A Flu that Left a Hundred Million Dead

by Étienne Forestier-Peyrat
, 28 May 2020

Caught between the great epidemics of the past and the horrors of the world war, the 1918-1919 flu has long struggled to be recognized as a major health disaster. Reactions to the current epidemic testify to the persistence of denial in the face of troubling outbreaks of disease.

A few days before dying of the scourge that ravaged the world in 1918, Guillaume Apollinaire still found the strength to wax ironical about this “high society” flu, which the Spanish king Alphonse XIII had contracted: “Without yet crying victory, one can now glimpse an end of the epidemic… The Spanish flu will no longer be anything but a bad memory.” Weakened by a war injury, the poet passed away on November 9, as people began to succumb in large numbers to what became known, in the French and English-speaking press, as the “Spanish flu.” The term was hardly appropriate: though Spain suffered a virulent outbreak in the spring of 1918, the flu’s origins probably lay elsewhere, notably in the American Midwest. A zoonosis—that is, an infectious disease transmitted from vertebrate animals (in particular birds, pigs, and cattle) to humans, the 1918-1919 flu already belonged to the H1N1 type, which became famous in 2009 due to an outbreak that provoked global concern. [1]

Globalization’s driving forces and the distinct context of the First World War’s end explain its rapid circulation, over nearly two years, across the planet, making it the first genuinely global pandemic and leaving between 50 and 100 million victims in its wake.

The 2018 book that the historian of health Freddy Vinet devotes to this flu reexamines the stakes of a disease whose scale even contemporaries struggled to grasp. He emphasizes the difficult of “thinking the flu,” even as the Pasteurian revolution seemed to have conquered great epidemics and the global conflict had focused attention on mass bloodletting. The incredulity was all the greater because, while it hit social classes and ethnic groups very unequally, it struck down what remained of a younger generation already devastated by the war.

Three deadly waves

If the flu was disorienting, it was because it struck in three waves, the chronology of which varied slightly by world region. From April to July 1918, the first wave was associated in France with high morbidity, notably in garrisons, but the death rate remained relatively low. The sense of a summer resurge was misleading, as a second wave began in August-September, when deadly pulmonary infections increased. Up to a third of the population was afflicted by the disease, as many of the youngest patients died. Morality reached its peak among 25- to 34-year-olds, eliciting doctors’ concern. At the beginning of 1919, a third wave brought a new round of high morbidity, though with fewer deaths.

In addition to his global analysis of the pandemic, Vinet emphasizes how, in local contexts, infection functioned by “bursts.” In rural France, the epidemic rarely hit the same village for more than two weeks and only established a lasting presence in large cities (p. 34-35). Suddenly, military units were incapacitated, like the British navy, which in May 1918 had to reduce its number of sorties as 10% of personnel was indisposed. These eruptions overwhelmed health services, whose limits had already been tested by the war, as a member of the French parliament noted on February 18, 1919: “There are currently a large number of sick people with influenza-pneumonia; many are dying due to lack of care, lack of doctors” (p. 32).

Just as important as the aspects that the historian records are those that elude him, due to lack of sources or attention. Newspapers reported that President Wilson and Clemenceau were briefly bedridden, but we know little about domestic servants in western Paris, who contributed significantly to the surplus mortality in these comfortable neighborhoods. Even less is known about the working classes and African Americans in the United States (p. 100-102). As for Asians—particularly Indians—and Middle-Easterners, their fate is for the most part unknown, which explains variations in the epidemic’s toll. One figure conveys this discrepancy: whereas the flue killed 240,000 in France, it seems likely that there were over 4 million deaths on the island of Java, whose population is roughly comparable (p. 71-72).

Social disarray…

Beyond these geographic variations, the book demonstrates the flu’s unfortunate timing, from the standpoint of canonical medical history. The latter has long tended to present the Pasteurian revolution as the beginning of the triumphant march against infectious disease, bringing to an end the “white fear” that cholera, for instance, had inspired during the nineteenth century. [2] Of course, the plague still struck Manchuria dramatically in 1910-1911, and the flu itself had a virulent outbreak in 1889-1890, but the disease no longer seemed in keeping with the times. Doctors were bewildered, feeding the population’s erratic quest for miracle cures.

The retrospective gaze does not dispel all uncertainty. We now have a better description of the virus type and its contagious properties, but issues relating to the virus’ possible mutations and the role of environmental factors have not met with consensus. While the contagion process was already known at the time, the search for climatic and meteorological factors continued to preoccupy contemporaries, even as discussions about predispositions and comorbidity grew. Thus the pneumococci that caused pulmonary infections attacked individuals who were already weakened, for example, due exposure to wartime gas.

