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A century ago, two words described influenza: interesting and frightening.

For a small but elite group of medical researchers, 1918 was when influenza got interesting. But for everyone else — from farmers in rural America to the swelling populations in cities — 1918 was when the flu became frightening.

The Spanish flu, as it was called (although it did not originate in Spain), killed 675,000 people in the U.S. at a time when the population was one-third the size of today.

Records are incomplete and mortality rate estimates vary, but it’s clear it was unusually high for influenza — around 2.5%, compared to about 0.1% for most seasonal flu outbreaks.

Worldwide, most estimates put the death toll in the range of 17 million to 50 million, although some go as high as 100 million. An estimated 500 million people were infected.

Many have compared the current coronavirus pandemic to the Spanish flu of 1918. Recently, former Food and Drug Administration commissioner Scott Gottlieb said that the coronavirus “would have been far more deadly than the Spanish flu if the coronavirus had appeared in 1918.”

Microsoft co-founder and philanthropist Bill Gates has been warning of a new pandemic for years. “A virus like the Spanish flu of 1918 would spread throughout the world very, very quickly,” Gates said in a TED talk in 2015.

“If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus rather than a war,” Gates said. “Not missiles, but microbes.”

But can the COVID-19 pandemic really be compared to the Spanish flu pandemic of 1918?

There are similarities. For one, the coronavirus spreads rapidly and efficiently among humans, as did the 1918 disease. But the world of 100 years ago was very different from the world today.

War and pestilence

Until recent years, the Spanish flu seemed mostly forgotten. Gina Kolata, a microbiologist and author, said the 1918 flu was never discussed in her college courses. In her book, “Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It,” she expressed dismay at her ignorance of an epidemic that changed the course of history.

“The 1918 influenza epidemic is one of history’s great conundrums, obliterated from the consciousness of historians, who traditionally ignore science and technology but not, for the most part, plagues,” she wrote.

Part of the reason is that World War I overshadowed the virus in public awareness. This focus on the war and its aftermath has continued through the decades, even though more Americans died in a single year from the Spanish flu than were killed in World War I and all of the United States’ subsequent wars combined.

In 2005, historian John M. Barry published what many consider the definitive book on the 1918 flu, “The Great Influenza: The Story of the Deadliest Pandemic in History.” The book reads like a detective novel as Barry tracks down the beginnings of the outbreak and follows its path to the battlefields of Europe. From Europe it circled the globe, mutated and returned to the U.S. with a vengeance.

Different theories exist about the origins of the virus. Barry’s research led him to conclude that it originated in rural Kansas in early 1918, where it jumped from infected pigs to humans (Spanish flu was a type of swine flu). He traced the first recognized cases to Haskell County, Kansas.

“Evidence further suggests that this virus traveled east across the state to a huge army base, and from there to Europe,” he wrote.

Scientists now know that viruses are constantly mutating, and infections tend to come in waves. The Spanish flu attacked in three waves, beginning with a wave in the spring and summer of 1918. This wave was concentrated in military camps.

The second wave came that fall, as troops were returning from the war. It arrived in ports and quickly spread to cities. This wave proved to be the most deadly. A third wave in 1919 was less contagious and had a lower fatality rate.

Not only did this flu kill, it could kill quickly. A doctor at Yale University said he saw patients dying in as few as 12 hours from the time they showed the first symptoms. Other victims would linger for days in their death bed.

An oddity of the 1918 pandemic was that it killed healthy 20- to 40-year-olds. Usually, it’s the elderly who are most susceptible to influenza, but Spanish flu killed people in the prime of their lives.

The cause of death was usually pneumonia due to secondary infection by bacteria. But another oddity of this virus was the bizarre symptoms exhibited by some patients.

While normal flu symptoms of fever, aches and coughing were present, in severe cases patients would turn blue, suffocating from a lack of oxygen. Doctors reported dark spots appearing on skin and patients bleeding from their nose, ears and even eyes.

