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Spanish Flu

By: History.com Editors

Updated: May 10, 2023 | Original: October 12, 2010

The Spanish flu pandemic of 1918-1919 was the deadliest pandemic in world history, infecting some 500 million people across the globe—roughly one-third of the population—and causing up to 50 million deaths, including some 675,000 deaths in the United States alone. The disease, caused by a new variant of the influenza virus, was spread in part by troop movements during World War I . Though the flu pandemic hit much of Europe during the war, news reports from Spain weren’t subject to wartime censorship, so the misnomer “Spanish flu” entered common usage. With no vaccines or effective treatments, the pandemic caused massive social disruption: Schools, theaters, churches and businesses were forced to close, citizens were ordered to wear masks and bodies piled up in makeshift morgues before the virus ended its deadly worldwide march in early 1920.

What Is the Flu?

Influenza , or flu, is a virus that attacks the respiratory system. The flu virus is highly contagious: When an infected person coughs, sneezes or talks, respiratory droplets are generated and transmitted into the air, and can then can be inhaled by anyone nearby.

Additionally, a person who touches something with the virus on it and then touches his or her mouth, eyes or nose can become infected.

Did you know? During the flu pandemic of 1918, the New York City health commissioner tried to slow the transmission of the flu by ordering businesses to open and close on staggered shifts to avoid overcrowding on the subways.

Flu outbreaks happen every year and vary in severity, depending in part on what type of virus is spreading. (Flu viruses can rapidly mutate.)

In the United States, “flu season” generally runs from late fall into spring. In a typical year, more than 200,000 Americans are hospitalized for flu-related complications, and over the past three decades, there have been some 3,000 to 49,000 flu-related U.S. deaths annually, according to the Centers for Disease Control and Prevention .

Young children, people over age 65, pregnant women and people with certain medical conditions, such as asthma, diabetes or heart disease, face a higher risk of flu-related complications, including pneumonia, ear and sinus infections and bronchitis.

A flu pandemic, such as the one in 1918, occurs when an especially virulent new influenza strain for which there’s little or no immunity appears and spreads quickly from person to person around the globe.

Spanish Flu Symptoms

The first wave of the 1918 pandemic occurred in the spring and was generally mild. The sick, who experienced such typical flu symptoms as chills, fever and fatigue, usually recovered after several days, and the number of reported deaths was low.

However, a second, highly contagious wave of influenza appeared with a vengeance in the fall of that same year. Victims died within hours or days of developing symptoms, their skin turning blue and their lungs filling with fluid that caused them to suffocate. In just one year, 1918, the average life expectancy in America plummeted by a dozen years.

What Caused the Spanish Flu?

It’s unknown exactly where the particular strain of influenza that caused the pandemic came from; however, the 1918 flu was first observed in Europe, America and areas of Asia before spreading to almost every other part of the planet within a matter of months.

Despite the fact that the 1918 flu wasn’t isolated to one place, it became known around the world as the Spanish flu, as Spain was hit hard by the disease and was not subject to the wartime news blackouts that affected other European countries. (Even Spain's king, Alfonso XIII, reportedly contracted the flu.)

One unusual aspect of the 1918 flu was that it struck down many previously healthy, young people—a group normally resistant to this type of infectious illness—including a number of World War I servicemen.

In fact, more U.S. soldiers died from the 1918 flu than were killed in battle during the war. Forty percent of the U.S. Navy was hit with the flu, while 36 percent of the Army became ill, and troops moving around the world in crowded ships and trains helped to spread the killer virus.

Although the death toll attributed to the Spanish flu is often estimated at 20 million to 50 million victims worldwide, other estimates run as high as 100 million victims —around 3 percent of the world’s population.  The exact numbers are impossible to know due to a lack of medical record-keeping in many places.

What is known, however, is that few locations were immune to the 1918 flu—in America, victims ranged from residents of major cities to those of remote Alaskan communities. Even President Woodrow Wilson reportedly contracted the flu in early 1919 while negotiating the Treaty of Versailles , which ended World War I.

Why Was The Spanish Flu Called The Spanish Flu?

The Spanish Flu did not originate in Spain , though news coverage of it did. During World War I, Spain was a neutral country with free media that covered the outbreak from the start, first reporting on it in Madrid in late May of 1918. Meanwhile, Allied countries and the Central Powers had wartime censors who covered up news of the flu to keep morale high. Because Spanish news sources were the only ones reporting on the flu, many believed it originated there (the Spanish, meanwhile, believed the virus came from France and called it the “French Flu.”)

Where Did The Spanish Flu Come From?

Scientists still do not know for sure where the Spanish Flu originated, though theories point to France, China, Britain, or the United States, where the first known case was reported at Camp Funston in Fort Riley, Kansas, on March 11, 1918.

Some believe infected soldiers spread the disease to other military camps across the country, then brought it overseas. In March 1918, 84,000 American soldiers headed across the Atlantic and were followed by 118,000 more the following month.

Fighting the Spanish Flu

When the 1918 flu hit, doctors and scientists were unsure what caused it or how to treat it. Unlike today, there were no effective vaccines or antivirals, drugs that treat the flu. (The first licensed flu vaccine appeared in America in the 1940s. By the following decade, vaccine manufacturers could routinely produce vaccines that would help control and prevent future pandemics.)

Complicating matters was the fact that World War I had left parts of America with a shortage of physicians and other health workers. And of the available medical personnel in the U.S., many came down with the flu themselves.

Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

Officials in some communities imposed quarantines, ordered citizens to wear masks and shut down public places, including schools, churches and theaters. People were advised to avoid shaking hands and to stay indoors, libraries put a halt on lending books and regulations were passed banning spitting.

According to The New York Times , during the pandemic, Boy Scouts in New York City approached people they’d seen spitting on the street and gave them cards that read: “You are in violation of the Sanitary Code.”

Aspirin Poisoning and the Flu

With no cure for the flu, many doctors prescribed medication that they felt would alleviate symptoms… including aspirin , which had been trademarked by Bayer in 1899—a patent that expired in 1917, meaning new companies were able to produce the drug during the Spanish Flu epidemic. 

Before the spike in deaths attributed to the Spanish Flu in 1918, the U.S. Surgeon General, Navy and the Journal of the American Medical Association  had all recommended the use of aspirin. Medical professionals advised patients to take up to 30 grams per day, a dose now known to be toxic. (For comparison’s sake, the medical consensus today is that doses above four grams are unsafe.) Symptoms of aspirin poisoning include hyperventilation and pulmonary edema, or the buildup of fluid in the lungs, and it’s now believed that many of the October deaths were actually caused or hastened by aspirin poisoning.

The Flu Takes Heavy Toll on Society

The flu took a heavy human toll, wiping out entire families and leaving countless widows and orphans in its wake. Funeral parlors were overwhelmed and bodies piled up. Many people had to dig graves for their own family members.

The flu was also detrimental to the economy. In the United States, businesses were forced to shut down because so many employees were sick. Basic services such as mail delivery and garbage collection were hindered due to flu-stricken workers.

In some places there weren’t enough farm workers to harvest crops. Even state and local health departments closed for business, hampering efforts to chronicle the spread of the 1918 flu and provide the public with answers about it.

How U.S. Cities Tried to Stop The 1918 Flu Pandemic

A devastating second wave of the Spanish Flu hit American shores in the summer of 1918, as returning soldiers infected with the disease spread it to the general population—especially in densely-crowded cities. Without a vaccine or approved treatment plan, it fell to local mayors and healthy officials to improvise plans to safeguard the safety of their citizens. With pressure to appear patriotic during wartime and with a censored media downplaying the disease’s spread, many made tragic decisions.

Philadelphia’s response was too little, too late. Dr. Wilmer Krusen, director of Public Health and Charities for the city, insisted mounting fatalities were not the “Spanish flu,” but rather just the normal flu. So on September 28, the city went forward with a Liberty Loan parade attended by tens of thousands of Philadelphians, spreading the disease like wildfire. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March 1919, over 15,000 citizens of Philadelphia had lost their lives.

St. Louis, Missouri, was different: Schools and movie theaters closed and public gatherings were banned. Consequently, the peak mortality rate in St. Louis was just one-eighth of Philadelphia’s death rate during the peak of the pandemic.

Citizens in San Francisco were fined $5—a significant sum at the time—if they were caught in public without masks and charged with disturbing the peace.

Spanish Flu Pandemic Ends

By the summer of 1919, the flu pandemic came to an end, as those that were infected either died or developed immunity.

Almost 90 years later, in 2008, researchers announced they’d discovered what made the 1918 flu so deadly: A group of three genes enabled the virus to weaken a victim’s bronchial tubes and lungs and clear the way for bacterial pneumonia.

Since 1918, there have been several other influenza pandemics, although none as deadly. A flu pandemic from 1957 to 1958 killed around 2 million people worldwide, including some 70,000 people in the United States, and a pandemic from 1968 to 1969 killed approximately 1 million people, including some 34,000 Americans.

More than 12,000 Americans perished during the H1N1 (or “swine flu”) pandemic that occurred from 2009 to 2010. The COVID-19 pandemic , which started in December 2019, spread around the world before an effective COVID-19 vaccine was made available in December 2020. By May of 2023, when the World Health Organization declared an end to the global coronavirus emergency, almost 7 million people had died of COVID-19.

Each of these modern day pandemics brings renewed interest in and attention to the Spanish Flu, or “forgotten pandemic,” so-named because its spread was overshadowed by the deadliness of World War I and covered up by news blackouts and poor record-keeping.

Salicylates and Pandemic Influenza Mortality, 1918–1919 Pharmacology, Pathology, and Historic Evidence. Clinical Infectious Diseases .

In 1918 Pandemic, Another Possible Killer: Aspirin. The New York Times.

How the Horrific 1918 Flu Spread Across America. Smithsonian Magazine.

What the Spanish Flu Debacle Can Teach Us About Coronavirus. Politico .

WHO declares end to Covid global health emergency. NBC News .

COVID-19 Dashboard. WHO .

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Influenza (“Spanish Flu” Pandemic, 1918-19)

By Thomas Wirth | Reader-Nominated Topic

As World War I drew to a close in November 1918, the influenza virus that took the lives of an estimated 50 million people worldwide in 1918 and 1919 began its deadly ascent. The United States had faced flu pandemic before, in 1889-90 for example, but the 1918 strain represented an altogether new and aggressive mutation that proved unusually resistant to human attempts to curb its lethality. The devastating effects of the virus, known today as H1N1, were first felt in late summer 1918 along the eastern seaboard in a military encampment outside of Boston. From there, influenza propagated ruthlessly across the country, claiming nearly 700,000 lives before running its course in the spring and summer of 1919.

The pandemic hit Philadelphia exceptionally hard after sailors, carrying the virus from Boston, arrived at the Philadelphia Navy Yard in early September 1918. In a city of almost two million people, a half a million or more contracted influenza over the next six months. Equally as startling, over 16,000 perished during this period, with an estimated 12,000 deaths occurring in little more than five weeks between late September and early November 1918. Historians and epidemiologists have identified several critical factors that shaped Philadelphia’s experience with influenza and help explain the peculiarly rapid and catastrophic spread of disease.

First, a severe shortage of medical personnel rendered the city partially defenseless against the pandemic. More than 25 percent of Philadelphia’s doctors, some 850 total, and an even greater share of its nurses were occupied with the war effort. In 1917 and 1918, three-quarters of the staff of Pennsylvania Hospital at Eighth and Spruce Streets was stationed at the Red Cross Base Hospital 10 in Le Tréport, France. Over two dozen physicians, fifty nurses, and nearly 200 aid workers with hospital training were called overseas, depriving the city of a skilled group of men and women on the eve of the pandemic. The absence of vital medical support made the difficult task of containing the flu and healing the sick even more challenging once the virus migrated from the military camps—including the Navy Yard, Camp Dix in New Jersey, and Camp Meade in Maryland—to the civilian population in late September.

Overcrowding’s Toll

The increased demand for labor during the war also compounded matters. While Philadelphia enjoyed a fantastic boom in employment in its shipbuilding, munitions, and steel industries, overcrowding turned the city’s well-documented but often ignored housing deficiencies into a legitimate public health crisis. As African American migrants from the Jim Crow South and immigrants from eastern and southern Europe fled their miserable circumstances in search of a better life, many found the opportunities gained in Philadelphia came at the price of their health and safety. Cramped, dilapidated, and unsanitary living quarters in places like the Seventh Ward —home to a third of the city’s African Americans in 1918—made the slums and tenement districts a fertile source for influenza.

If the city’s execrable living conditions and depleted medical corps made suppressing influenza difficult, its unabated proliferation in the fall of 1918 likely had its origins in the response of city health officials who drastically underestimated the flu’s potency. On September 21, just days after 600 sailors at the Navy Yard fell ill and the first civilian flu cases were confirmed, Philadelphia’s major newspapers reported that Dr. Paul A. Lewis of the Henry Phipps Institute at the University of Pennsylvania had determined the cause of the disease—a bacteria known as Pfeiffer’s B. influenzae. The Philadelphia Inquirer wrote that Lewis’s findings had now “armed the medical profession with absolute knowledge on which to base its campaign against the disease.”

