No killer haunted the 20th century with greater efficiency.
In the United States alone, at least 675,000 people died, more than the nation’s combined military casualties for World War I, World War II, the Korean War and the Vietnam War.
But even as our society recounted the grim battles from two world wars, felt the trauma of genocides and shared fears of nuclear annihilation, we let slip lessons from the influenza outbreak of 1918-1919, which stands as the deadliest wave of disease in recorded history.
Historians sometimes refer to it as the “forgotten pandemic.”
Now, as another pandemic unsettles the world, they say we have much to learn from the influenza outbreak that devastated humanity. From satellite images of mass graves in Iran, to accounts of racism against Chinese-Americans, to leaders hesitating to mandate social distancing, echoes of 1918 abound.
And for all the scientific and medical advances of the last 101 years, countries around the world are fighting COVID-19 with many of the same approaches our ancestors used, or failed to use, against influenza.
“Here we are, more than 100 years later, and we’re taking out the same old-fashioned public-health tools,” said Dr. Marian Moser Jones, a professor at the University of Maryland School of Public Health who has written on the influenza pandemic.
In 1918, cities that implemented social distancing policies quickly and maintained them with discipline — like St. Louis — wound up with fewer deaths from influenza. Those are the same sacrifices now called for by Maryland Gov. Larry Hogan and leaders across the world.
The final months of 1918 were among the most terrifying in U.S. and recent world history. A global population still coping with the carnage of World War I watched helplessly as the mutating flu virus ravaged cities with little warning and left piles of bodies within a few days of striking.
That world differed from ours in many respects, with no antibiotics, computers, drive-through restaurants or widespread commercial aviation. But it was not so different in the ways it facilitated the spread of a highly contagious virus.
The flu, relatively mild in its first wave in spring 1918, moved with soldiers and sailors as they traveled the country and world in preparation for the last battles of World War I. It became known as Spanish flu, not because the virus originated in Spain but because it was written about honestly there in a year when many other countries were practicing wartime censorship.
The disease struck children and the elderly but cut a swath through previously healthy adults, ages 20-40. Doctors encountered critically ill patients with blood streaming from their nostrils, ribs fractured by violent coughs and skin turned blue by respiratory failure.
Wagons made grim processions up and down city streets, carrying the afflicted from their homes to mass graves. A sloping section of New Cathedral Cemetery in West Baltimore became known as Flu Hill. Church bells tolled continuously to honor the dead, while the living swarmed any physician in sight, desperately seeking answers.
With resources already strained by the war effort, Baltimore faced critical shortages of firefighters, police officers, doctors, nurses, postal workers, garbage collectors and phone operators as the virus sickened a quarter of the city’s almost 600,000 residents, according to a study by Johns Hopkins medical anthropologist Monica Schoch-Spana.
More than 3,000 Baltimoreans died just in October. The news was even worse in Washington, Philadelphia, Boston, Pittsburgh and New Orleans.
At least 50 million and possibly many more died worldwide at a time when the global population was less than a quarter of its current 7.7 billion. The death toll for Maryland is unclear, though a report from the Baltimore Health Department placed the city’s total at 4,125 for 1918.
Schoch-Spana, who studied the pandemic on a neighborhood level in Baltimore, found quieter impacts that stretched far wider and longer than the wave of gruesome deaths. Families were permanently traumatized by the losses of children and parents. Doctors and nurses were overwhelmed to the point that some never returned to previous levels of productivity. Even those people who escaped sickness felt isolated and shaken as they were cut off from societal pillars such as school and church.
“One intervention that caused major angst was the closure of places of worship,” Schoch-Spana said. “Many people said, ‘You are taking away our source of solace at the very moment when we need it the most.’ People were hurting. It isn’t just about disease. It’s about human suffering in the broadest of senses.”
When the deadly second wave hit in September 1918, patients quickly overwhelmed the available beds and medical staff at overcrowded bases. Cities took insufficient precautions as leaders played down the threat.
Even as the surging pandemic struck military installations at Camp Meade and Fort McHenry, Baltimore health commissioner John D. Blake dismissed it as “the same old influenza that the physicians have recognized and treated for many years,” according to a 2006 retrospective in The Baltimore Sun.
Though many doctors criticized him, Blake believed the panic he might cause by banning public gatherings would be worse than the flu itself, according to a digital encyclopedia of the pandemic assembled by the University of Michigan Center for the History of Medicine. Public schools closed over Blake’s objections before he finally banned public gatherings on Oct. 9. By then, two weeks after the first influenza cases emerged at Camp Meade, the city’s hospitals were overwhelmed and its businesses struggling to operate.