Medicine and science

Barry’s book goes beyond detailing the suffering and death caused by the illness. He presents the pandemic as the first great challenge to the modern American medical establishment. He writes about the heroic efforts of William Henry Welch, the first dean of the Johns Hopkins School of Medicine, and other leading researchers such as Paul Lewis, William Park, Anna Williams and Oswald Avery.

This small but elite group revolutionized medical science in America. Most medical schools of the era depended solely on student tuition for income and did not engage in research. The only requirement for getting into medical school was to be able to pay. Doctors were not required — or even expected — to have a scientific background in order to practice medicine.

This could explain why trust in doctors was not particularly high among the general public. Although the American Medical Association, founded in 1847, spoke out against the worst of the quackery, its members had their hands full dealing with charlatans peddling fake (sometimes dangerous) treatments not based on science. These included popular elixirs, like “Dr. Peeples’ Epilepsy Remedy” (8.4% alcohol and 22% ammonia).

The reality was that mainstream medicine did not exist yet. But that was soon to change. While educators and laboratory researchers failed to stop the pandemic, their careful collection of data and rigorous experimentation became the norm. They handed their allegiance to science down to the next generation. Health care in America was slowly dragged into the modern era.

Tale of two cities

When the lethal second wave of flu hit America in the fall of 1918, outbreaks varied from city to city. A lot depended on whether public officials heeded or ignored the warnings coming from health experts and people on the front lines of the epidemic.

With the war winding down, shiploads of infected soldiers were being unloaded in ports in New York, Boston and other places. Sick soldiers were taken to local hospitals and often weren’t quarantined.

The deadliest outbreak came to Philadelphia. On Sept. 7, a group of 300 sailors arrived from Boston at the Philadelphia Navy Yard. The city, an industrial hub, was teeming with people even before the war. Housing was scarce, and factory workers lived in crowded tenements.

More sailors reported sick each day. When the Navy hospital ran out of beds, the Navy began using civilian hospitals. Soon, sailors and civilians began to die.

The Pennsylvania public health director, William Krusen, did nothing. He denied that influenza posed a serious threat to the city. Philadelphia’s public officials were hesitant to close schools, theaters and other meeting places.

The city had planned a war bonds parade on Sept. 28. Officials decided to go ahead with the parade against the advice of doctors.

“It was to be the greatest parade in Philadelphia history, with thousands marching in it and hundreds of thousands expected to watch it,” wrote Barry. Krusen, along with the city mayor and other officials, assured people there was no danger. The city’s newspapers printed nothing to contradict that notion.

Three days after the parade, the hospitals were overwhelmed. Every bed in the city’s 31 hospitals was filled. Three weeks after the parade, the death toll was at 4,500. Funeral homes couldn’t handle the bodies. Mass graves were dug, and people were buried without coffins.

Before the epidemic was over, Philadelphia had suffered through half a million cases of flu and at least 13,000 fatalities — the highest influenza death toll of any city in the U.S.

In Lisa Laden’s documentary film, “We Heard the Bells,” she records the story of an immigrant family in South Philly. Reba Haimovitz, a child at the time, recalls the atmosphere of dread.

“There was a sadness over the city. When you looked out, you saw hardly anybody walking around. People stayed in their houses, because they were afraid. If it killed you, it did it fast. I remember them telling me about a young neighbor. They watched from a window him coming home from work. And the next afternoon, they carried him out. He died.”

If decisive action was taken early, cities fared better. A historical documentary by Education World contrasts Philadelphia with San Francisco: “While Philadelphia’s government was still denying there was a problem, San Francisco authorities were distributing 100,000 face masks. Police enforced the face mask rule at gunpoint.”

The first wave had spared San Francisco, and William Hassler, chief of the city’s Board of Health, took strong preventive measures before the second wave struck. Naval bases were quarantined, schools closed and the public educated about hand washing and hygiene. The city was divided into districts, with each district having its own medical team and supplies.