The city’s top health administrators concurred and yet promptly contradicted their own best advice for staving off the grippe: avoid crowds. With virtually no resistance from the city’s leading public health officials at the Department of Public Health and Charities, a rally for the Fourth Liberty Loan Campaign brought 200,000 Philadelphians together into the city’s streets on September 28. A concert at Willow Grove Park featured the music of John Philip Sousa, stoking patriotic fire. Philadelphia raised $600 million in war bonds as a result, but this success immediately revealed a Faustian bargain. Within three days of the event, 635 new civilian cases of influenza signaled the beginning of the single most deadly period of pestilence ever recorded in the city’s history.

Influenza tore through Philadelphia at a ferocious pace in October and early November. During the second week of October 2,600 people succumbed to the flu, and the following week saw that number nearly double. Though the disease knew no gender, racial, or ethnic boundaries, infecting black and white men and women at an equally high rate, the city’s immigrant poor suffered hard. Those born of foreign parents in the Russian, Hungarian, and Italian communities, among others, died at a higher rate, with some 1,500 more total deaths than those born to American mothers. In a war time atmosphere on the eve of the Red Scare, immigrants were the primary target of inflamed nativist sentiment. Public health officials and private citizens alike scrutinized the personal hygiene habits of the foreign born and often linked insalubrious tendencies to the supposedly questionable morals associated with “alien” cultures. One “disgusted woman” wrote to the Public Ledger in October 1918 demanding that “don’t-spit signs be placed in our post-office building in all languages necessary, to reach all foreign men, and with fines for violations.” The city set fines for spitting at $2.50 and in one day, October 23, the Evening Bulletin reported 114 arrests.

Deluge of Corpses

As death stalked the city, unembalmed bodies piled up by the dozens in a lone morgue at Thirteenth and Wood Streets. The extreme circumstances of the pandemic also meant, however, that many bodies simply rotted for days in the streets. Eventually five makeshift morgues, including one at a cold-storage facility on Cambridge and Twentieth Streets, were established to meet the deluge of corpses. Cemeteries lacked the space and manpower to adequately bury the dead, too. At Holy Cross Cemetery in Lansdowne seminarians turned grave-diggers took in an average of 200 bodies a day in October and deposited hundreds of coffins into a large common grave. “On one occasion,” recalled Reverend Thomas C. Brennan of St. Charles Borromeo Seminary, “the students worked on this task until 10:30 p.m. by the light of the October full moon, the long rows of coffins in the trench presenting a weird and impressive picture in the moonlight.”

Those attempting to care for the living at Philadelphia General Hospital on Thirty-Fourth Street faced similarly overwhelming circumstances. Already at its capacity of 2,000 patients when the virus struck, the hospital had to find room for 1,400 more people as it peaked in mid-October. With hospitals inundated and facing a shortage of medical staff, volunteers were culled from religious organizations, civic associations, and, most prominently, the city’s medical and nursing schools. Across Philadelphia these men and women turned parish houses and armories into temporary emergency hospitals, but on the whole extra assistance remained scarce. As one volunteer recalled, “if you asked a neighbor for help, they wouldn’t do so because they weren’t taking any chances…It was a horror-stricken time.”  And yet just as quickly did the horror arrive did it also depart. When 10,000 dosages of a flu vaccine finally arrived in Philadelphia on October 19, the virus was already in the beginning stages of a rapid decline. By the second week of November, deaths caused by influenza and pneumonia were less than a quarter of what they were the week prior, and by the end of the month the death toll had dipped under 100 for the week for the first time since early September. Still, the city’s death rate from influenza, at approximately 407 per 100,000 people, exceeded that of all other American cities in 1918.

Statistics such as these provide a tangible sense of the staggering loss of life that occurred in Philadelphia during this short period, though tell us next to nothing about how influenza inflicted widespread fear and distress across the city. For an instant in the fall of 1918 it was as if Philadelphia had been transported back to the fourteenth century to that grisly time when victims stricken with plague were often found dead within twenty four hours of contracting it. Perhaps the words of the renowned cardiologist Isaac Starr, a third-year medical student at the University of Pennsylvania at the time of the outbreak, came closest to encapsulating the ordeal of late 1918 when he noted simply that it was as if “the life of the city had almost stopped.”

Copyright 2011, University of Pennsylvania Press

Philadelphia Fights Back Against the Epidemic

Special Collections Research Center, Temple University Libraries

To combat the influenza epidemic, Philadelphia enacted an extensive anti-spitting ordinance. Practitioners were unclear about the cause of the flu, but they knew that it was an airborne disease and therefore instituted a public campaign against coughing, sneezing, and spitting in public. The Philadelphia Board of Health posted signs like this one in public places and inside public transport vehicles toward the end of 1918 and distributed pamphlets instructing citizens to use handkerchiefs while coughing. Several public places like churches, shops, and libraries closed, but most that remained open displayed such signs. The city’s ordinance made spitting a criminal offense – those found spitting without covering their mouths were fined $2.50 and sometimes even arrested.

Related Topics

• City of Medicine
• Greater Philadelphia
• Philadelphia and the World

Time Periods

• Twentieth Century to 1945
• South Philadelphia
• Children’s Aid Society of Pennsylvania
• Typhoid Fever and Filtered Water
• World War I
• Board of Health (Philadelphia)
• Philadelphia Navy Yard
• Infectious Diseases and Epidemics

Related Reading

Barry, John M. The Great Influenza: The Epic Story of the Deadliest Plague in History . New York: Viking, 2004.

Brennan, Thomas C. “The Story of the Seminarians and their Relief Work during the Influenza Epidemic.” Records of the American Catholic Historical Society of Philadelphia 30 (2) (June, 1919): 115-177.

Crosby, Alfred W. America’s Forgotten Pandemic: The Influenza of 1918 . New York: Cambridge University Press, 1989.

Hardy, Charles. “ I Remember When: What Became of the Influenza Pandemic of 1918 .” Audio recording, January 18, 1983.

Starr, Isaac. “Influenza in 1918: Recollections of the Epidemic in Philadelphia.” Annals of Internal Medicine 85 (4) (October 1, 1976): 516-518.

Wirth, Thomas. “Urban Neglect: The Environment, Public Health, and Influenza in Philadelphia, 1915-1919,” Pennsylvania History 73 (Summer 2006): 316-42.

Related Collections

• Philadelphia Inquirer, North American, and Public Ledger Newspaper Collections Free Library of Philadelphia 1901 Vine Street, Philadelphia.
• Philadelphia Evening Bulletin newsclipping collection and the Housing Association of the Delaware Valley Records, 1908-1975 Urban Archives, Temple University Libraries 1900 N. Thirteenth Street, Philadelphia.

Related Places

Pennsylvania Hospital , 800 Spruce Street, Philadelphia.

Philadelphia Navy Yard , 5100 S. Broad Street, Philadelphia.

Backgrounders

Connecting Headlines with History

• Fear of the sick stranger (WHYY, November 4, 2014)
• Philadelphia News Coverage of the Epidemic (Influenza Encyclopedia, University of Michigan)
• Newspaper clipping, 1920: "Prohibition guards against influenza" (Drexel University College of Medicine Legacy Center)
• The Deadly Virus (National Archives Online Exhibit)
• American During the 1918 Influenza Epidemic (Exhibit, Digital Public Library of America)

Connecting the Past with the Present, Building Community, Creating a Legacy

The Spanish flu: The global impact of the largest influenza pandemic in history

Parts of the article were revised in May 2023, and the chart on death tolls from flu pandemics was updated in April 2024.

In the last 150 years the world has seen an unprecedented improvement in health. The visualization shows that in many countries life expectancy, which measures the average age of death, doubled from around 40 years or less to more than 80 years. This was not just an achievement across the countries shown here; life expectancy has doubled in all regions of the world.

What also stands out is how abrupt and damning negative health events can be. Most striking is the large, sudden decline of life expectancy in 1918, caused by an unusually deadly influenza pandemic that became known as the ‘Spanish flu’.

To make sense of the fact life expectancy declined so abruptly, one has to keep in mind what it measures. Period life expectancy , which is the precise name for this measure, captures the mortality in one particular year . It summarizes the mortality in a particular year by calculating the average age of death of a hypothetical cohort of people for which that year’s mortality pattern would remain constant throughout their entire lifetimes.

This influenza outbreak wasn’t restricted to Spain and it didn’t even originate there. Recent genetic research suggests that the strain emerged a few years earlier, around 1915, but did not take off until later on. The earliest recorded outbreak was in Kansas in the United States in 1918. 1

But it was named as such because Spain was neutral in the First World War (1914-18), which meant it was free to report on the severity of the pandemic, while countries that were fighting tried to suppress reports on how the influenza impacted their population to maintain morale and not appear weakened in the eyes of the enemies. Since it is very valuable to speak openly about the threat of an infectious disease I think Spain should be proud that it was not like other countries at that time.

The virus spread rapidly and eventually reached all parts of the world: the epidemic became a pandemic. 2 Even in a much less-connected world the virus eventually reached extremely remote places such as the Alaskan wilderness and Samoa in the middle of the Pacific islands. In these remote places the mortality rate was often particularly high. 3

How many people died in the Spanish flu pandemic?

The global death count of the flu today:.

To have a context for the severity of influenza pandemics it might be helpful to know the death count of a typical flu season. Current estimates for the annual number of deaths from influenza are around 400,000 deaths per year. Paget et al (2019) suggest an average of 389,000 with an uncertainty range 294,000 from 518,000. 4 This means that in recent years the flu was responsible for the death of 0.005% of the world population. 5 Even in comparison to the low estimate for the death count of the Spanish flu (17.4 million) this pandemic, more than a century ago, caused a death rate that was 182-times higher than today’s baseline.

Global deaths of the Spanish flu

Several research teams have worked on the difficult problem of reconstructing the global health impact of the Spanish flu.

The visualization here shows the available estimates from the different research publications discussed in the following. The range of published estimates for the Spanish flu is particularly wide.

The widely cited study by Johnson and Mueller (2002) arrives at a very high estimate of at least 50 million global deaths. But the authors suggest that this could be an underestimation and that the true death toll was as high as 100 million. 6

Patterson and Pyle (1991) estimated that between 24.7 and 39.3 million died from the pandemic. 7

The more recent study by Spreeuwenberg et al. (2018) concluded that earlier estimates have been too high. Their own estimate is 17.4 million deaths. 8

The global death rate of the Spanish flu

How do these estimates compare with the size of the world population at the time? How large was the share who died in the pandemic?

Estimates suggest that the world population in 1918 was 1.8 billion.

Based on this, the low estimate of 17.4 million deaths by Spreeuwenberg et al. (2018) implies that the Spanish flu killed almost 1% of the world population. 9

The estimate of 50 million deaths published by Johnson and Mueller implies that the Spanish flu killed 2.7% of the world population. And if it was in fact higher – 100 million as these authors suggest – then the global death rate would have been 5.4%. 10

The world population was growing by around 13 million every year in this period which suggests that the period of the Spanish flu was likely the last time in history when the world population was declining. 11

Other large influenza pandemics

The Spanish flu pandemic was the largest, but not the only large recent influenza pandemic.

Two decades before the Spanish flu the Russian flu pandemic (1889-1894) is believed to have killed 1 million people. 12

Estimates for the death toll of the “Asian Flu” (1957-1958) range from 1.7 to 2.7 million according to Spreeuwenberg et al. (2018). 13

The same authors estimate that the “Hong Kong Flu” (1968-1969) killed between 2 and 3.8 million people. 13

The “Russian Flu” pandemic of 1889-1890 is believed to be caused by an H3 pandemic virus. 14 According to Spreeuwenberg et al. (2018) around 3.7 to 5.1 million people died worldwide. 13

The “Swine flu” pandemic of 2009-2010 was caused by a new H1N1 pandemic virus. Several research groups have made estimates of the global death toll, which ranges from 130,000 to 1.87 million people worldwide. 15

What becomes clear from this overview are two things: influenza pandemics are not rare, but the Spanish flu of 1918 was by far the most devastating influenza pandemic in recorded history.

The impact of the Spanish flu on different age groups

This last visualization here shows the life expectancy in England and Wales by age.

The red line shows the life expectancy for a newborn, with the rainbow-colored lines above showing how long a person could expect to live once they had reached that given, older, age. The light green line, for example, represents the life expectancy for children who have reached age 10.

It shows that life expectancy increased at all ages, which means that the often-heard assertion that life expectancy ‘only’ increased because child mortality declined is not true .

With respect to the impact of the Spanish flu it is striking that the visualization shows that the pandemic had little impact on older people. While the life expectancy at birth and at young ages declined by more than ten years, the life expectancy of 60- and 70-year olds saw no change. This is at odds with what one would reasonably expect: older populations tend to be most vulnerable to influenza outbreaks and respiratory infections. If we look at mortality for both lower respiratory infections (pneumonia) and upper respiratory infections today, death rates are highest for those who are 70 years and older.

This data tells us that young people accounted for a large share of the deaths, this made this pandemic especially devastating.