'Places that isolated ... survived’
The virus was hard on immigrant communities in East Baltimore and on the city’s African American population, who were refused treatment at most hospitals. The city’s main African American cemetery, Mt. Auburn, ran out of burial plots and needed help from a volunteer corps of black soldiers to dig fresh graves, the University of Michigan study found.
Because COVID-19 is moving more slowly through the population, with a longer incubation period, it gives governments more time to implement dramatic social distancing policies, said John Barry, who wrote “The Great Influenza,” an acclaimed popular history of the 1918 pandemic.
Nonetheless, Barry’s words about the 1918 outbreak read as a harrowing warning to those who’ve crowded into beaches, bars and other public spaces as COVID-19 has swept the country.
“No medicine and none of the vaccines developed then could prevent influenza. ... Only preventing exposure to the virus could,” Barry writes. “Places that isolated themselves survived.
“The closing orders that most cities issued could not prevent exposure; they were not extreme enough. Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer.”
The devastation did spur leaps in medicine, spawning its share of heroes. Barry’s book tells the stories of scientific-minded physicians either trained or inspired by Dr. William Welch, the first dean of the Johns Hopkins School of Medicine and founder of what is now the Bloomberg School of Public Health. This small band of doctors and researchers did not defeat the virus, but their numbers grew exponentially in its wake, and their work would lead to greater understanding of immunology and genetics.
Wade Hampton Frost, founding chair of the epidemiology department at Hopkins’ School of Public Health, developed a chronology of the pandemic’s spread from the U.S. — Barry traces it to Haskell County, Kansas, though medical historians have long debated its exact origin point — to Europe and Asia. Frost’s work became the model for mapping subsequent outbreaks.
'Tell the truth’
The worst of the influenza pandemic was condensed to a six-month period. In Baltimore, Blake lifted restrictions on stores and churches by the end of October, and schools reopened in early November.
Residents still succumbed to the virus but in far smaller numbers. The crisis persisted elsewhere, with violent flare-ups in cities such as Savannah, Georgia, Phoenix and San Francisco. A particularly deadly wave struck New York in early 1920. That’s one reason why so many researchers have warned us to expect secondary waves of COVID-19 after initial restrictions have been loosened.
But populations around the world developed immunity, and the influenza virus mutated to become less deadly.
People moved on. They wanted to forget.
“Unless you had a family member who died in it, even if you did, it was buried,” said Jones, from the University of Maryland. “With the world wars, you have these stories you can tell your grandchildren about dad who came back from the Battle of the Bulge or Normandy, mom who was moonlighting with the Red Cross or working at a factory.
"But with a pandemic ... it’s dreadful. They’re not going to bring it home and talk about all of their wrenching stories.”
Now, however, scientists and historians say there are stories beyond the medical ones — tales of the worst in humanity and the best — that are worth remembering as society confronts COVID-19.
The pandemic intensified nationalist animosities, with rumors suggesting that Germany had unleashed germ warfare. Marylanders fretted that a German nurse had started the initial outbreak at Camp Meade, and some referred to influenza as a “Hun of a disease.” Misinformation was rampant; newspapers ran advertisements for fraudulent cures next to articles quoting medical professionals. Public officials played down the danger of the virus in hopes of preventing panic.
“The No. 1 lesson that came out of 1918?” said author Barry. “Tell the truth."
He sees similarities today: ill-informed social media posts, accounts of racism against Chinese Americans, leaders hesitating to mandate social distancing. He noted inconsistent messaging from the White House about the severity of the coronavirus pandemic, arguing that the nation’s response could be undermined by a lack of credible leadership.
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"If 30 percent of the population ignores public health recommendations,” he said, “then the virus will not be stopped.”
Looking forward, Hopkins’ Schoch-Spana recently prepared an article for Scientific American in which she advocates a response system to address the psychological and social damage rippling from the coronavirus pandemic.
But she also sounded a positive note about the resilience of humanity, stemming from her study of 1918-1919.
“People stood up,” she said. “People loaned their cars out so visiting nurses wouldn’t have to rely on the trolleys. You had people making custard and broth and bringing it to people who were convalescing.”
Those efforts are echoed in current reports of neighbors fetching groceries for the elderly, of workers from unrelated industries sewing masks, of scientists from around the world collaborating on a vaccine.
Another Hopkins physician and medical historian, Dr. Jeremy Greene, has taken heart from finding such examples of humanity in century-old writings from the influenza pandemic.
“When we look at the diaries and letters of people who found their lives upended in a time of great anxiety, who were not sure they were going to see their loved ones again, we see reflected some of our own heightened anxieties and despair," he said. "But also day-by-day forms of vitality and finding ways of maintaining not just individual hope, but communities and collectives.”