.
This allowed researchers to rebuild the virus particles. They then used these to infect mice, ferrets, and monkeys. This gave them important information about how the flu virus works. It also helped them learn how to prevent and control future pandemics.
In January 2007, a study reported that monkeys infected with the recreated flu strain showed classic symptoms of the 1918 pandemic. They died from an overreaction of their immune system. This might explain why the Spanish flu affected younger, healthier people so much. People with stronger immune systems might have had a stronger overreaction.
In December 2008, research linked three specific genes and a protein from the Spanish flu to its ability to cause pneumonia. These genes were put into a modern H1N1 strain. They caused similar symptoms in animal tests.
In 2008, a study looked at the immune response in 32 survivors of the 1918 flu. All of them still had signs of immunity. Seven out of eight tested had special cells that could make antibodies against the virus. This showed that their bodies remembered the virus many decades later.
In June 2010, a team found that the 2009 flu pandemic vaccine offered some protection against the Spanish flu strain.
One of the few things known for sure about the 1918 flu was that it only affected humans, except in labs.
In 2013, a research group studied the 1918 pandemic. They estimated what a similar pandemic would do today. They found that a modern "Spanish flu" could cause an extra US$15.3–27.8 billion in life insurance losses in the U.S. alone. It could also cause 188,000–337,000 deaths in the U.S.
In 2018, Michael Worobey, a professor studying the 1918 pandemic, found tissue slides from a doctor who reported on a breathing illness in 1916. This illness was likely the virus. Worobey is studying these slides to learn more about where the virus came from.
Why More Men Died
The high death rate of the Spanish flu made it different from other diseases. Another difference was that more men died than women. Men with other health problems were at much higher risk. Tuberculosis was a very deadly disease in the 1900s. It killed more men than women. When the flu spread, tuberculosis cases in men went down. Many experts have noted that tuberculosis increased the flu death rate in men. This lowered their life expectancy.
The death rates were especially high for people aged 20–35. The only other disease like this was the Black Death in the 1300s. Studies show that tuberculosis and influenza affected each other. The ages of men dying from the flu show that tuberculosis was a factor. Since more men had tuberculosis at the time, they had a higher death rate. Men's life expectancy dropped during the pandemic. But it went up again two years later.
The Island of Newfoundland
Social behavior was a major reason the flu spread. Men moved around more than women because of their work. Even though more men died overall, each region had different results. This was due to things like poor nutrition. In Newfoundland, the pandemic spread very differently. The flu affected people of all social classes.
Even though social movement helped the disease spread geographically, it tended to spread faster and affect men more. This was because of their jobs and social contact. Before the pandemic, tuberculosis was the main cause of death in Newfoundland. This was a serious underlying condition that increased the death rate when people got the flu.
Men and women in Newfoundland had different jobs that involved daily interaction. Fishing was a big part of the economy. So, men moved around more than women. They had more contact with other parts of the world. The pandemic started spreading in spring 1918. But Newfoundland did not see the deadly wave until June or July. This was when there was a high demand for fishing jobs. Most men worked along the coast in the summer. Whole families often moved to Newfoundland for work. Studies show a much higher death rate in men compared to women. But during the first, second, and third waves, the death rates shifted. Men had a higher death rate in the first wave. But women's death rates increased and were higher in the second and third waves. The female population was larger in some parts of Newfoundland. This had a bigger impact on the death rate there.
Canadian Soldiers and the Flu
Records show that most deaths during the first wave were among young men in their 20s. This matches the age of soldiers joining the war. The movement of young men in 1918 was linked to the flu's spread. This caused the biggest wave of the epidemic. In late 1917 and throughout 1918, thousands of male troops gathered at the Halifax port before going to Europe. Any sick soldier who could not leave stayed in Halifax. This increased the number of flu cases among men during the war.
To find out the cause of death during the pandemic, scientists used records from the Commonwealth War Graves Commission (CWGC). This group reported that under 2 million men and women died during the wars. They kept records of those who died from 1917 to 1918. The movement of soldiers and transportation between the United States and Canada likely had a big effect on the pandemic's spread.
See also
In Spanish: Pandemia de gripe de 1918 para niños
- 1918 flu pandemic in India
- 2009 swine flu pandemic
- Anti-Mask League of San Francisco
- COVID-19 pandemic
- Pandemic
- List of epidemics
- List of Spanish flu cases