Why were older people so resilient to the 1918 pandemic? The research literature suggests that this was the case because older people had lived through an earlier flu outbreak – the already discussed ‘Russian flu pandemic’ of 1889–90 – which gave those who lived through it some immunity for the later outbreak of the Spanish flu. 16

The earlier 1889-90 pandemic might have given the older population some immunity, but was a destructive event in itself. According to Smith 132,000 people died in England, Wales, and Ireland alone. 17

How the Spanish flu differs from the Coronavirus outbreak in 2020

Writing in early March 2020 it is an obvious question to ask how the ongoing outbreak of Covid-19 compares. There are a number of important differences that should be considered.

They are not the same disease and the virus causing these diseases are very different. The virus that causes Covid-19 is a coronavirus, not an influenza virus that caused the Spanish flu and the other influenza pandemics listed above.

The age-specific mortality seems to be very different. As we’ve seen above, the Spanish flu in 1918 was especially dangerous to infants and younger people. The new coronavirus that causes Covid-19 appears to be most lethal to the elderly, based on early evidence in China. 18

We’ve also seen above that during the Spanish flu many countries tried to suppress any information about the influenza outbreak. Today the sharing of data, research, and news is certainly not perfect, but very different and much more open than in the past.

But it is true that the world today is much better connected. In 1918 it was railroads and steamships that connected the world. Today planes can carry people and viruses to many corners of the world in a very short time.

Differences in health systems and infrastructure also matter. The Spanish flu hit the world in the days before antibiotics were invented; and many deaths, perhaps most, were not caused by the influenza virus itself, but by secondary bacterial infections. Morens et al (2008) found that during the Spanish flu “the majority of deaths … likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria.” 19

And not just health systems were different, but also the health and living conditions of the global population. The 1918 flu hit a world population of which a very large share was extremely poor – large shares of the population were undernourished, in most parts of the world the populations lived in very poor health , and overcrowding, poor sanitation and low hygiene standards were common. Additionally the populations in many parts of the world were weakened by a global war. Public resources were small and many countries had just spent large shares of their resources on the war.

While most of the world is much richer and healthier now , the concern today too is that it is the poorest people that are going to be hit hardest by the Covid-19 outbreak. 20

These differences suggest that one should be cautious in drawing lessons from the outbreak a century ago.

But the Spanish flu reminds us just how large the impact of a pandemic can be, even in countries that had already been successful in improving population health. A new pathogen can cause terrible devastation and lead to the death of millions. For this reason the Spanish flu has been cited as a warning and as a motivation to prepare well for large pandemic outbreaks, which have been considered likely by many researchers. 21

Worobey, M., Han, G.-Z., & Rambaut, A. (2014). Genesis and pathogenesis of the 1918 pandemic H1N1 influenza A virus. Proceedings of the National Academy of Sciences, 111(22), 8107–8112. https://doi.org/10.1073/pnas.1324197111

Barry, J. M. (2004). The site of origin of the 1918 influenza pandemic and its public health implications. Journal of Translational Medicine, 2(1), 3. https://doi.org/10.1186/1479-5876-2-3

For the definitions of epidemic and pandemic see the CDC here .

Burnet F. M., Clark E. (1942) – Influenza: A Survey of the Last 50 Years in the Light of Modern Work on the Virus of Epidemic Influenza. London: Macmillan. Partly online on Google books.

The mortality rate in some populations like Alaska and Samoa were said to be 90% and 25% respectively. See the following two publications:

McLane, J. R. (2013). Paradise locked: The 1918 influenza pandemic in American Samoa. Sites: a journal of social anthropology and cultural studies , 10(2), 30-51.  

Mamelund, S. E. (2017). Profiling a Pandemic. Who were the victims of the Spanish flu?{ref} While peak mortality was reached in 1918 the pandemic did not wane until two years later in late 1920.

Paget et al (2019) suggest an “average of 389 000 (uncertainty range 294 000-518 000) respiratory deaths were associated with influenza globally each year”.

John Paget, Peter Spreeuwenberg, Vivek Charu Robert J Taylor, A Danielle Iuliano, Joseph Bresee, Lone Simonsen, Cecile Viboud,3 and for the Global Seasonal Influenza-associated Mortality Collaborator Network and GLaMOR Collaborating Teams (2019) – Global mortality associated with seasonal influenza epidemics: New burden estimates and predictors from the GLaMOR Project. In J Glob Health. 2019 Dec; 9(2): 020421. Published online 2019 Oct 22. doi: 10.7189/jogh.09.020421 PMCID: PMC6815659 PMID: 31673337 Online here .

This is (389,000/7,500,000,000)*100=0.0052%

From the paper: Further research has seen the consistent upward revision of the estimated global mortality of the pandemic, which a 1920s calculation put in the vicinity of 21.5 million. A 1991 paper revised the mortality as being in the range 24.7-39.3 million. This paper suggests that it was of the order of 50 million. However, it must be acknowledged that even this vast figure may be substantially lower than the real toll, perhaps as much as 100 percent understated.

Johnson, N.P. and Mueller, J. (2002) – Updating the accounts: global mortality of the 1918-1920 “Spanish" influenza pandemic. In Bulletin of the History of Medicine, 76(1), pp.105-115. Online here .

The paper includes detailed breakdowns of mortality estimates by world region and country.

Patterson and Pyle (1991) wrote 'we believe that approximately 30 million is the best estimate for the terrible demographic toll of the influenza pandemic of 1918' and published a range from 24.7-39.3 million deaths.

Patterson, K.D. and Pyle, G.F. (1991) – The geography and mortality of the 1918 influenza pandemic. Bulletin of the History of Medicine, 65(1), p.4. Online here .

P. Spreeuwenberg; et al. (1 December 2018). "Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic". American Journal of Epidemiology. 187 (12): 2561–2567. doi:10.1093/aje/kwy191. PMID 30202996. Online here .

The calculation is (17,400,000/1,832,196,157)*100=0.95

50,000,000 deaths / 1,832,196,157 people = 0.02729 And with a death count twice is high: 0.05458.

In available historical reconstructions (like this one ) this decline is not shown. The reason for this is that precise annual counts of the world population are not available for the past.

Instead historians try to reconstruct the population figures for 5-year or 10-year intervals and the annual estimates are interpolations between these estimates.

In other words, if we had precise annual counts they would likely show a decline of the world population in 1918.

Nickol, M.E., Kindrachuk, J. (2019) – A year of terror and a century of reflection: perspectives on the great influenza pandemic of 1918–1919. BMC Infect Dis 19, 117 (2019). https://doi.org/10.1186/s12879-019-3750-8

According to Smith (1995) 132,000 died in England, Wales, and Ireland alone.

Smith F. B. (1995) – The Russian influenza in the United Kingdom, 1889-1894. Soc. Hist. Med. 8 55–73. Online here .

Spreeuwenberg, P., Kroneman, M., & Paget, J. (2018). Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic. American Journal of Epidemiology, 187(12), 2561–2567. https://doi.org/10.1093/aje/kwy191

Dawood, F. S., Iuliano, A. D., Reed, C., Meltzer, M. I., Shay, D. K., Cheng, P.-Y., Bandaranayake, D., Breiman, R. F., Brooks, W. A., Buchy, P., Feikin, D. R., Fowler, K. B., Gordon, A., Hien, N. T., Horby, P., Huang, Q. S., Katz, M. A., Krishnan, A., Lal, R., … Widdowson, M.-A. (2012). Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: A modelling study. The Lancet Infectious Diseases, 12(9), 687–695. https://doi.org/10.1016/S1473-3099(12)70121-4

Simonsen, L., Spreeuwenberg, P., Lustig, R., Taylor, R. J., Fleming, D. M., Kroneman, M., Van Kerkhove, M. D., Mounts, A. W., Paget, W. J., & the GLaMOR Collaborating Teams. (2013). Global Mortality Estimates for the 2009 Influenza Pandemic from the GLaMOR Project: A Modeling Study. PLoS Medicine, 10(11), e1001558. https://doi.org/10.1371/journal.pmed.1001558

Gagnon et al. (2013) – Age-Specific Mortality During the 1918 Influenza Pandemic: Unravelling the Mystery of High Young Adult Mortality.PLoS One. 2013; 8(8): e69586. Published online 2013 Aug 5. doi: 10.1371/journal.pone.0069586. Online here .

The Russian flu pandemic was a devastating event in itself. Smith (1995) estimates that the Russian flu killed 132,000 in England, Wales, and Ireland.

Zhonghua Liu Xing Bing Xue Za Zhi (2020) – The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Feb 17;41(2):145-151. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003. Online here .

Morens D. M., Taubenberger J. K., Fauci A. S. (2008) – Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J. Infect. Dis. 198 962–970. 10.1086/591708. Online here .

Gilbert, Marius, Giulia Pullano, Francesco Pinotti, Eugenio Valdano, Chiara Poletto, Pierre-Yves Boëlle, Eric D’Ortenzio, et al. (2020) – “Preparedness and Vulnerability of African Countries against Importations of COVID-19: A Modelling Study.” The Lancet (February 20, 2020). https://doi.org/10.1016/S0140-6736(20)30411-6 .

Alyssa S. Parpia, Martial L. Ndeffo-Mbah, Natasha S. Wenzel, and Alison P. Galvani (2016) – Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. In Emerg Infect Dis. 2016 Mar; 22(3): 433–441. doi: 10.3201/eid2203.150977 PMCID: PMC4766886 PMID: 26886846 Online here .

See for example: Pandemic influenza preparedness and response – WHO guidance document. Published in 2009 by the WHO. Online here .Roman Duda (2016) – Problem profile: Biorisk reduction. Published by 80,000 hours. Online here .

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Lesson Plan: Lessons Learned from the 1918 Influenza Pandemic

The 1918 Spanish Flu Pandemic

Historian Nancy Bristow talked about the 1918 influenza pandemic and how it devastated American communities and soldiers during World War I. She explained how this version of the flu was different than previous seasonal versions of the flu at the time.

Description

In 1918, a strain of influenza spread throughout the globe causing 50 million deaths worldwide. Sometimes referred to as the Spanish Flu, this pandemic was unique in its severity and the segments of the population that were affected. This lesson has students hear from historians, scientists and doctors to explore the factors that led to the spread of the disease. With this information, students will develop a list of lessons that can be learned from the 1918 influenza pandemic.

Before beginning class, have the students brainstorm answers to the following questions. Address any misconceptions that student may have about the flu and early 1900s.

• Describe what you know about the flu and how it usually spreads. What are ways that are used to prevent it?
• Describe what was occurring around the world in 1918.

INTRODUCTORY VOCABULARY:

Have the students either define each of the following terms in their own words or provide them with a brief overview of these terms. This vocabulary will be used through the video clips included in this lesson.

• Public Health

INTRODUCTION:

After students have an understanding of the vocabulary terms mentioned above, have them view the following video clip that provides an overview of the 1918 Spanish Flu. Student should answer the questions provided to focus their viewing.

VIDEO CLIP 1: The 1918 Spanish Flu Pandemic (5:15)

What is the common belief about the origin of the 1918 influenza pandemic?

How did World War I help intensify the spread of the Spanish Flu?

How did the Spanish Flu affect certain age groups differently than previous flus? Why was this significant to society?

Describe the symptoms of the Spanish Flu.

• What factors led to the Spanish Flu having a significant impact on society in the United States?

EXPLORATION:

Provide students with the 1918 Influenza Pandemic Handout. Students should watch the video clips provided below to complete the graphic organizer. Students will take notes on the factors that contributed to the spread of the flu and actions taken to stop the spread of the flu.

HANDOUT: 1918 Influenza Pandemic (Google Doc)

VIDEO CLIPS:

VIDEO CLIP 2: The Outbreak of the 1918 Influenza Pandemic (1:52)

VIDEO CLIP 3: The Spanish Flu and World War I (1:49)

VIDEO CLIP 4: Social and Cultural Norms during the 1918 Influenza Pandemic (4:23)

VIDEO CLIP 5: The Spread of 1918 Spanish Flu in Urban Areas (4:01)

VIDEO CLIP 6: Remembering the 1918 Influenza Pandemic (2:33)

• VIDEO CLIP 7: Lessons Learned from the 1918 Spanish Flu Pandemic (2:30)

APPLICATION AND CONCLUSION:

After students have completed their graphic organizer, have them develop a list of 3-5 lessons learned or recommendations that can be taken from the 1918 pandemic. For each, they should explain how these lessons or recommendations could prevent the spread of similar pandemics in the future.

EXTENSION/ALTERNATIVE ACTIVITIES:

Oral Histories: Using the Department of Health and Human Service documentary, We Heard the Bells, The Influenza of 1918 , choose one of the people from the film who witnessed the 1918 pandemic. Provide a summary of their experiences and explain how their story relates to some of the factors that contributed to the spread of the flu.

1918 Influenza Pandemic Memorial- As Professor Bristow mentioned in the video clip, there is not a national memorial to honor the victims of the 1918 influenza pandemic. Using the information provided in the clips and outside research, design a memorial that commemorates the pandemic. In addition to creating a design for the memorial, provide an explanation of where you would locate the memorial and how this memorial symbolizes the 1918 pandemic.

ADDITIONAL PROMPTS:

Should the federal government take a more active role in preventing epidemics and pandemics?

How did World War I contribute to the spread of the Spanish Flu?

How did the Spanish Flu impact World War I?

In what ways did the social and racial divisions impact the severity of the 1918 influenza?

• Why do you think the 1918 influenza pandemic is not remembered as much as other events?

