The Spanish Influenza 1918-1920: Devastating for Public Health

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Table of Contents

Introduction
Summary
Government and Health Organizations Response
Role of Influencing Factors
Conclusion
References

Introduction

In 1918, the world saw the spread of one of the deadliest global pandemics in history known as the Spanish Influenza. The H1N1 virus was unique as it predominately affected young individuals. The origin of the virus remains unknown to this day, but many believe it to have originated in America, eventually spreading to Europe and Asia (Reid et al., 1999). Due to the lack of vaccinations and effective treatments, the number of flu cases skyrocketed, resulting in devastating public health consequences.

To address this, pandemic health and government officials had to take unprecedented measures and develop new means of containing the inter-community spread of the virus. Public authorities attempted to prevent the transmission of the influenza virus by enforcing quarantine, public education, and the creation of new regulations for public spaces.

Summary

The Spanish Influenza was a global pandemic lasting from 1918 up to 1920. It infected at least 500 million people, causing acute illness for 25-30% of the world’s population, resulting in an estimated 40 million deaths (Taubenberger, 2006). Sequencing the virus has been a challenging undertaking by several researchers during the 20th century. Eventually, the technology helped identify that the H1N1 influenza virus caused the Spanish Influenza with genes derived from avian-like and swine influenza virus strains. The specific 1918 H1N1 genome was unique, resulting in a mortality rate of 5-20% higher than usual for influenza, due to a higher proportion of complications of infection in the respiratory tract rather than other organ systems (Taubenberger, 2006).

The infected experienced typical flu symptoms of fatigue, fever, and chills, but as the disease became more deadly, victims began to die in a matter of days, if not hours, with observed cyanosis and fluid filling the lungs. An unusually young age group was most affected by the mortality rate, with many children and healthy young or middle-aged adults dying. Furthermore, waves of influenza activity exacerbated the public health problem, which resulted in three outbreaks in one year that is highly unusual (Taubenberger, 2006).

There are multiple hypotheses regarding the origin of the Spanish Influenza. Historians such as Alfred Crosby (2003) suggested the virus originated in Kansas, U.S.A. One of the first reported cases of the virus had been diagnosed on March 11, 1918, in Fort Riley, with unsanitary conditions leading to outbreaks in the city and later other military installments in the United States. Later, researchers suggested that the Kansas outbreak was much milder, but the study suggested the virus still had North American origins with reassortment occurring in 1915 (Worobey et al., 2019).

Another hypothesis suggests that the source was in China since the country was one of the least affected by the pandemic, supposedly due to the already acquired immunity. Historians argued that the spread occurred through either Chinese immigration to the United States, eventually shifting to Europe, or due to thousands of Chinese laborers behind the frontlines in Europe. However, this theory also seems to have been disapproved, suggesting the epidemic was circulating Europe months if not years before the pandemic began (Worobey et al., 2019).

A major troop camp and hospital for the U.K. in Étaples, France is also considered, if not the origin, then an epicenter of the outbreak. The overcrowded location was ideal for the spread of the virus, and more than 100,000 soldiers passed through the camp as well as having live poultry and pigs for provisions (Worobey et al., 2019). Historians believe that the virus was circulating in European armies, with Étaples serving as the epicenter of the further outbreak in Europe (Worobey et al., 2019).

In either of these scenarios, one of the critical factors of the outbreak was the ongoing World War I at the time, which created optimal conditions in war-torn cities and army installments for the spread of the virus. Furthermore, no matter if the virus originated in the U.S., Europe, or China, it was virally spread through the world most likely as a result of troop transportation and supply chains to the frontlines from virtually all regions of the globe (Erkoreka, 2009).

The first wave of the outbreak in the spring of 1918 was seasonal benign influenza, and only by spreading to the frontlines of WWI, it became a much viral and devastating disease by the fall of 1918, inextricably linked to the soldiers and their conditions. The combination of an international mix of populations in Western Europe, poor quality of life and infrastructure, destruction of war, and numerous other injuries and corpse decay were human factors that may have contributed to transmission. Ecological factors included climate and exposure to elements, as well as an agglomeration of humans contacting with animals, and each other contributed to the extremely high virulence of the Spanish Influenza (Erkoreka, 2009).

Government and Health Organizations Response

At the time, medicine in its present form was only beginning to develop, encouraged by World War I. There were no vaccines and lab tests, with governments and healthcare facilities relying on observations and autopsies to determine the disease and eventual cause of death (Barry, 2020). Meanwhile, government officials had to utilize non-pharmaceutical interventions to manage the disease and prevent transmission, such as imposing quarantine and limits on public gatherings. In general, cities experienced worse outbreaks than rural areas, and there were notable differences at times between infection and mortality rates in various cities (Strochlic & Champine, 2020).

