The Forgotten Killer

In the ten months between September 1918 and June 1919, 675,000 Americans died of influenza and pneumonia. When compared to the number of Americans killed in combat in World War I, World War II, Korea, and Vietnam combined- 423,000- it becomes apparent that the influenza epidemic of 1918-1919 was far more deadly than the war which it accompanied. (Crosby, 206-207) The United States and the rest of the world had been exposed to such epidemics in the past, but never at such a severe cost in human life.

The influenza epidemic came in two waves. The first wave, in the spring of 1918, took far fewer victims than the second. Americans stricken with the flu that spring wondered at the intensity of its symptoms and its incredible contagion. Doctors noticed that the virus seemed to spread more quickly than it ever had before that year, but did not realize how quickly it would reach epidemic proportion. As summer approached, the disease appeared to have satisfied its appetite for new victims.

However, the second, deadlier wave of influenza was just about ready to unleash itself on the world, and it did so quickly. By August 1918, the Surgeon General of the Army reported that the death rate from disease for American soldiers was almost 2/3 lower than the annual rate for civilian males of the same age. At the end of the month, the Spanish influenza virus mutated, and "epidemics of unprecedented virulence" exploded in the same week in three port cities thousands of miles apart: Freetown, Sierra Leone, Brest, Belgium, and Boston, Massachusetts. (Crosby, 37) It is still unknown whether this was the result of three appearances of a single mutation or three different simultaneous mutations.

The influenza epidemic caused many more deaths than any of the other epidemics which had preceded it, largely because of a general lack of awareness. The first wave began in the spring of 1918; for the most part, America's public health system ignored it. Generally, public health departments did not receive reports of influenza. Most doctors cited pneumonia on the death certificates of those killed, since flu came first and weakened the resistance of the sick, then pneumonia followed and was the eventual cause of death for most people.

The problem of diagnosis caused much confusion in determining the actual number of cases of flu. The Denver Post ran an article during that first wave to inform its readers of how to tell the difference between a cold and the flu. According to the Post , "the onset of a cold is not so sudden, its ache not so severe, its fever not so high, and it is marked by chilliness rather than definite chills." (Crosby, note on 41) Bacteriological tests did not provide any further insight, and doctors around the country argued the merits and drawbacks of various diagnostic methods.

Finally, the spring wave of flu went largely unnoticed for the most part because the United States did not have a sufficient network of federal, state, and local public health departments. They could not communicate properly to compile existing data on influenza and pneumonia in 1918 into some sort of picture of the epidemic. The only clear picture came from such institutions and organizations as prisons and the Armed Forces. They held complete jurisdiction over their inhabitants and members and had to care for them when they got sick.

Simultaneously, the rapidly advancing American war effort contributed to the lack of attention paid to the victims of the spring flu. In March 1918, 84,000 Americans left for Europe, and in April, 118,000 followed. (Crosby, 18) Perhaps the military's Medical Corps would have paid more attention to the spring wave of flu if it had known just how widely the wave had spread. The rate at which the disease killed young adults is another distinction of the spring flu wave which should have grabbed the attention of army medical personnel. Historian Alfred W. Crosby, Jr. said of the epidemic, "Influenza and pneumonia, when they kill, usually kill those of two extremes of life, the very young and the old." (Crosby, 21) The mortality rates for this flu were highest for the 20-29 age group. This age group paralleled those already dying in the greatest proportions in the European War.

The flu received a lot of attention in Europe- more than it did in the United States. It appeared in the British Expeditionary Force and in the German forces in April, in the French troops in May, and an estimated eight million Spaniards caught it by the end of June, giving the disease its nickname of "Spanish influenza." (Crosby, 26) In the civilian populations of Europe, it killed only a few of those it infected, but again, an extraordinarily high proportion of those were between 20 and 45 years of age, despite the fact that so many of their young men were away fighting. (Hoehling, 38) Still, the flu received only a fraction of the attention it would have earned in peacetime, due to both wartime censorship and the fact that the war was much more interesting than flu.