Related Article

• 1918 Pandemic (H1N1 virus) | Pandemic Influenza (Flu) | CDC

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Epidemics and trust: The case of the Spanish Flu

Arnstein aassve.

1 Bocconi University, Milan Italy

Guido Alfani

2 Innocenzo Gasparini Institute for Economic Research (IGIER), Bocconi University, Milan Italy

Francesco Gandolfi

Marco le moglie.

3 Catholic University of the Sacred Hearth, Milan Italy

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Recent studies argue that major crises can have long‐lasting effects on individual behavior. While most studies focused on natural disasters, we explore the consequences of the global pandemic caused by a lethal influenza virus in 1918–19: the so‐called “Spanish Flu.” This was by far the worst pandemic of modern history, causing up to 100 million deaths worldwide. Using information about attitudes of respondents to the General Social Survey, we find evidence that experiencing the pandemic likely had permanent consequences in terms of individuals' social trust. Our findings suggest that lower social trust was passed on to the descendants of the survivors of the Spanish Flu who migrated to the United States. As trust is a crucial factor for long‐term economic development, our research offers a new angle from which to assess current health threats.

1. INTRODUCTION

A century ago, an influenza‐A virus caused the greatest pandemic in human history, the “Spanish Flu.” It infected about a third of the world population and caused an estimated 50–100 million victims (Johnson & Mueller,  2002 ; Taubenberger & Morens,  2006 ). The long‐term effects of the Spanish Flu went well beyond the immediate demographic losses that it caused. Much research has been conducted into its consequences for the health of survivors, even when experienced in‐utero (Almond,  2006 ; Bengtsson & Helgertz,  2015 ; Myrskylä, Mehta, & Chang,  2013 ). Fewer studies exist on the way in which experiencing the Spanish Flu‐shaped individual behavior and human societies at large (Almond,  2006 ; Bengtsson & Helgertz,  2015 ; Carillo & Jappelli,  2020 ; Cohn,  2018 ; Galletta & Giommoni,  2020 ; Guimbeau, Menon, & Musacchio,  2019 ; Karlsson, Nilsson, & Pichler,  2014 ; Lin & Liu,  2014 ). Yet a growing literature argues that the second‐worst pandemic in human history, the Black Death, had long‐term economic, social and cultural consequences, shaping behavior well into the 20th century (Alfani,  2020 ; Alfani & Murphy,  2017 ; Jedwab, Johnson, & Koyama,  2016 ; Richardson & McBride,  2009 ; Voitgländer & Voth,  2012 ). Here we show that similarly to the Black Death, also the Spanish Flu had long‐lasting social consequences, leading to a decline in social trust. This would result from having experienced the social disruption and generalized mistrust characterizing the pandemic period.

Uncovering the broader societal impact of an historical pandemic, such as the Spanish flu, is obviously challenging. In the case of attitudes and social trust, which we study here, no direct survey measures exist. Instead we exploit information about the descendants of those who experienced the historical event (Algan & Cahuc,  2010 ). This method leverages on the fact that cultural traits and attitudes are inherited across generations, passing on from parents to children (Dohmen, Falk, Huffman, & Sunde,  2012 ). We use the General Social Survey (GSS), which is a representative survey of the US population. Social trust is derived from those respondents who were direct descendants of migrants to the United States, and by using this information, we are able to provide an estimate of social trust for each country of origin before and after the spread of the Spanish Flu. Importantly, the derived measure of trust from the GSS is exogenous to socioeconomic differences between countries at that time. For each country of origin, we compare the estimated levels of social trust for the two periods, and we analyze how the possible difference in trust depends on the pandemic mortality rate by adopting a difference‐in‐difference (DiD) approach.

The results of our analysis suggest a negative and significant effect of the Spanish Flu on trust. An increase in influenza mortality of one death per thousand resulted in a 1.4 percentage points decrease in trust. This result is robust to an extensive set of tests, including a falsification test, different samples and variable definitions, different functional specifications and different control strategies. We also provide evidence on the possible mechanism underlying the change in trust, namely the neutrality of the home country in world war I (WWI). A narrower resonance of the war within neutral countries, together with the specific lack of war censorship on media, might have led their respective citizens to internalize the extent and severity of the pandemic, and thus altered their social interactions accordingly. 1 Consistently with this hypothesis, we do find a stronger reduction in social trust for the descendants of people migrating from countries heavily hit by the epidemic and that remained neutral during the war.

Trust is an important determinant of long‐run economic development (Tabellini,  2010 ), and recent literature has shown its reactivity to natural disasters such as earthquakes or floods (Carlin, Love, & Zechmeister,  2014 ; Skidmore & Toya,  2014 ). By bringing attention to major epidemics, our study also provides useful insights into how more recent events, such as the HIV pandemic or the recent Ebola epidemic of 2013–2016 as well as the one which started in 2018 and is currently ongoing, might have lasting consequences on the societies affected (Hayden,  2014 ; Young,  2005 ), possibly compromising their economic performances for years to come. However, we also argue that the effects of a specific pandemic or epidemic cannot be easily generalized, as they depend on its characteristics both in terms of infection rates and chances of survival, as well as on the cultural and social‐economic context in which it took place. This conclusion is in line with the recent literature on the consequences of large‐scale plagues in European history (Alfani & Percoco,  2019 ). Finally, the fact that the impact of the Spanish Flu on trust in neutral countries is different from belligerent ones, illustrates how the portrayal of a pandemic by the media plays an important role in affecting societies. The possible lesson from history is that, during large‐scale pandemic crises, including the current one caused by COVID‐19, availability of open, accurate and reliable information might contribute to contain persistent damage to social capital. This, however, remains an hypothesis that it would be unfeasible to formally test in this study.

In the next section, we provide an overview of the Spanish Flu and its main impact on society. Section  2 describes the data employed in the analysis while Section  3 the methodology applied to carry it out. In Section  4 , we report our main findings as well as an extended set of robustness tests. Finally, Section  5 concludes, and highlights the relevance of our findings for the current crisis caused by COVID‐19.

2. THE INFLUENZA PANDEMIC AND ITS IMPACT ON SOCIETY

The first wave of the Spanish Flu pandemic started in spring 1918 and spread rapidly across the world. Earlier scholarship placed its origin in the United Stated, where the influenza was first identified in March 1918, however this is now doubted (Crosby,  1976 ; Taubenberger & Morens,  2006 ). The pandemic was caused by an influenza H1N1 virus, whose entire genome has been sequenced (Taubenberger et al.,  2005 ; Tumpey et al.,  2005 ). All influenza, A pandemics since 1918, have been caused by descendants of the Spanish Flu virus (Taubenberger & Morens,  2006 ) and vaccines developed to protect against the 2009 H1N1 virus would also work against the original Spanish Influenza virus (Medina et al.,  2010 ). While this offers some reassurance about the health threats associated to H1N1, it is also one of the two factors explaining why the Spanish Flu continues to be the object of considerable interdisciplinary attention. The other is its exceptional severity, especially during the second wave (September–November 1918) and the third (early 1919). The third wave, which involved fewer countries, was probably exacerbated by the end of WWI, with soldiers returning home and the resuming of commerce (Crosby,  1976 ; Taubenberger & Morens,  2006 ). However, looking at the average mortality rates associated with the influenza pandemic showed in Figure  1 , there is no considerable differences across neutral and belligerent countries.

Spanish Flu mortality by participation to World War I. The figure shows the influenza mortality rates for the sample countries employed in the analysis, divided by their participation in World War I. Horizontal lines represent the mean death rate for each group while the dashed horizontal lines show the 95% confidence intervals

The exceptionally high mortality is the combined result of the extremely high infectiousness of the disease and of a case‐fatality rate of >2.5%, which is high compared to the <0.1% characterizing other influenza pandemics (Taubenberger & Morens,  2006 ). Overall, this resulted in at least 50, and possibly as much as 100 million victims globally (Johnson & Mueller,  2002 ; Taubenberger & Morens,  2006 ). These grim statistics place the Spanish Flu at the top of the ranking of the worst pandemics in human history, at least looking at the number of deaths (Alfani & Murphy,  2017 ). Another striking characteristic of the Spanish Flu was that most of its victims were young adults. This is different from the standard influenza outbreaks that tend to affect the very young and older strata of the population, thereby leading to the well‐known U‐shaped relationship between age and flu mortality. The Spanish flu in contrast, killed disproportionately young adults aged 15–34. The resulting relationship between age and deaths is W‐shaped (Mamelund,  2011 ), and very similar across genders, as shown in Figure  2 .

Age‐Specific excess mortality rates. The figure shows the median excess mortality rates by sex and age group, based on data for 13 countries, namely Australia, Denmark, England, Finland, France, Italy, Netherlands, New Zealand, Norway, Spain, Sweden, Switzerland, and the United States America (Source: Murray, Lopez, Chin, Feehan, & Hill,  2006 )

Explaining differences in trust has attracted considerable interest. This is in part driven by the fact that social trust matters for a whole range of societal outcomes—including economic prosperity. Additionally, this interest comes from the observation that social trust appears rather stable over time, though with significant differences across countries. Consequently, it is important to identify the cultural roots of social trust. Some have focused on climate variation, arguing that in agricultural societies, unfavorable weather conditions may have encouraged cooperation, and therefore created differences in trust over time (Buggle & Durante,  2017 ). Others have emphasized historical developments (Guiso, Sapienza, & Zingales,  2016 ), such as the slave trade and colonial medicine in Africa (Lowes & Montero,  2018 ; Nunn & Wantchekon,  2011 ), the establishment of Leaper colonies in Colombia (Ramos‐Toro,  2019 ), or mass‐surveillance in East‐Germany (Lichter, Loeffler, & Siegloch,  2015 ), that might have generated long‐standing distrust in those societies exposed to them. Another strand of literature has focused on the potential role of natural disasters in affecting social trust (Calo‐Blanco, Kovářík, Mengel, & Romero,  2017 ; Carlin et al.,  2014 ; Uslaner & yamamura,  2016 ), a literature related to our current study.

This literature does not make clear‐cut predictions for how a natural disaster may alter social trust. On the one hand, a natural disaster could increase trust as citizens get together through rebuilding efforts. But in so far as a natural disaster brings about economic destitution and poverty, individuals may be forced to fend for themselves rather than engaging in healthy cooperation, which may in turn lower social trust.

A similar issue applies for pandemics. It seems natural to hypothesize that a highly contagious disease would reduce social contacts from fear of contracting the disease. People would naturally avoid social interaction with those they do not know and perhaps avoid large gatherings, and over time, the social trust will decline. For the Spanish Flu, measures of public health, and the general encouragement from the authorities and the media to avoid inter‐personal contacts, created a profound climate of suspicion and mistrust (Cohn,  2018 ). However, social distancing alone would probably have had limited consequences. It was high mortality and the concentration of deaths among young adults that increased the ability of the pandemic to disrupt the social tissue. Indeed, historical accounts of the Spanish Flu show that panic was so widespread that the red cross in rural Kentucky reported “people starving to death not from lack of food but because the [healthy] were panic stricken and would not go near the sick” (Barry,  2005 ). Different locations attempted to combat the pandemic with a variety of methods. Quarantines, closing schools, bars, churches and other gathering places and compulsory gauze masks were implemented, though most of these actions turned ineffective in containing the disease (Crosby,  1976 ; Johnson,  2012 ). In other words, the fear of contracting a lethal influenza dramatically altered social interactions (Phillps & Killingray,  2003 ). Some scientists worried that “ If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear from the face of the earth within a matter of a few more weeks ” (Collier,  1974 ). However, comparatively speaking, the Spanish Flu was not merely as lethal as other epidemics, such as the Ebola. An important aspect of the Spanish Flu was instead its sheer magnitude. The world struggled to cope as vaccines were not developed and none of the suggested cures were effective (Crosby,  1976 ; Taubenberger & Morens,  2006 ). Across Europe and the United States, civilian hospitals were severely understaffed, in part because doctors and nurses were involved in the war efforts, but also because of the very large number of people contracting the disease. The case of the Spanish Flu is consequently a textbook case of utter failure of health care institutions both in containing the spread of an epidemic and in providing effective care. Observing the failure of institutions and society to cope with the crisis (a failure whose most visible result was the widespread mortality) is what, we believe, led to significant and persistent consequences on individual's social trust—a point which, as discussed in the conclusion, might have some relevance for the current crisis caused by COVID‐19.

Other pandemics may have different impact. The case‐fatality rate from contracting Ebola is way higher than the Spanish Flu, for instance. But its extent, in terms of infections rates and overall mortality, has been dramatically lower so far, and the areas where one may contract Ebola are typically very small. Individuals will know instantly about an outbreak as they observe fellow villagers dying from the disease. But given the (relatively) small scale, it is not at all sure that an Ebola epidemic would have a big impact on social trust. In fact, a recent study found evidence that effective public intervention to contain Ebola outbreaks might have actually increased trust in government authorities (Flückiger, Ludwig, & SinaÖnder,  2019 ). The same study, however, did not find a strong effect on social trust. In contrast to the Ebola outbreaks, the number of people who were infected by the Spanish Flu—but survived—was orders of magnitude greater and those survivors (and their relations) might have experienced the deepest changes in their attitudes. Indeed, the survivors were those who had been faced more directly with the collapse of traditional networks of social support as well as with the inability of public institutions to provide adequate care and relief.

