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The Forgotten Flu

February 1, 2008
by Stephen M. Soreff, MD and Patricia H. Bazemore, MD
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The often-overlooked 1918 pandemic offers important lessons for the next major outbreak

In 1918, an outbreak of influenza swept over the earth, becoming the deadliest pandemic in history. Between 50 and 100 million people died, including 675,000 Americans.1 One-third of the world's population and one-fourth of Americans were infected.2

In this article, we provide an overview of how the pandemic affected American society. We also examine the impact on psychiatric hospitals. As we prepare for the next flu pandemic, the lessons learned from the 1918 outbreak remain relevant and instructive.

A Global Catastrophe

Despite intensive investigations, much about the virus (H1N1) that caused the 1918 pandemic remains a puzzling mystery.2 We do know that it first infected birds before transforming to infect swine and humans.3 Although some evidence suggests that human infection began in Canton, China, most historians say the pandemic began in Kansas near an Army base in February 1918.1,3

Fort Riley was a huge Army training facility in Kansas that had nearly 60,000 soldiers. As Barry states in

The Great Influenza: The Epic Story of the Deadliest Plague in History, “It is impossible to prove that someone from Haskell County, Kansas, carried the influenza virus to Camp Funston [which contained Fort Riley's infirmary]. But the circumstantial evidence is strong.”

1 At Fort Riley thousands of military personnel developed the flu in the spring, summer, and fall of 1918. The first official influenza sick call at Camp Funston occurred on March 4, 1918, and within three weeks at least 1,000 soldiers required hospitalization for severe symptoms.

1




Although people dutifully wore masks, these provided only a very limited protection against the influenza virus. when it came to treating influenza patients, doctors, nurses, and druggists were at a loss during the flu pandemic.
Photos provided by the U.S. Office of the Public Health Service Historian; http://1918.pandemicflu.gov. Used with permission. These photos are representative of the period; they may not have been taken during the height of the pandemic.


Although people dutifully wore masks, these provided only a very limited protection against the influenza virus. When it came to treating influenza patients, doctors, nurses, and druggists were at a loss during the flu pandemic.


The virus spread east in the United States and on to Europe, Asia, the South Pacific, and Australia. By May 1918 influenza was epidemic in Spain. Spain, a neutral country during World War I, did not have press censorship. Thus, reports of the large numbers of influenza cases circulated widely, and the illness became known as the Spanish Flu or La Grippe.1 Influenza advanced around the world in three waves: spring 1918, fall 1918, and winter 1919.2

The 1918 flu had three significant clinical features: rapid death, fatal secondary bacterial infection, and highest mortality among those 20 to 40 years old (People born before 1889 were thought to have some immunity from exposure to a prior epidemic2). More U.S. soldiers died from the flu than from combat.4

Reactions at Home

Denial. Many Americans denied the outbreak's seriousness, based on limited news coverage and the stance of local and federal authorities. For example, officials in Philadelphia downplayed the significance of early cases and, in fact, encouraged large public gatherings.5 Yet if the public had known of the flu's dangers, more might have participated in quarantine efforts which, when complete, were surprisingly effective.

Hatchett et al compared the flu's peak mortality rates in different U.S. cities to demonstrate the proven effectiveness of nonpharmacologic interventions (NPIs).5 Communities that used several such interventions (e.g., preventing public gatherings and closing schools) had a reduction in peak incidence of influenza cases by 50%, although the overall number of cases was reduced by only 20% (still an impressive figure). Philadelphia had one of the highest mortality rates of major U.S. cities, attributed to a failure to implement NPIs and to allowing a citywide parade on September 28, 1918, which 200,000 people attended.

Mistrust. Some saw influenza as a German weapon brought to the United States by U-boats.1 Others blamed the outbreak on immigrants. For example, Denver residents singled out Italians.1

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