When the second wave of influenza broke out in Boston, it spread with remarkable speed, but both the city and the state of Massachusetts fooled themselves as to the epidemic's seriousness. On August 27, the first case reported to sick-bay on the Navy's Commonwealth Pier. Within two weeks, 2,000 officers and men of the First Naval District had the flu. (Hoehling, 49) Even so, Boston and Massachusetts did not take any measures to protect their citizens against the epidemic for several more weeks. The flu was ignored for quite a long time in one of America's most important port cities for shipping troops and equipment to the front lines in Europe. The general good health of the city encouraged officials not to examine the epidemic too closely; despite a population increase of 12,000 for the year, death rates were down from 1917. (Crosby, 45) Additionally, residents were distracted by the upcoming Senate vote on women's suffrage, the conviction and sentencing of Eugene Debs under the Espionage Act, the Boston Street Railway carmen's strike, the ongoing saga of the Bolsheviks in Russia, and the victory of the Boston Red Sox in the 1918 World Series. The rest of the country was similarly distracted. Not until the end of September, when the flu had struck navy bases as far away as Louisiana, Puget Sound, and San Francisco, and army camps from Massachusetts to Georgia to Washington, did the United States government realize that they could no longer afford to ignore the flu, no matter what was happening overseas. As Crosby stated, "The unthinkable was happening: something had appeared of greater priority than the war." (Crosby, 49)

Growing awareness of the flu epidemic did not prevent Americans from doing a very efficient job of spreading the virus from sea to sea, and then across the sea to Europe. Doctors warned health departments that dire consequences might result if the right precautions were not taken. They urged cities to quarantine the sick and restrict attendance at large public gatherings, Yet patriotic war fervor led many communities to resist the advice and continue to hold large rallies. In one ironic example, just a day after Washington officials acknowledged the epidemic in the capital, 13 million men (of the age group being killed most often by the flu and its complications) crammed into federal buildings to register for the draft and cough and sneeze on each other at the same time. By not restricting such mass meetings, the government merely offered more chances for its citizens to become infected with the flu virus.

For the country as a whole, the lack of solid information contributed most directly to the huge number of deaths from flu. In order to distribute its forces most efficiently, the United States Public Health Service (USPHS) needed daily reports from every state. It needed to compile these reports and broadcast them to the entire country because most physicians knew little about Spanish influenza, and incorrect information circulated almost as rapidly as the disease itself. This created an instant opportunity for those who made and sold quack remedies. Since no one knew what caused the flu, no one knew how to cure it, and many people were ready to try almost anything.

In its efforts to fight the flu, the USPHS also struggled with a lack of organization. Unprepared for an epidemic of this magnitude, the USPHS quickly found itself in the same position as the army had when the war first broke out. Crosby noted, "It was suddenly called upon to do a job for which it had been created in theory, but for which it had never been prepared in reality." (Crosby, 49) The USPHS did appoint a director for the fight against influenza in each state, but now that it had a "general" for each state, it needed "troops" for the general to command. Boston alone requested 500 doctors, more than the entire USPHS could produce. (Crosby, 50) The shortage of nurses created an even more desperate situation. Since there was no cure for the flu, doctors were not the essential members of the team fighting the disease; the nurses were. All that the medical community could do for the flu patients consisted of the basic care which they provided. Many people died due to the lack of nurses. The telegram from the USPHS to Bath, Maine which read, "Can send all the doctors you want but no nurses," was a common one for the fall of 1918. People got sick faster than the nurses could be found to take care of them, and they often died from dehydration, starvation, and poor care.

The United States government did not have any trouble finding the money to fund research of the epidemic. The House and Senate passed in two hours a resolution to appropriate one million dollars to the USPHS to fight Spanish influenza. But the use of this money to combat the spread of the epidemic meant that there was less money to be spent on the war effort. To remedy this problem, Congress offered the Fourth Liberty Loan, consisting of six billion dollars in bonds, to the American people. Unfortunately, the thousands of meetings and rallies, and millions of door-to-door solicitations involved in the bond drive served only to encourage the spread of a disease which really did not need any help.

The armed forces played a crucial role in exacerbating the influenza epidemic; the navy carried the flu from coast to coast on troopships, and the army did the same on its railways. Crosby noted, "The flu struck the two armed services earlier and more severely than the civilian population and, to a considerable extent, the armed services were the foci from which the civilian population received the disease." (Crosby, 56) The first few weeks of the epidemic's second wave greatly afflicted the navy. Naval shore personnel were stationed on the coast nearest the war, where the epidemic had its first great effect on the country. From seaport to seaport, the sailors carried the disease with them, sharing it with their mates in all parts of the nation. The conditions on troopships going back and forth to Europe seemed practically designed to spread the flu. Once the men boarded the ship in the United States, they stayed on it until they reached their destination, no matter how many fell ill. As more and more sailors contracted the flu, the medical officers ran out of room in sick-bay and had to take over the quarters of healthy sailors, crowding them into fewer and fewer spaces and creating more opportunities for infection.