3. DATA: INHERITED TRUST AND SPANISH FLU MORTALITY

The data employed in this work are mostly obtained from the GSS. The GSS is a repeated cross‐sectional survey held in the United States and nationally representative of the US population of adults (18 + ) speaking either English or Spanish. 2 The questionnaire is provided face‐to‐face with an in‐person interview by National Opinion Research Center at the University of Chicago, and the response rate is generally above 70%. The survey was conducted every year from 1972 to 1994 (except in 1979, 1981, and 1992). Since 1994, it has been conducted each two years. It contains a standard core of demographic, behavioral, and attitudinal questions that are repeated in each wave of the survey. This gives access to a vast pool of respondents providing the information required for our analysis. In particular, we use the waves from 1978 to 2018.

The main variable of interest that can be obtained from the GSS is generalized trust. This variable comes from the question “Generally speaking, would you say that most people can be trusted or that you can't be too careful in dealing with people?“ . First formulated by Almond and Verba ( 1963 ), the question is extensively used in the literature to measure generalized trust on the basis of surveys (Algan & Cahuc,  2014 ). We code generalized trust as a dummy variable that takes value 1 (high trust) for the people that answered “Can Trust” and 0 (low trust) for those who answered either “Cannot Trust” or “Depends” . 3

Survey respondents were also asked about their country of ethnic origin and a series of questions regarding their migration history: whether they were born in the United States or not, whether their mother and father were born in the United States and the number of grandparents born outside the country. Using this information, we group respondents on the basis of their country of ethnic origin and categorize them in three waves of immigration: second‐generation Americans (i.e., people born in the United States with at least one parent and all the grandparents born abroad), third‐generation Americans (i.e., people with at least two immigrant grandparents and both parents born in the United States) and fourth‐generation Americans (i.e., people with more than two grandparents born in the United States and both parents born in the United States). We exploit different waves of immigration to measure the inter‐generational path of social capital transmission by people migrated before and after the spread of the Spanish flu (i.e., 1918), following the methodology introduced by Algan and Cahuc ( 2010 ) and Tabellini ( 2008 ).

We measure the severity of the Spanish flu using the data on flu mortality, expressed in deaths per thousand inhabitants, collected by Johnson and Mueller ( 2002 ). This is the most comprehensive published study in terms of countries coverage, and it presents estimates for flu mortality, pooling together the results of multiple studies on single countries. Specifically, the countries for which the estimates of Spanish flu death rates are available that are included in our analysis are Austria, Canada, Denmark, Finland, France, Germany, Hungary, Ireland, Italy, Mexico, the Netherlands, Norway, Portugal, Russia, Spain, Sweden, Switzerland, and the United Kingdom. 4 Note that we focus on mortality and not on other epidemiological variables, like morbidity, as a measure of the severity of the Spanish Flu for two reasons: first, because estimates of mortality rates are available for more countries and are of better quality compared to morbidity rates, and secondly, because for the general population it was experiencing a sharp increase in the number of deaths and the failure of institutions to prevent it that can reasonably be expected to have had the stronger consequences on psychology and behavior.

4. METHODOLOGY

4.1. estimation of inherited trust in the home countries.

In order to obtain estimates for the level of trust in each country before and after the spread of the Spanish flu, we follow the method proposed by Algan and Cahuc ( 2010 ) and Tabellini ( 2008 ). Algan and Cahuc ( 2010 ) leverage on the evolution of trust of descendants of the US migrants to detect historical changes in the level of trust in the home country. The starting point is that a part of social attitudes, including trust, is shaped by the contemporary environment and society while another is due to beliefs and norms inherited from earlier generations (Dohmen et al.,  2012 ). By estimating the latter part using the GSS survey, they obtain a proxy for the level of generalized trust that was present in the countries of origin at the time of the ancestors' migration to the United States. Since the date of departure of the respondents' ancestors is not directly available from the survey, the authors infer it from the year of birth of the person interviewed and whether he is second‐, third‐ or fourth‐generation American. Assuming a 25‐year gap between generations, Algan and Cahuc ( 2010 ) hypothesize that the respondent's ancestor moved to the United States before the date Y if (I) the respondent is a second‐generation American born before Y or (II) the respondent is a third‐generation American born before Y+25 or (III)the respondent is a fourth‐generation American born before Y+50. Algan and Cahuc ( 2010 ) also assume that the respondent's ancestor moved to the United States after the date Y if (I) the respondent is a second‐generation American born after Y or (II) the respondent is a third‐generation American born after Y+25 or (III) the respondent is a fourth‐generation American born after Y+50. Having created these two groups, for each of them Algan and Cahuc ( 2010 ) regress the individual levels of trust on a set of variables, including dummies for each country of origin. Thus, the levels of trust for a specific country of origin before and after date Y are captured by the coefficients of the fixed effect for that country in each of the two regressions.

This approach provides two main advantages in the estimation of country‐level trust. First and foremost, it allows us to calculate inherited trust starting from a measure of present trust that is exogenous to socioeconomic differences between countries at the time of the pandemic. Furthermore, we can rely on a single survey and on questions that are consistent across the waves, granting the comparability of the variables both between countries and between periods.

As in Algan and Cahuc ( 2010 ) we run two separate regressions: one to estimate trust up to 1918 and the other to estimate trust after 1918. Furthermore, as in Algan and Cahuc ( 2010 ), we assume a 25‐year gap between generations. Specifically, in the sample used to estimate inherited trust before 1918 we include (I) all the second‐generation respondents that were born in 1918 or earlier (II) all the third‐generation respondents that were born by 1918 + 25 (i.e., 1943), and (III) all the fourth‐generation Americans that were born by 1918 + 50 (i.e., 1968). As for trust after 1918, we sample (I) all the second‐generation respondents that were born after 1918, (II) the third‐generation respondents born after 1918 + 25 (i.e., 1943), and (III) all the fourth‐generation Americans born after 1918 + 50 (i.e., 1968).

Differently from Algan and Cahuc ( 2010 ), we are interested in the variation of inherited trust around a precise date, 1918, and this requires higher accuracy in the identification of the respondents whose ancestors migrated before or after such date. Taking for example second‐generation Americans, since we infer the date of migration of their parents from their year of birth, including in the post‐1918 sample also people born immediately after such date (i.e., 1919, 1920, etc.) might lead to consider as migrated after the spread of the epidemic also some individuals whose parents actually migrated before that date. Such risk of misclassification of the period in which individuals' parents migrated is decreasing in the time distance L between their birth date and the date of the outbreak of the Spanish flu (1918). Thus, to address this possible issue we run two sets of robustness tests. In the first one, we allow for the existence of a lag between the time of migration and having a child in the country of arrival, and we test the robustness of our baseline results to the use of different lengths for such lag. In the second one, we run a set of “donut” regressions by directly removing individuals arriving in the United States in a year close to the cutoff. The results of both sets of tests are not significantly different with respect to the main specification.

Concerning the empirical specification adopted in the baseline analysis, we estimate inherited trust in both periods by Ordinary Least Squares (OLS) and using the following equation:

where i identifies the individual and c the country of ethnic origin. We exclude from the estimation all those countries which are present within only the pre‐1918 sample or only the post‐1918 one, and those for which there are less than 25 observations in one of the two periods, in order to guarantee a minimum level of representation within each sample (see Section Sensitivity Tests ). We are interested in estimating the coefficients β c , that is the coefficients of the country‐of‐origins fixed effects. Each of these coefficients should capture the average level of trust transmitted to their descendants by people that moved from one of the sample countries of origins to the United States with respect to the reference country of origin, that is Austria. Given the dichotomous nature of the dependent variable each coefficient represents the variation in the predicted probability of trusting others (i.e., Trust i  = 1) for a given country of origin with respect to Austrian Americans. The vector X i includes all the controls used in the regression, namely age, age squared, gender, education, income, religion, employment status, number of immigrant grandparents and whether he is second‐, third‐ or fourth‐generation American. Standard errors are adjusted for heteroskedasticity and clustered at country‐of‐origins level to account for serial correlation.

Appendix  A provides a detailed list of all the variables employed in the estimation of inherited trust together with their description, while Table  1 shows the summary statistics for all of them. Table  2 , instead, provides the estimated value of inherited trust (i.e., the predicted probability of trusting the others) for each country of origin, separately for the pre and post‐1918 samples.

Estimating inherited trust: Summary statistics

Note : The table displays the summary statistics for the variables used in the estimation of inherited trust.

Estimates of inherited trust

Dependent variable: Trust . Each coefficient represents the predicted probability of trusting the others in one of the country of origin included in the estimation samples for the pre‐1918 and post‐1918 periods. The predicted probability are calculated using the estimates of Equation ( 1 ) for both periods.

The pre‐ and post‐1918 sample of the GSS are not the same in terms of size. This is in part due to the large immigration waves to the US before 1918. 5 The use of a time varying control for changes in migration flows from each country of origins to the US, as described in Section 3.2, as well as the inclusion of the interaction between the post‐1918 dummy and the value of change in migration flows before 1918 as a robustness test in Section  4.1 , should rule out any concern related that these samples differ in size. Another reason behind the difference in size between the two samples comes from the way we reconstruct the time of arrival in the United States of the GSS respondents' ancestors, and in particular to the fact that we consider a lower bound in the time window for defining each generation before and after 1918, but not an upper bound. 6 Given that, in Section  4.1 , we explicitly test the robustness of the main results to the use of a 25‐years‐long period for defining each generation before and after 1918, thus with both an upper and a lower bound. The main results remain unaffected.

4.2. Inherited trust and Spanish Flu

In order to evaluate how inherited trust varied due to the spread of an epidemic, we compare its evolution before and after the outbreak of the Spanish flu. Thus, the estimates of inherited trust for each country of origin for the pre‐1918 and post‐1918 periods obtained as explained in Section Estimation of Inherited Trust are now used as the dependent variable.

To isolate the effect of the Spanish flu on inherited trust we adopt the following empirical approach:

where c identifies one of the 18 countries of origin and t the period of migration (i.e., pre‐ or post‐1918). The dependent variable, inherited trust is the predicted probability of trusting the others for each country as given in Table  2 . The coefficient of interest here is β 2 , that captures the effect of the treatment: mortality in the home country interacted with post 1918, a dummy that takes value 1 for the post‐1918 observations and 0 for those before 1918. It broadly measures the variation in the level of inherited trust of people whose ancestors emigrated to the United States after the outbreak of the Spanish flu from countries highly affected by the pandemic with respect to those whose ancestors came from less affected countries.

The equation includes X c , t which collects the country of origin‐level controls. We focus on five main variables that could affect both the level of trust of people emigrating from a specific country and their propensity to migrate from that country. Among these factors, which we collected for the pre‐ and post‐1918 periods, we take into consideration the GDP per capita, the population density, primary school enrollment, a general index for the quality of the home country institutions (Polity‐IV score) and the rate of change in migration flows from the home country to the United States. Moreover, we also include the interaction between post 1918 and a dummy, neutral, which is equal to one if the country of origins remained neutral during WWI, and 0 otherwise. Given the time overlap between the spread of the epidemic and the end of WWI, the inclusion of such interacting term is aimed at controlling for different kinds of heterogeneity in the post 1918 period for neutral and belligerent countries, respectively. In fact, the literature have found that experiencing a war may either lower or foster the level of trust among individuals (Bauer et al.,  2016 ), thus controlling for the participation of the countries to WWI becomes crucial in our setting in order to avoid a possible bias in our estimates due to this alternative source of long‐lasting change in trust that is contemporaneous to the outbreak of the Spanish flu. 7 Lastly, country of origin fixed effects are captured by δ c , 8 while standard errors are adjusted for heteroskedasticity.

The validity of the DiDapproach just described relies on the assumption that countries heavily hit by the flu are on parallel trends of generalized trust with respect to those less affected in the pre‐1918 period. We test is this is indeed the case by also running an event study approach. In particular, we adapt the Algan and Cahuc's procedure described in Section 3.1 to estimate the level of trust for two different periods before 1918 (i.e., 1891–1900 and 1901–1910), and for one after (i.e., 1926–1935) 9 We estimate the following regression equation:

where Period 1 t is a dummy indicating if the observation is related to the 1891–1900 period, and Period 3 t if it instead refers to the 1926‐1935 period. To assess the validity of our DiD approach, interest lies in consistently estimating β 3 and β 4 , which represent the differential change in the level of trust for the two periods, between countries more affected by the flu and those less affected, with respect to the last period before the epidemic, that is, our reference period that is 1901–1910. In other words, if our DiD is valid, we should expect the former to be not significant, while the latter to be negative and significant. The set of control variables X c , t is the same as included in Equation ( 2 ), with the only difference that now they are calculated for three different periods. As before, δ c controls for country of origins fixed effect and the standard error are robust to heteroschedasticity.

Appendix  A provides a detailed list of all variables employed in the estimation of the effect of the pandemic on inherited trust together with their description, while Table  3 reports the summary statistics for all of them.

Spanish flu and trust: Summary statistics

Note : The table displays the summary statistics for the variables used in the estimation of the relationship between inherited trust and Spanish flu mortality.