The death rate of St. Louis (385 per 100,000) was half that of Philadelphia (807 per 100,000), one of the hardest-hit cities of North America. American cities responded with restrictions rapidly. New York City, having reacted earliest and with most stringent methods of virtually closing its borders, imposing mandatory quarantines, and regulating strict closures and controls for public gatherings, had one of the lowest mortality rates in the world (Strochlic & Champine, 2020).

Cities that implemented preventive measures early on had up to 50% lower mortality rates than those that did so later or not at all. Furthermore, statistics show that early relaxation of intervention measures could lead to secondary waves of outbreaks and relapses of a stabilizing city, as occurred in St. Louis that relaxed rules after two months (Strochlic & Champine, 2020).

The public health response implemented by New York City will be discussed in this paper as one of the most successful locales to mitigate the 1918 pandemic. NYC approached the epidemic by taking advantage of its robust public health infrastructure, which helped prevent the spread of contagion and increase disease surveillance capacities alongside a large-scale health education campaign (Aimone, 2010).

The city had some experience with epidemics such as tuberculosis in recent history at the time and suggested that public health infrastructure plays a critical role in shaping practices and policies during a health crisis. The city officials declared a modified maritime quarantine, almost a month before the first cases appeared in the city as well as partial land-based quarantine. For New York, one of the busiest seaports, this was significant (Aimone, 2010).

The city utilized its infrastructure by converting various gymnasia, armories, and other facilities into temporary hospitals for the duration of the epidemic. The surveillance capacity for new cases increased through stringent health inspections and physician reporting. The local health department increased its surveillance capacity by utilizing independent inspectors and nongovernmental organizations (Aimone, 2010).

New policies and regulations were explicitly developed for public places to ensure cleanliness. The city made sure to sterilize public infrastructure, such as water fountains. Meanwhiles, public places such as theaters remained open in order to reach a greater population with information about preventive methods. Still, they were forced to adhere to strict regulations and inspections to ensure sanitation (Aimone, 2010).

Other countries, such as Europe, Spain, and the U.K. often imposed similar measures. The rigidity and compliance with these regulations depended on the authority of local governments or health departments. Unfortunately, the measures had only mild effects due to lack of medical treatment and war-time censorship (Martini et al., 2019). These factors resulted in distrust for the government and actions it was implemented to control the pandemic (Martini et al., 2019).

Role of Influencing Factors

Socio-Cultural

Social factors played an important role regarding the transmission and response to the 1918 influenza pandemic. Similar to modern-day, social distancing was a persistent recommendation by governments around the world at the time. In combination with the strict measures described previously, health officials hoped it would reduce the spread of disease. Social and public health education was unusually prevalent in major cities such as New York, where posters and pamphlets were distributed. While schools remained open, children were educated about the disease and informed of safe health practices to prevent transmission.

Sanitary codes were put into place and enforced throughout American cities (Aimone, 2010). Fines were issued for citizens that did not follow social distancing guidelines and practiced dangerous behaviors such as spitting in public or coughing without covering their faces. Many wore handmade protective masks. New York also established 150 emergency districts that helped manage health service distribution and manage home care and case reporting. Business hours were regulated by the board of health timetables to prevent crowding in public transit and streets (Aimone, 2010).

Political

As discussed earlier, World War I was ongoing when the 1918 pandemic emerged. Governments strongly relied on both domestic economies turned towards war efforts as well as the well-being of their troops. Despite such prevalent death tolls of influenza, it is often overlooked in history in relation to that time. People had little to no understanding of disease and virus contagious. Meanwhile, governments in many places chose to hide or obstruct the fact that there was an ongoing pandemic in order not to upend the war effort (Martini et al., 2019). Governments imposed press censorship in most of the countries involved in WWI, such as Germany, the U.K., France, and the U.S.A.

In many locales, authorities refused to reveal epidemiological statistics and mortality rates, resulting in widespread mistrust of the government since populations were openly devastated by the disease. The 1918 flu pandemic has got its name, the “Spanish Influenza,” due to significant press coverage in Spain which was neutral in the war and did not instill censorship (Martini et al., 2019). Moreover, Spain arguably was taking the most aggressive actions in containing the pathogen (Martini et al., 2019).

Healthcare and Medical

People knew very little about influenza at the time, and many scientists accepted that the Pfeiffer’s bacillus bacteria were the cause. Germ theory by Robert Koch, based on the findings of the French biologist Louis Pasteur in the 1850s, made a connection that disease was caused by micro-organisms (Tognotti, 2003). However, this theory was highly controversial at the time and had no proof. Richard Pfeiffer identified the pathogenic influenza agent in a bacterium, Haemophilus influenza. Researchers attempted to test if the Pfeiffer’s bacillus was the cause of Spanish Influenza. Since they were unable to reject the theory, it remains unknown whether the bacterium had any role (Tognotti, 2003).

However, viruses, unlike bacteria, could not be seen through an optical microscope, although some research existed regarding their role in disease, yet nobody suspected it could be causing the flu. The modern genome classification of the remaining samples showed it was the H1N1 virus. Even so, antibiotics were not discovered until almost a decade later to treat infections accompanying the flu, and hospitals had limited treatment options (Kassraie, 2020).