In the army, the tight quarters offered for traveling soldiers guaranteed the rapid spread of any respiratory illness among troops. During the day, three men crammed themselves into every double seat on the trains, and in the sleeping cars, one man slept in the upper bunk and two in the lower. The intense physical training the men underwent in camps only helped to weaken their resistance and make them more susceptible to the disease.

Among civilians, the urban dwellers fell victim to the flu most rapidly. Crowded, dirty, and poorly ventilated living conditions contributed to the spread of the disease. The large immigrant populations who had little or no experience with public health principles of sanitation and quarantine factored into the problem as well. They could not speak enough English to communicate with doctors, nurses, or public health officials. These people had little confidence in either medical or political officials in America, and they often had no money to pay for treatment.

Large public gatherings in support of the war, such as parades, bond rallies, and loan drives, brought masses of people together to breathe on each other and spread the flu. A population who did not appreciate the amount of danger it was in ignored closing orders for schools, churches, theaters, and other places of public meetings. Many cities refused to halt their massive public transportation networks until the flu forced them to do so by felling hundreds of transit authority employees.

Hospitals overflowed with patients and had to set up emergency expansion quarters; this only intensified the shortage of medical personnel. Overwork and overexposure to the disease soon took its toll on those fighting it, decimating their forces even more. The constant wearing of masks, a procedure instituted midway through the epidemic, did little to prevent the spread of the flu from patients to their caregivers.

Those who collected the dead, prepared them for burial, and then interred them (the most valuable service in an epidemic), found themselves overwhelmed in many cities. The accumulation of corpses only served to create opportunities for secondary epidemics caused by the organisms which live in dead flesh. These problems combined together to make America's cities the hardest-hit victims of the epidemic.

People's indifference to the flu epidemic of 1918-1919, both at the time and today, led directly to the rapid and deadly spread of the disease. Although more people died in the flu epidemic of 1918-1919 than ever before in as short a time period, few Americans were or are impressed by that fact. President Woodrow Wilson's administration considered the amount of time and money put into flu research the most that had ever been devoted to a single disease. (Hoehling, 103) But in reality, that amount was inconsequential when compared to the number of victims, and the effort was "uncoordinated and underfinanced and feeble." (Hoehling, 104) Although appropriations for the USPHS increased in proportion to population growth and the increasing consciousness of importance of public health, Congress never appropriated any funds specifically for influenza research. Most politicians concentrated on the war and ignored the epidemic, since the war efforts were successful and could be reported to their constituents as such.

Many felt that lethal epidemics were a common factor in their lives. At first, the flu seemed no different. Most people had already lived through at least one epidemic of some disease, even if on a much smaller scale. Hearing about another incurable disease sweeping the world had little effect on those who had already survived epidemics of cholera, yellow fever, and malaria. The flu news paled in comparison to the news coming from the European Front.

The war itself was probably the most important cause of people's indifference to the epidemic. Most of those who died from flu were of the same age as those who died in combat, and that helped to conceal the demographic effect of the epidemic within that of the war. Also, many people thought of the flu as just another aspect of the war. Death was death, and the cause of the death of a loved one was really not an issue for those left behind.

The flu moved quickly, killed ambiguously, and spared the rich and famous for the most part; all factors which contributed to its lack of remembrance. It arrived in a town, flourished for a time, and left before many people had an opportunity to realize how great the danger actually was. Also, the flu did not always kill, and when it did, it killed quickly, and did not linger or leave long-lasting effects, like polio or cancer. If the flu had killed a famous figure of the time, it would have been more widely remembered, but the most famous individuals were over the age of 40, and out of the stage of young adulthood where the flu claimed its greatest number of victims.

The flu epidemic helped the war to rob America of almost 800,000 lives. But the disease itself had some help too. As Crosby wrote, the United States "was not merely unprepared to control the spread of influenza. It had carefully, if unintentionally, prepared itself to expedite the cultivation and dissemination of just precisely the influenza virus of 1918." (Crosby, 31) In subsequent years, America showed that it had learned from its experience in 1918. Flu epidemics in the thirties and the fifties never approached the magnitude of the 1918-1919 disaster. Research across the world eventually isolated and identified the virus which causes influenza and the microorganisms which so often accompany it and cause deadly complications like pneumonia and strep and staph infections. The American public health system is one of, if not the, best in the world today at educating its citizens and preventing the spread of communicable disease. Historians can only speculate about what would have happened if people had applied the knowledge of today to the devastating epidemic of so many years ago.

WORKS CITED

Crosby, Alfred W., Jr. Epidemic and Peace, 1918. Westport, CT: Greenwood Press, 1976.

Hoehling, A.A. The Great Epidemic. Boston: Little, Brown and Company, 1961.