5. THE IMPACT OF THE SPANISH FLU ON SOCIAL TRUST

The main results of our analysis are presented in Table  4 . In column (1) we run Equation ( 2 ) without any control, in column (2) we add the time‐varying controls, while in column (3) we also include the interaction between Post 1918 and Neutral. Instead, column (4) investigates how the neutrality of the home country in WWI eventually channeled the impact of the epidemic on trust by including a triple interaction between Flu Mortality, Post 1918, and the dummy Neutral.

The effect of Spanish flu on inherited trust: DiD estimates

Dependent variable: Inherited Trust . FluMortality is the country‐level death rate for Spanish flu (i.e., deaths per thousand inh.). Post 1918 is a dummy taking the value 1 for the observations after 1918 and 0 otherwise. Columns (2), (3), and (4) include time‐varying controls. The controls are: GDP per capita (PPP), population density, primary school enrollment (%), Polity‐IV index and the change in migration flows to the US. Columns (3) and (4) also includes the interaction between the dummy Post 1918 and the dummy Neutral , which is equal to 1 if the country of origins remained neutral during WWI and 0 otherwise. Standard errors are robust to heteroschedasticity.

*, **, *** indicate statistical significance at 10%, 5%, and 1% level, respectively.

As columns (1)–(3) show, we find a negative and significant effect of the Spanish Flu on trust, suggesting that large‐scale epidemics can indeed have a negative impact on the latter. According to the most complete estimates (i.e., column [3]), an increase in influenza mortality of 1 death per thousand resulted in a 1.4 percentage points decrease in trust, while a 1 standard deviation increase in mortality (i.e., an increase of 4.4 deaths per thousands) decreased our measure of trust by 6.6 percentage points, corresponding approximately to a 1 standard deviation in trust.

The results showed in column (4) provide suggestive evidence on the possible mechanism through which the main effect took place: the impact of the pandemic on trust was significantly more negative in countries that remained neutral during WWI. In fact, an increase in influenza mortality of 1 death per thousand in neutral countries resulted in a 2.2 percentage points decrease in trust. This evidence is strongly consistent with the idea that the narrower resonance of the war within these countries, and in particular the specific lack of war censorship on media, allowed citizens to fully perceive the extent and severity of the pandemic, and thus alter their social interactions in a stronger way.

Figure  3 gives a graphical representation of the main results obtained from running the event study specification with all the controls described in Equation ( 3 ), that is the estimates for the coefficient β 3 and β 4 . 10 In line with our expectation, the estimation of the coefficient for the period 1891–1900 is not significant, signaling that the parallel trend assumption does hold, whereas the coefficient for the post‐flu period 1926–1935 is still negative and strongly significant. 11 This ultimately provides further support for the validity of our baseline approach.

The Effect of Spanish Flu on inherited trust: Event study. The figure shows the point estimates and the confidence intervals at 90% (i.e., least‐wide spikes), at 95% (i.e., medium‐wide spikes) and at 99% (i.e., widest spikes) for the coefficients β 3 and β 4 showed in Equation ( 3 ). The dependent variable is generalized trust. Among the time‐varying controls included in the regression there are: GDP per capita (PPP), population density, primary school enrollment (%), Polity‐IV index, the change in migration flows to the United States, countries of origins fixed effect and the interaction between the dummy Post 1918 and the dummy Neutral, which is equal to 1 if the country of origins remained neutral during WWI and 0 otherwise. Standard errors are robust to heteroschedasticity

5.1. Robustness checks

In Table  5 , we present the results of several tests to assess the robustness of the baseline results presented in column (3) of Table  4 , which, as already said, we consider the most complete specification of our baseline regression model.

Robustness tests

Dependent variable: Inherited Trust . Coefficients showed in column (1) refers to the interaction term between FluMortality and Post 1918 showed in Equation ( 2 ), while column (2) reports the standard errors of such coefficients. Column (3) reports the R 2 , whereas columns (4)‐(6) the number of observations in the first step of the estimation procedure, those in the second one and the total number of countries included i each specifications, respectively. In row (1), we do not set a minimum number of GSS respondents for a country to be included in the sample, thus adding Japan. In row (2), we set a minimum of 50 GSS respondents. In row (3), we set bounded age interval to defining the generations before and after 1918. In row (4), we exclude Mexico from the sample countries. In row (5), we use a one‐step procedure for the estimation, while in row 6) and 7) we use as estimation model a logit and an order logit respectively. In rows (8), (9), and (10), we test different lags L to separate the pre‐1918 and post‐1918 GSS respondents groups. In rows (11), (12), and (13), we remove individuals at different distance from the cutoff of 1918. In rows (14) and (15), we define generations as being of 20 and 30 years respectively. In panel (d), we adopt discrete measures of flu mortality: in row (16), FluMortality is coded as 1 if a country belongs to the top 40% of the flu mortality distribution, while in row (17), if it belongs to the top 10%. In row (18), we exclude population density as a control, in row 19) we add the interaction between the number of WWI fatalities and the dummy Post1918 as further control, while in row (20), we add the interaction between participation to WWII and the dummy Post 1918. In rows (21)–(25), we separately include the value of each control before 1918 interacted with Post 1918, and jointly in row (26). In row (27), we adjust standard errors for small sample size. In row (28), we use as dependent variable Trust in the army. In row (29), we use as dependent variable Trust in the federal government, while in row 30) trust in medicine. If not diversely specified, the controls are GDP per capita (PPP), population density, primary school enrollment (%), Polity‐IV, migration to US and the interaction between the dummy Post1918 and the dummy Neutral, which is equal to 1 if the country of origins remained neutral during WWI and 0 otherwise. Standard errors are heteroskedastic‐robust.

*, ** ***indicate statistical significance at 10%, 5%, and 1% level, respectively.

In Panel (a), we test different ways of constructing the sample for estimating inherited trust in the pre‐ and post‐1918 periods, as well as the exclusion of Mexico from the analysis. Specifically, in row (1), we remove the minimum threshold of 25 respondents in each period, which essentially means adding also Japan to the sample of countries of origins taken into account. Instead, in row (2), we increase this threshold to 50 respondents. On the one hand, this implies an increase in the degree of representativeness of our estimates of inherited trust, but on the other hand it leads to a narrower sample of countries of origins. 12 In row (3), we consider 25‐year‐long periods for defining each generation before and after 1918, thus with both an upper and a lower bound. As pointed out in Section 3.1, this test is aimed at reducing any enedogeneity related to differences in size between the pre‐ and post‐1918 samples. In row (4), we exclude Mexico from our estimation since it represents an outlier both in terms of deaths due to the epidemic and size of the migration flow toward the United States.

Next, in Panel (b), we test an alternative functional forms for Equation ( 1 ). In row (5), we implement a one‐step procedure, thus estimating an individual‐level regression on GSS respondents that include individual controls, country‐fixed effects, time‐varying country characteristics, and the dummy Post 1918 to measure if the respondent's ancestors migrated before or after the epidemics. As in the baseline model, we interact Post 1918 with Spanish flu mortality in the home country to assess the impact of the epidemics on generalized trust. In particular, this test helps us to address any possible concern related to the precision of the second step‐coefficients of our procedure eventually connected to the fact that the values of dependent variable for this step are not directly observed but instead estimated through the first‐step. In row (6), we take into consideration the dichotomous nature of the dependent variable in Equation ( 1 ) and we estimate this latter by using a nonlinear regression model in the place of OLS, that is a Logit regression model. Next, while in the baseline we code trust as 1 for “Most people can be trusted” and 0 for “Cannot be too careful” or “Depends”, in row (7), we estimate trust using an ordered logit model, thus separating the respondents that answered “Depends” from those that answered “Cannot be too careful”.

Following, in Panel (c), we show the results of a set of tests aimed at better differentiating the respondents whose ancestors migrated before the flu epidemic from those whose ancestors migrated after that. As explained in Section 3.1, we do that by two batteries of tests. In the first set of tests, we introduce a lag L for selecting the respondents to include in the post‐1918 sample according to their birth date. In details, the post‐1918 sample will include now (I) all the second‐generation respondents that were born after 1918+L, (II) the third‐generation respondents born after 1943+L, and (III) all the fourth‐generation Americans born after 1968+L. As pointed out in Section 3.1, this is a departure from Algan and Cahuc ( 2010 ), and it is due to the fact that differently from them, we are interested in the variation of inherited trust around a precise date, 1918, thus requiring higher accuracy in the identification of the respondents whose ancestors migrated before or after such date. Taking for example second‐generation Americans, since we infer the date of migration of their parents from their year of birth, including in the post‐1918 sample also people born immediately after such date (i.e., 1919, 1920, etc..) might lead to consider as migrated after the spread of the epidemic also some individuals whose parents actually migrated before that date. Indeed, it is fair to assume the existence of a lag between the time of migration and having a child in the country of arrival, for instance related to the adaptation to the new context. Such risk of mis‐classification of the period in which individuals' parents migrated is decreasing in the time distance L between their birth date and the date of the outbreak of the Spanish flu (1918). Allowing for greater values of L would mean that we are allowing for a wider adaptation period, thus we are more likely to include only people whose parents did migrate after 1918 and then they had the child. On the contrary, very high values of L might lead us to consider in the post‐1918 sample many individuals whose parents did not really experience the epidemic in their home country because they were too young at that time or still not born. In row (8), L is equal to 5 years, it is equal to 10 years in row (9), while it is equal to 15 in row (10). As for the second kind of test, and similarly to the approach proposed in Barreca, Guldi, Lindo, and Waddell ( 2011 ), we run a set of “donut” regressions by simply removing individuals close to the 1918 cutoff. Specifically, we implement separately three regressions that in turn exclude individuals whose ancestors arrived in the US within 5 (row [11]), 10 (row [12]), and 15 (row [13]) years before or after 1918. As additional tests regarding the definition of ancestors' arrival, we also present the coefficients obtained by separately using two different lengths for the gap between generations, which are 20‐ and 30‐years (rows [14] and [15]). 13

In Panel (d), we present alternative discrete measures for the Spanish flu mortality in each county. Indeed, the method used to calculate the death rates employed in the main analysis varies from study to study, on the basis of the data available for each country. Such heterogeneity in how the death rates are calculated for each country could undermine the reliability of the comparison based on the continuous measure, mainly due to the difficulty of measuring marginal differences in such rates across countries. Moreover, in terms of size of the effect, the continuous measure captures the effect of the Spanish flu on trust only at the average level of the former, while it says nothing on the existence of possible non linearities in the relationship between the two variables. For this reasons, we repeat the analysis using two discrete measures of Spanish flu mortality related to its general distribution across all the countries included in our sample. In row (14), countries are assigned to the high flu mortality group if they belong to top 40% of the flu mortality distribution and 0 otherwise. In row (15), countries are assigned to the high flu mortality group if they belong to the top 10% of the flu mortality distribution and 0 otherwise. These measures, given their non‐parametric nature, should make the analysis of differences across countries both more reliable and more insightful than the use of a continuous measure of the impact of the Spanish flu.

In Panel (e), we test different control strategies for our baseline regression. In row (16), we do not include population density as a control in the regression, since population density after 1918 was potentially affected by the Spanish flu epidemic. In row (17)–(18), we allow the dummy Post 1918 to vary differently with respect to the country's deaths due to WWI, and its participation to WWII, respectively. We do so by including the interaction of Post 1918 separately with the number of WWI deaths at the country level as compiled by Barro, Ursua, and Weng ( 2020 ) 14 , and with a dummy taking value 1 if a country participated in WWII and 0 otherwise. Similarly, in rows (19)–(24). we include as controls a set of interactions between the dummy Post 1918 and the pre‐1918 value of the controls present in the baseline regression, first separately and then all taken together. The aim of this set of tests is to control for other possible major shocks experienced by some countries in the post‐1918 period by allowing the post‐1918 fixed effect to vary across different levels of each control variable. 15

Given the reduced number of observations for estimating Equation ( 2 ), in row (25) of Panel (f), we allow for small‐sample correction of the standard errors. In row (26) of Panel (g), we run a falsification test for the baseline specification by analyzing another social attitude that, while correlated with generalized trust, is unlikely to be significantly altered by the Spanish flu pandemic, that is, trust in the army.

All the tests presented through Panels (a)–(f) show that the coefficient of interest remains significantly negative, whereas the falsification test presented in Panel (g) is not statistically different from zero. These results ultimately confirm the robustness of the main findings: social trust appears to have decreased in countries that were hit the hardest by the pandemic.

In Panel (h), we extend our analysis and we show the effect of the Spanish flu on other two outcomes potentially related to our main analysis on generalized trust, which are trust in federal government (row [27]) and medicine (row [28]). 16 On the one hand, we do not find any significant effect on the former. This is a quite interesting result, especially in the light of the work by Flückiger et al. ( 2019 ) on the Ebola outbreak in Africa. In fact, while for Ebola there is no effect on social trust but a positive one on trust in government, just the opposite seems to be true for the Spanish flu. This eventually reflects how different features of the two diseases led to different impacts on individual attitudes. On the other hand, we also observe a negative and significant effect of the Spanish flu on the general level of trust in medicine, which is in line with our argument that the pandemic was an utter failure of health care institutions, and that such failure could have helped to catalyze the negative impact of the epidemic on peoples' level of generalized trust.