Significance

In light of the ongoing COVID-19 pandemic, the Spanish Influenza has become a common reference point as the most recent historical pandemic of such global magnitude, drawing numerous parallels. Response by authorities tends to follow similar patterns to identify and prevent transmission. During the infamous bubonic plague in the Middle Ages, patients were put in isolation and encouraged to take precautions. However, there was a large lack of knowledge and awareness about the transmission that resulted in at least a third of the European population being wiped out and continuing pockets of outbreaks for close to 2 centuries (Hsieh et al., 2006).

As evident, during the Spanish Influenza pandemic, governments adopted similar measures with more improved recommendations and stricter enforcement that were based on knowledge of medical science at the time.

Nevertheless, there are eerie parallels between the current COVID-19 pandemic and the Spanish Influenza. In 2020, many of the same approaches help prevent the spread of the virus in a global pandemic (WHO, 2020). Similar to other pandemics, the COVID-19 outbreak sees identical measures. Once the virus began to show spread, areas affected by the virus, especially its origin and epicenter of Wuhan, China, were put into lockdown.

All people, except for those who had the essential professions, were ordered to stay at home. The sick, once tested and identified, were put into isolation (BBC, 2020). To enforce these measures, many countries have increased surveillance and law enforcement capacity. Public events are canceled to minimize person-to-person contact in public gatherings (BBC, 2020). Notably, many countries took these strong measures to prevent transmission too late, when community spread has already been initiated. This resulted in several new epicenters of disease arising and a tremendous peak in cases.

Conclusion

Evidently, approaches used by authorities largely remain the same as the Spanish Influenza, with the emphasis being put on modern medicine and vaccination research to prevent widespread infection and deaths. Public authorities, both in 1918 and today, attempt to prevent the transmission of the influenza virus by enforcing quarantine, public education, and the creation of new regulations for public spaces. Since the risk of influenza and future pandemics is expected, governments and health organizations should invest in effective influenza vaccines and medications as well as take a more competent approach in recognizing outbreaks and limiting their transmission (Hsieh et al., 2006).

One of the main lessons, according to historian John Barry, is that in a pandemic, one has to tell the truth in a public health setting, something that governments have failed to do in the current crisis (Barry, 2020). The COVID-19 outbreak is similar in many ways to the Spanish Influenza, and once the disease passes, there will be significant research and reviews on the ongoing situation. It is necessary to learn from historic, albeit devastating events such as these to develop new methods of response and management, particularly in a modern globalized world.

References

Aimone, F. (2010). The 1918 influenza epidemic in New York City: A review of the public health response. Public Health Reports (1974-), 125, 71-79. Web.

Barry, J. M. (2020). The single most important lesson from the 1918 influenza. The New York Times. Web.

BBC. (2020). Coronavirus: How are lockdowns and other measures being enforced?BBC News. Web.

Crosby, A. W. (2003). America’s forgotten pandemic: The influenza of 1918. Cambridge University Press.

Erkoreka, A. (2009). Origins of the Spanish Influenza pandemic (1918-1920) and its relation to the First World War. Journal of Molecular and Genetic Medicine, 3(2). Web.

Hsieh, Y. C., Wu, T. Z., Liu, D. P., Shao, P. L., Chang, L. Y., Lu, C. Y., … Huang, L. M. (2006). Influenza pandemics: Past, present and future. Journal of the Formosan Medical Association, 105(1), 1-6. Web.

Kassraie, A. (2020). Spanish Flu: How America fought a pandemic a century ago. AARP. Web.

Martini, M., Gazzaniga, V., Bragazzi, N. L., & Barberis, I. (2019). The Spanish Influenza Pandemic: A lesson from history 100 years after 1918. Journal of Preventive Medicine and Hygiene, 60(1), E64–E67. Web.

Reid, A., Fanning, T., Hultin, J., & Taubenberger, J. (1999). Origin and evolution of the 1918 “Spanish” Influenza virus hemagglutinin gene. Proceedings of the National Academy of Sciences of the United States of America, 96(4), 1651-1656. Web.

Strochlic, N., & Champine, R.D. (2020). How some cities ‘flattened the curve’ during the 1918 flu pandemic. National Geographic. Web.

Taunbenberger, J. K. (2006). The origin and virulence of the 1918 “Spanish” influenza virus. Proceedings of the American Philosophical Society, 150(1), 86-112. Web.

Tognotti, E. (2003). Scientific triumphalism and learning from facts: Bacteriology and the “Spanish flu” challenge of 1918. Social History of Medicine, 16(1), 97–110. Web.

World Health Organization. (2020). Report of the WHO-China joint mission on coronavirus disease 2019. Web.

Worobey, M., Cox, J., & Gill, D. (2019). The origins of the great pandemic. Evolution, Medicine, and Public Health, 2019(1), 18–25. Web.

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