The contradictory signals displayed by the epidemic during its various waves added themselves to this confusion and explain doctors’ initially reassuring words. Thus the Journal de médecine et de chirurgie pratique (Journal of Medicine and Practical Surgery) could write on September 10, 1918, on the eve of the second wave: “The flu is not a particularly serious affliction; quarantine and disinfection measures at borders, which can apply to other diseases, would in this case be unjustified and, moreover, useless.” (p. 113). A few weeks later, the tone had completely changed.

…and “government boasting”

Censorship and self-censorship in the belligerent countries explain why it was not until the fall of 1918 that anyone dared grant any importance to the flu. Even military doctors, who were on the front line of alertness and whose reports are crucial to analyzing the epidemic, could not neglect the war effort. By contrast, the Spanish press extensively discussed the epidemic, giving credence to the notion that the virus was Spanish in origin. This confusion reflects the difficulty of locating the epidemic’s circuits in a globalized economy: the age of “Eastern plagues,” which could be contained by a mixture of targeted quarantines and sanitation measures, had passed. [3]

Thus it is hardly surprising that the measures taken by authorities in different countries struggled to address this medical catastrophe. There was no desire to close borders, so as not to block war supplies, nor did anyone dare to take too drastic measures against economic, cultural, and social life, lest they aggravate the war’s economic consequences. Prophylactic measures were weakly applied at the national level, and local authorities were given the “disagreeable privilege … of taking unpopular measures to control [the disease’s] propagation as much as possible” (p. 112).

This weak reaction is a reminder that political, diplomatic, and social factors often weighed more heavily than medical and health considerations in the measures taken. The lack of medical and nursing personnel, as well as shortages in supplies, hindered satisfactory management of the sick in all affected areas. At the same time, authorities waffled over whether to close schools, entertainment venues, and gathering places, and the population’s embrace of prophylactic measures was minimal. Ultimately, it was rising absenteeism that created pressures to reconsider operating rules, as in the Paris subway, which experienced a steep decline in use in October 1918.

Compared to the health disaster it constituted on a global scale, the great flu left but a slim trace in collective memory, due to its failure to “resonate” with the broader twentieth century: while its name is legendary, its underlying realities have disappeared. Its disparate chronology does not lend itself to canonical descriptions of great catastrophes and it is ultimately its banality, making it hard to distinguish from seasonal flu, that has resulted in the “invisible enemy’s” effacement behind older great epidemics. [4] Besides medical history’s minimal interest in this event before the 1980s, the book rightly recalls the guilty conscience of a generation that preferred to glorify the death of its children who died in the war, even as it hid “its negligence and powerlessness during this episode” (p. 178-179).

But could this episode’s uncertain status in collective memory not be explained by its political dimension? Vinet’s book echoes questions about the ability of liberal regimes to respond to epidemiological challenges, in the same vein as the American historian Alfred W. Crosby, who noted: “During an epidemic, democracy can be a very dangerous form of government.” [5] The French people’s insouciance in 1918 mirrors, in a troubling way, the disorientation displayed in early 2020.

While COVID-19 reminds us that “the return of epidemics” [6] concerns Europe as much as the rest of the world, despite considerable progress in medicine and virology, it is primarily an occasion for testing the capacity of societies to respond to a collective and intuitively elusive threat. It is precisely the enormous discrepancy in “epidemiological cultures” (p. 204) informed by recent and more distant history that has been revealed in this spring in which, once again, our world has the flu.

[1] See https://laviedesidees.fr/La-grippe-une-catastrophe-mondiale.html.

[2] Patrice Bourdelais, Histoire du choléra en France, 1832-1854. Une peur bleue, Paris, Payot, 1987.

[3] Daniel Panzac, Quarantaines et lazarets: l’Europe et la peste d’Orient, XVIIe-XXe siècles, Aix-en-Provence, Edisud, 1986; Sylvia Chiffoleau, Genèse de la santé publique internationale: de la peste d’Orient à l’OMS, Rennes-Beyrouth, PUR-IFPO, 2012.

[4] Carlo M. Cipolla, Contre un ennemi invisible. Épidémies et structures sanitaires en Italie de la Renaissance au XVIIe siècle, Paris, Balland, 1992.

[5] Crosby contrasts the example of American Samoa, which under the authoritarian rule of Governor Poyer imposed a drastic quarantine and escaped the epidemic to the laissez-faire approach followed in neighboring Western Samoa, which was under New Zealand’s tutelage and where 22% of the population perished. Cited p. 124, referring to Crosby’s classic text, America’s Forgotten Pandemic. The Influenza of 1918, Cambridge, Cambridge University Press, 2003 (1989).

[6] See https://laviedesidees.fr/Le-retour-des-epidemies.html.