Lastly, it is worth reflecting on the fact that in principle, our estimates might be explained by the existence of negative selection on high‐trust migrants from each country of origins, which is positively correlated with the intensity of Spanish flu in the country, rather than by the effect of epidemics on trust. In fact, it is possible that people with a higher level of trust had higher mortality from the flu, and so they migrated less. Here the argument would be that high trust individuals would have a lower reduction in their social interactions, and consequently increase their probability of becoming infected and dying. Unfortunately, the complete absence of cross‐countries data about social trust among migrants to the United States for the periods considered in our analysis makes any kind of empirical test of such hypothesis simply unfeasible in our framework. Nonetheless, the literature on the role of trust in mediating the probability of infection during an epidemic seems to point toward to the opposite dynamics (Barrios, Benmelech, Hochberg, Sapienza, & Zingales,  2020 ; Chuang, Huang, Tseng, Yen, & Yang,  2015 ; Rönnerstrand,  2013 ). In particular, the higher the level of social trust, the more people will comply with the policy recommendation to avoid contagion, thus decreasing their likelihood to get infected. This would mean that if a selection on high‐trust of migrants induced by the flu does exist, it would be a positive one ultimately generating an attenuation bias in our estimates.

6. CONCLUSIONS

Our analyses suggest that experiencing the Spanish Flu and the associated condition of social disruption and generalized mistrust had permanent consequences on individual behavior in terms of lower social trust. These mutated individual social traits were inherited by descendants, at least to some significant degree. Our results are in line with recent studies showing how large‐scale crises affect individual behavior in a lasting way. This literature, however, has focused on natural disasters, and not on epidemics or pandemics. Moreover, disasters of different kinds also produce different consequences for trust (Albrecht,  2017 ; Skidmore & Toya,  2014 ). In other words, not all natural disasters would necessarily reduce social trust. Among those that do, however, earthquakes and floods feature prominently (Carlin et al.,  2014 ; Skidmore & Toya,  2014 ). Our finding suggests that major pandemics should be added to this list of trust‐reducing catastrophes. Although we are unable to undertake similar studies for pre‐Spanish Flu pandemics, one can hypothesize that processes of this kind might also have been triggered by other major mortality crises of the past, which would include the medieval Black Death and the severe Cholera pandemics of the nineteenth century. Our findings are fully in line with recent research on the lasting consequences of some of these episodes, consequences that can be felt for several centuries (Alfani,  2020 ; Alfani & Murphy,  2017 ; Jedwab et al.,  2016 , 2019 ; Koyama & Johnson,  2019 ; Richardson & McBride,  2009 ; Voitgländer & Voth,  2012 ). Although our evidence involves a much shorter time period and we do not claim that the effects of the Spanish Flu will be felt centuries from now, our key result has important implications for our understanding of socioeconomic development of today's societies. Given the enduring differential in health levels across world regions, and considering the fact that the most recent major epidemics have mostly involved relatively poor countries, one may argue that any forecasting of their future performance should account for the lasting damage to social trust, which has elsewhere been shown to have pivotal impact on the quality of institutions (Knack,  2002 ) and economic success (Algan & Cahuc,  2010 ). This feature might be relevant for the African sub‐Saharan countries which have been affected by Ebola in recent years. Indeed, during the 2013–16 Ebola epidemic episodes of social mistrust were reported, involving not only those infected but also the survivors who carried a heavy social stigma several months after they had recovered from the disease (Hayden,  2014 ; O'Grada,  2016 ; Reardon,  2015 ). The trauma suffered caused lingering clinical mental health conditions to the survivors (Reardon,  2015 ), but the consequences of Ebola and of other severe epidemics and pandemics—both future and past—might be more subtle, last longer, and in the end be more harmful to society as a whole than what can be detected clinically.

Our findings are also relevant for the ongoing debate about the economic consequences of COVID‐19. A general point to make, is that based on the experience of the Spanish Flu, we should consider the possibility that beyond immediate and relatively easy to measure effects on national economies, other, more elusive effects of the pandemic might be equally relevant and should be properly taken into account. A particularly important point is that if, during the Spanish Flu, the failure of government institutions and national health care services to contain the crisis led civil societies to experience a serious breakdown due to the climate of generalized suspicion (a situation further exacerbated by mistakes in communication, also due to war censorship) and this increased the persistent damage to social capital, then governments facing COVID‐19 today might have an additional reason to opt for strong policies of pandemic containment. While these are undoubtedly costly in the short run, it might be that they will contribute to minimize some economic costs to be paid in the long run.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

Supporting information

Supporting information S1

ACKNOWLEDGMENT

We are grateful to Gianmarco Daniele, Noel Johnson, Federico Masera and the participants at Giornate di Studio sulla Popolazione (Popdays) 2019 for the useful comments. We gratefully acknowledge financial support from the European Research Council with grant no. 694145.

1 In fact, as described by Honigsbaum ( 2013 ), p. 184, in belligerent countries, “propaganda discourses encouraged the cultivation of stoicism at the expense of other emotional scripts” , which might have gone a long way toward reducing the impact of the pandemic on individual behavior and on public memory (Crosby,  1976 ).

2 The 1972–1974 surveys used modified probability designs while for the remaining waves a full‐probability sample design has been adopted.

3 In a robustness test included in Section  4 , we also consider the three categories separately.

4 There are three other countries for which this information is available, that is Japan, India and the Philippines. Concerning Japan, it is excluded from the baseline due to its very limited representation within the final samples used to run our main analysis. However, among the sensitivity tests, we re‐run the regression including this country and the results are almost unaffected. Regarding India and the Philippines, they are excluded because of missing values in the control variables. It is also worth mentioning that an estimation of the Spanish flu mortality is also available for Brazil from a specific administrative source and it has been employed in Guimbeau et al. ( 2019 ), but such estimation cannot be used in our study since it regards only a specific region within the country (i.e., the state of São Paulo), thus not comparable with those at the country level provided in Johnson and Mueller ( 2002 ).

5 In fact, our estimation samples contain mostly European countries, and the arrival of people from these countries before the Spanish flu mostly happened during two specific periods: (i) the first part of the 19th Century and (ii) between 1880 and 1920.

6 This mechanically implies a higher number of individuals available to estimate the pre‐1918 level of trust than for the one for post‐1918, simply because there is a longer time window for arriving in the US and having descendants.

7 This interaction also helps us to address potential concerns related to any kind of trend in the reported number of deaths for Spanish flu linked to WWI.

8 It is worth to notice that among the many potentially observable and unobservable confounders, which the inclusion of country of origin‐fixed effects eventually controlled for, there is the possible existence of country‐specific measurement error in the numbers of reported deaths for Spanish flu, as for example the one linked to the participation of the country to WWI. In fact, it is fair to assume this error to be fixed at the country of origins level, at least in the one year and half during which the epidemic spread, and so captured by the country of origin‐fixed effects.

9 The estimates for the three periods are presented in Appendix  B . Given the possibility of misclassification around the cutoff described in Section 3.1, we exclude from this specification the period between 1911 and 1925. Furthermore, it is worth to notice that, given the lower and upper limits imposed on the time window for each period, the number of individuals available for estimating the level of trust in the first stage of our procedure is strongly reduced with respect to the DiD specification. For this reason, we prefer to maintain the event study only as a complementary approach to the DiD implemented in the baseline.

10 This specification is directly comparable with the estimates presented in column (3) of Table  4 .

11 We run the event study approach using the most complete specification, that is the one including time‐varying controls, country of origins fixed effects and the interaction between the period dummies and the status of the country during WWI. For sake of brevity and clarity we omit the regression tables with the coefficients of the first and second stage of our procedure. Instead they are reported in Appendix  B .

12 Specifically, using the threshold of 50 respondents we are left only with Canada, the United Kingdom, France, Germany, Ireland, Italy, Mexico, Netherlands, Norway, Russia, Spain, and Sweden.

13 Note that using a shorter or a longer definition does not have much sense in our specific framework, since we are interested in estimating inherited trust around a specific date (i.e., 1918). A significantly shorter definition for the generational gap would magnify the concerns related to the differentiation between respondents whose ancestors migrated before the flu epidemic and those whose ancestors migrated afterward, which we try to partially address in rows (8)–(13) of Table  5 . For example, with 10‐years generations we would consider as third‐generation Americans all the individuals born after 1929, thus likely also including many respondents whose ancestors actually emigrated before the onset of the pandemic. Similarly, a longer definition would also increase the likelihood to mis‐classified the arrival individuals' ancestor with respect to 1918, but just in the opposite direction. Indeed, a significantly longer generational gap, as for example one of 50 years, would imply to consider the ancestors of third‐generation Americans born up to 1968 to have migrated to the United States before 1918, a rather questionable assumption.

14 Data are unavailable for Finland and Ireland.

15 In particular, the test presented in row (24) allow for the possibility of changes in the US migration policy both between countries and periods.

16 These measures, as the one employed in row (26), are calculated with the same methodology employed in the main analysis, but using different GSS survey questions.

DATA AVAILABILITY STATEMENT

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The Spanish Influenza 1918-1920: Devastating for Public Health Essay

Introduction, government and health organizations response, role of influencing factors.

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.

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).

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).

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).

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.

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.

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Bibliography

IvyPanda . "The Spanish Influenza 1918-1920: Devastating for Public Health." March 25, 2024. https://ivypanda.com/essays/the-spanish-influenza-1918-1920/.

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• World Vision: Influenza Pandemic Preparedness Plan
• Microbiology: Influenza Viruses
• The Y2K Bug and the Spanish Flu Pandemic of 1918 Research Methods
• Influenza in Australia: Are We Ready to Fight With It?
• Environmental Health Project: Swine Flu
• Syphilis Outbreak Prevention
• Infection Control and Prevention of a Pandemic
• ICU Ethics Committee Meeting: The Spread of the Novel Coronavirus
• Attitude to a Sick Person
• Social Distancing: Communication With Patients Families

The 1918 Flu Pandemic: Why It Matters 100 Years Later

Here are 5 things you should know about the 1918 pandemic and why it matters 100 years later.

1. The 1918 Flu Virus Spread Quickly

In 1918, many people got very sick, very quickly. In March of that year, outbreaks of flu-like illness were first detected in the United States. More than 100 soldiers at Camp Funston in Fort Riley Kansas became ill with flu. Within a week, the number of flu cases quintupled. There were reports of some people dying within 24 hours or less. 1918 flu illness often progressed to organ failure and pneumonia, with pneumonia the cause of death for most of those who died.  Young adults were hit hard. The average age of those who died during the pandemic was 28 years old.

2. No Prevention and No Treatment for the 1918 Pandemic Virus

3. Illness Overburdened the Health Care System

As the numbers of sick rose, the Red Cross put out desperate calls for trained nurses as well as untrained volunteers to help at emergency centers. In October of 1918, Congress approved a $1 million budget for the U. S. Public Health Service to recruit 1,000 medical doctors and more than 700 registered nurses.

At one point in Chicago, physicians were reporting a staggering number of new cases, reaching as high as 1,200 people each day. This in turn intensified the shortage of doctors and nurses.  Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

4. Major Advancements in Flu Prevention and Treatment since 1918

There is still much work to do to improve U.S. and global readiness for the next flu pandemic. More effective vaccines and antiviral drugs are needed in addition to better surveillance of influenza viruses in birds and pigs. CDC also is working to minimize the impact of future flu pandemics by supporting research that can enhance the use of community mitigation measures (i.e., temporarily closing schools, modifying, postponing, or canceling large public events, and creating physical distance between people in settings where they commonly come in contact with one another). These non-pharmaceutical interventions continue to be an integral component of efforts to control the spread of flu, and in the absence of flu vaccine, would be the first line of defense in a pandemic.

5. Risk of a Flu Pandemic is Ever-Present, but CDC is on the Frontlines Preparing to Protect Americans

CDC works tirelessly to protect Americans and the global community from the threat of a future flu pandemic. CDC works with domestic and global public health and animal health partners to monitor human and animal influenza viruses. This helps CDC know what viruses are spreading, where they are spreading, and what kind of illnesses they are causing. CDC also develops and distributes tests and materials to support influenza testing at state, local, territorial, and international laboratories so they can detect and characterize influenza viruses.  In addition, CDC assists global and domestic experts in selecting candidate viruses to include in each year’s seasonal flu vaccine and guides prioritization of pandemic vaccine development. CDC routinely develops vaccine viruses used by manufacturers to make flu vaccines. CDC also supports state and local governments in preparing for the next flu pandemic, including planning and leading pandemic exercises across all levels of government. An effective response will diminish the potential for a repeat of the widespread devastation of the 1918 pandemic.

Visit CDC’s 1918 commemoration website for more information on the 1918 pandemic and CDC’s pandemic flu preparedness work.

63 comments on “The 1918 Flu Pandemic: Why It Matters 100 Years Later”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy » .

Hi, Thank you for this article. Very informative. Maybe the people that do not understand and do not accept the vaccination campaign will change their minds.

Excellent historical perspective on the 1918 incident. We have come a long way in treatment protocols and diagnostic advancements with respect to infectious diseases. The major concern,at this time, is an unknown pathogen which will be quickly spread worldwide my international jet travel. A few sick people on an aircraft entering the US could easy spread the disease from one end of the Country to the other. Depending on the conditions’ incubation period many more people will be affected before public health officials begin to see a problem. I guess the only thing we can be sure of is something similar will occur again , it’s just a matter of the right conditions and time.