This organized response worked, and the city fared better than Philadelphia and other East Coast cities. San Francisco would end with a reported 23,000 cases and 2,100 deaths. Unfortunately, the third wave brought the flu back to the city, but the effects were far less severe.

The Sedition Act

Functioning societies require reliable information, especially in times of crisis. People in 1918, facing a fearful and uncertain threat, were lied to by officials, and had no means of getting the truth.

Because of the war, newspapers were pressured by governments not to print anything that might hurt morale. Many complied and whitewashed their coverage of the flu epidemic.

President Woodrow Wilson was able to get the Sedition Act of 1918 passed through Congress. The Sedition Act covered a broad range of offenses, and made it a crime punishable by 20 years in jail to “utter, print, write or publish any disloyal, profane, scurrilous, or abusive language about the government of the United States.”

Free speech is often the first casualty in times of war. If the greatest weapons against a pandemic are truth and transparency, then government officials and the press failed the public.

That’s how the disease came to be called the Spanish flu. Spain was neutral during the war, and when the outbreak hit Spain, reports were shared openly by the Spanish wire news service. America and other allied countries being kept in the dark on their own casualties assumed Spain was where the outbreak originated.

Congress repealed the Sedition Act in 1920, after both war and epidemic had ended.

COVID-19 and change

In 2018, Barry wrote a new afterward to his book for the 100th anniversary of the 1918 epidemic. He noted that if a new virus caused a 1918-like pandemic today, modern medicine could likely prevent half or more of the fatalities. Antibiotics, for example, would significantly reduce the number of deaths from secondary bacterial infections.

But he noted that “other issues exist that could moot many medical advances.” Hospitals have gotten more efficient by cutting costs — including beds. “On a per capita basis the United States has far fewer hospital beds than a few decades ago,” he wrote. Similarly, hospitals only keep enough respirators on hand for typical use. During a regular flu season, respirator use can approach 100 percent at many hospitals.

A sudden influx of very sick patients could overwhelm medical facilities. This is particularly true of states with a lot of rural hospitals, such as West Virginia.

In recent years, the emergence of the H5N1, H1N1 (related to the Spanish flu pathogen) and West Nile viruses was a warning, a test run. Researchers and government agencies took notice; West Nile, in particular, received a lot of attention.

But events move on. New governments come in with different priorities, different agendas. And now, the arrival and spread of the COVID-19 virus has changed modern life for the foreseeable future.

The U.S. has struggled to deal with the COVID-19 crisis. Spotty testing capability, shortages of masks and other personal protection equipment for medical workers, the faltering efforts to get more ventilators in hospitals — these issues have laid bare the fragility of the modern health care system.

But even so, medical science is infinitely better than in 1918. No one knew what caused the Spanish flu, and no one knew how to stop it. The germ theory was still new at the time (and not universally accepted). It took another 20 years for the role of viruses to be discovered.

If you got sick, there was no treatment. No antibiotics. No antivirals. Even in cities, hospitals didn’t have intensive care units. There weren’t enough nurses to meet the demand for care (although the American Red Cross worked heroically to fix that).

The only thing that worked was isolation, but too many officials were slow to order quarantines. By the time steam shovels were digging mass graves, it was too late for social distancing.

Lessons learned — or not?

In a recent interview with David Rubenstein for a National Book Festival presentation, Barry was asked what the history of the 1918 flu can teach us about the coronavirus.

The first lesson, he said, was that “the best way to handle an outbreak like that was for leadership to tell the truth.” The second lesson was “take action early.”

Neither happened in 1918. As horrible as the disease was, public officials made things worse by lying to the public, by making false assurances and by failing to take aggressive measures.

Ultimately, the Spanish flu pandemic changed the way scientists did research, changed the way medicine was practiced, and changed the way public officials handled pandemics.

At the conclusion of his book, Barry returns again to the themes of fear and trust:

“Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best.

“A leader must make whatever horror exists concrete. Only then will people be able to break it apart.”

Robert Saunders can be reached at