This is a wonderful article on the influenza virus. I have extensively read about the pandemic, and its devastating effect on people. I must admit that I am appalled at the refusal to use trained nurses because they were Black Americans. That nonsense was part of the failure to help people in need of care at this crucial time . I must say it was hateful and ignorant of White Americans. White Americans are not reminded enough that they are immigrants to America just like any other race that came to this country from another country. America does not belong to white people. I don’t believe sick people care who is attending to them when they are on the brink of death.

Well done article. However. You could include a list of historical accounts for Further reading materials.

The possibility of another potential outbreak of any kind is a very scary and real test of how very little know. We indeed have come along way but still have a distance to go. .. Thank you for sharing this fascinating story.

Two of my grandparents were killed in their 30s by this epidemic, leaving my 1 year-old mother, my aunt, and my uncle orphaned. This is important stuff; people need to take influenza seriously.

My grandfather was a doctor in the Spokane Wa area and died from the flu in July of 1918 at age 46 . He was from the St Louis Missouri area and had been in the Spokane area for several years but could have visited or was visited by people from the St Louis area which is close to Kansas City to have caught the flu . Spokane was very isolated . This article gives no answer but gives some background to how he caught the flu in the middle of nowhere at the beginning of this pandemic

Would the mortality rate be as bad as the flu pandemic in 1918 where 675,000 people were killed? How would our economy be affected? Any thoughts?

The book “The Great Influenza” by John M. Barry has many historical references on this topic.

Good summary of the 1918 flu pandemic. But the sentence “The average age of those who died during the pandemic was 28 years old” (end of the first section) is inaccurate. Twenty-eight was the age at which mortality peaked among young adults, who were the hardest hit, along the very young and the very old. As for the average, variations in infant or old adult mortality could easily tip the balance away from 28 years.

In researching flu a few years ago, I read that one reason this flu killed people of supposedly optimum age for strength and resistance (~28 years), was for exactly that reason – their immune systems responded so quickly – with fluid in the lungs – that they drowned. People who responded more slowly, with less fluid produced less quickly – were more likely to survive.

By the way, if this thing posts (my first post ever on this site), I’m getting this message:

You are posting comments too quickly. Slow down.

(Please check your software)

I would agree with Tonya and Robert, there is an ever-present threat of a variant flu virus reeking havoc as many go unprepared for each flu season by not vaccinating, but also with a new, unknown pathogen. With the climate changing and the glacier ice melting to new low levels, bacteria, viruses and parasites previously encased in ice soon may be exposed to air, water, and humans. I am thankful for the diligent surveillance that the CDC and the WHO provides.

Thank you for that summary. The pandemic took my grandmother in the Spring of 1919. My father and his two sisters were orphans then. Their father had died in France, November 1918. It is always so sad for me to read about this.

Any plan to slow or stop a pandemic would include quickly identifying those who are contagious and minimizing their contact with others. However we do not have in place policies that would encourage that behavior, particularly in the low income and immigrant populations, including people who: * cannot afford to take time off work without pay * would lose their jobs if they did not show up * have no health insurance and can’t afford medical care * are afraid to seek care because of immigration status (their own or family member’s) And anyone who was quarantined would want to know that their basic needs would be met if they complied. I believe these issues would be best addressed in advance to overcome resistance. Once a potential pandemic starts, it will be difficult to get the necessary public and private buy-in, resources and authority until it is too late.

It’s surprising that to see that the first three items listed would apply to any similar pandemic of unknown origin today. Today’s air travel would spread an illness at previously unheard of rates. Couple that with an unknown origin and our health care systems would be over run just as they were in 1918.

Thank you so much for this article. I appreciate the information included and I pray that it convinces people with reservations to keep their own and their families health in mind for everyone’s sake but especially their own.

My grandmother was 11 years old in 1918. The family was from Philadelphia. I remember her telling me that she had to help load dead bodies into wagons. They would yell in the neighborhoods, “throw out your dead!” She never got the flu, but it must have been horrible! That is why we were always told never to spit on the streets. It can carry diseases, etc. People—Don’t think this cannot happen again. We live in an age where we can prevent the worst from happening when it comes to flu and other diseases. Get your flu shots!

Very educative write-up. A big lesson for us in Africa. The surveillance of influenza viruses must be sustained especially at animal-human interface to monitor possible new mutations. Thank you.

My grandfather was 15 years old. His parents and his two siblings were very ill with the flu so he ran to get help. By the time he got back to the house they were all dead. I am lying in bed with the H1N1 right now. Probably the sickest I’ve ever been. I personally believe facemasks should be mandatory and all public transportation. What a tragedy all the way around.

Great information on the flu pandemic. Very educative and sad.

History has taught us much about various past outbreaks. It’s the future unknown pathogens manmade or natural we need to worry about.

Great article on the flu pandemic. I have done a lot of studying on the issue. John Barry has written many books about the pandemic I find it incredible and riveting to learn about how people would wake up in the morning feeling fine and be dead in the evening. I have spoken to many people who experienced the flu through their families. I have always wondered if this can never happen again. Let’s hope not.

Great informative article thanks I`ve just been watching THE LATEST NEWS ON THE 2020 CORONAVIRUS! making me wonder ?? I also remember COLLAPSING as I was walking down the street with HONG KONG FLU in 1956 Woke up in hospital…..TOOK MANY WEEKS TO RECOVER!!

while air travel will spread the virus faster today than before, the news of such virus is traveling even faster today, as can be seen in the current outbreak of 2019CoV. People around the world are in a state of panic as soon as it is reported. China did a total lock down pretty quickly. Nowadays, we get more information about the characteristics of the virus, like the temperature and humidity condition that is favorable/unfavorable to it, Scientists can produce a vaccine much sooner than before. So yes, we should be vigilant, but we do not need to be too scared to live our life normally.

Reading this in 2020, and it looks like the U.S. has not learned much.

those who do not know history are doomed to repeat it.

Actually, if you read how fast the flu spread, and how many died, some within 24 hours, we have come a long way! It took over 30 years to develop a flu vaccine, and within 3 months of coronavirus hitting, we have already started the clinical trials of a vaccine. Amazing!!

It’s like you saw into the future. The very not so distant future. Thanks for writing this as it reinforces the steps and procedures being followed today. If only they had been implemented sooner.

Here we go all over again

From this article I think WHO and CDC have not learned much to be in preparation. After 100 year another virus is here to take million lives away. Poor nation like Africa is in trouble. America should have known better to be prepare after 100years. God save us all

Apparently, there was no national plan then either. The lack of leadership by politicians on national and local levels is appalling and the realization that many top officials refuse to accept and follow recommendations of the CDC and other experts is terrifying. We are following exactly the same recommendations as were suggested in 1918, and there is inconsistent use of the precautions that we know help. Please support those who are taking the Coronavirus seriously and working to help us all. Bless the CDC and Drs and nurses on the front lines trying to save us all.

Great information

Watching the overrun hospitals, lack of supplies and reliance on local and state authorities because the federal government cannot or will not help. Schools are canceled. All groups more than 10 people. Social distancing rules are in place. The economy is crashing. No possible vaccine. History is repeating itself. I am literally hiding in my home with my family, knowing it’s the only way to avoid it.

Thank you for this article. It certainly puts the current COVID-19 pandemic in perspective, as well as reinforcing the need for social distancing! We are fortunate to live in a time when significant advances have been made in medicine and technology.

The CDC dropped the ball on this one, we need to shut down the country to prevent a worst case scenario. (writing this on 3/30/20) The economy will tank no matter what, but we can prevent millions of deaths yet.

My mother’s cousin was 21 when the 1918 influenza epidemic hit. He had cerebral palsy and was at risk for disease and he died. It’s hard though to comprehend how the influenza reached his tiny town outside of Abilene, Texas. There was very little medicine for colds or pneumonia for anyone in that time period.

100 years later viruses are still a problem.

The history repeats itself, we can see USA as the richest country, powerful country, is so unprepared! Doctors and nurses are lacking of protective gears, yet they have to work with the patients who are infected with the virus! The States have to bid against one another for ventilators etc. So many people are infected and die from this neglected, unguided way ! So sad!

Very informative information and thanks to all those people that put this information together. It seems to be working for this coronavirus we are currently experiencing. Keep up the good work and lets try to do our best to improve what we have learned from this virus and make it better next time around as we can see …. there will be a next time …. just currently unknown as to when.

Sydney Daniels Looking back at the comments in 2018 it is haunting. The accuracy of concerns and predictions! The rapid spread through international travel , the less privileged forced to continue working ,not only to perish but spread it. The fear of an unknown pathogen and it’s economic impact. The parallels of past and present are too hard to ignore. The Spanish flu acting very similar to Coronavirus. There are several stories in the news of patients over 100, who were alive during the 1918 flu, surviving coronavirus. Is it a stretch to think whatever immunity they acquired back in 1918 could have given them an edge or are they just tough as nails!? Is it immunologically impossible being a different virus and the years past? Just a thought? Unfortunately the reassurance, given in this article, that we have multiple guardrails in place to prevent such a huge spread again was wishful thinking. God bless everyone and stay safe.

My grandfather died from the Spanish flu and struck both my father and uncle as children. My father suffered cardiomyopathy and succumbed to it decades later. Financial struggles where perhaps worse since women had less legal rights and job opportunities that had any semblance of equal pay. My grandmother supported her family through a variety of seamstress jobs and cleaning for those that could afford that luxury. History is a good teacher if we can learn from it.

Watching the BOSSA. 45 min documentary on the spanish flu of 1918 so enlightening also. The symptoms of severe cases were bizarre and freakish, fatal in less than 24 hrs. A second wave (fall 2020) of covid must be minimized if world wants to prevent millions of deaths. Unfortunately, so many spoiled americans are selfish and very impatient willing to risk and sacrifice many others lives for a day at the beach or a new tattoo. If only they all could have done a 6 month sentence in county jail they would see that they could stomach months of quarantine in their own homes standing on their head, provided ample food and necessities are avialable.Too bad history will be repeated and this will be a disaster for so many more that shall lose their lives

here we go again!

102 years later and the struggles that our ancestors dealt with daily are being resurfaced again. As an RN working in the frontlines with the current flu pandemic, the level of stress that is experienced among health care workers is almost unbearable. Just as the 1918 flu was fast to spread with no prevention or treatment plan in place, this new outbreak is fast to spread and hard to treat and prevent. Taking a lesson from the 1918 pandemic, our facility took to making the staff and the patients wear mask for all interactions during their stay at our facility in an effort to reduce the risk of spreading patient to nurse or nurse to patient. The most unnerving concern to me personally is the fact that unlike the 1918 flu, an estimated 50% of individuals who have the COVID-19 virus have experienced zero symptoms. This makes the task of identifying the positive patients from simple screening procedures much more difficult due to lack of testing ability to confirm actual positive patients. For example, we had an elderly man in our facility for more than two weeks for an unrelated health care issue, screening upon admission declared he was a zero risk for COVID-19 and he never exhibited a single symptom during his admission, however upon discharge and transfer to a rehab facility, he had a COVID-19 positive test result. He continues to have ZERO symptoms but has exposed multiple health care workers and family members to COVID-19. The risk of infecting health care workers who are already spread thin only increases the workload demand on those still able to work.

We are currently short staffed at our facility with most nurses working four to six 12 hour shifts per week to keep the work demand in our facility at a manageable level. With the re-opening of our surgical units and other outpatient services, the “extra” support we were receiving from their health care staff has diminished but the increased workload demand on the inpatient staff is ever growing as the community continues to open up and social distancing is not adhered to. Our COVID-19 related ER visits more than doubled over one weekend when beaches alone opened up. As with the 1918 pandemic, the call for help in many areas had been made even to the point of allowing current nursing students to perform duties as an RN.

Because health care facilities across our nation are short staffed and limited on PPE, the task of identifying positive flu patients is important to isolate the continued spread of the virus but to also protect the health care workers and reduce the waste of precious PPE. Just as our health care workers in the past, social distancing, hand washing and face covers are the best methods that we have available to help slow the spread of this virus.

A hard lesson learned in the 1918 pandemic was that the early shut down of large social events and gatherings could help slow the spread and decrease the the burden on the local healthcare facilities. The CDCs plans of closing down schools, shopping centers, social gatherings of large numbers, and bars/clubs was the outcome of that hard learned lesson from 1918. Our community seems to have fared well with the early closing as we have not had many local citizens hospitalized with COVID-19, we do have a many COVID-19 patients in our facilities due to hospital transfers however due to our location being near two other States, one of which is a well known hot zone. We are all in this together and just like our 1918 health care teams, we too have answered the call to aid our neighboring States.

Opening up the public with care and caution is going to have to occur as many small business owners have already had to close their doors to our community permanently due to the length of time they went with no income. The economical impact this virus had already had on our community is evident and will only be truly seen in the future as things begin to return to our “New” normal.

COVID19 will also last for years as compared to Spanish flu and we should take the precautionary measures seriously

That was hard to read , here we are again in 2020.

im postin just to post kepp up the good work guys

It was so good but it was only 100 years and we have a sickness that is killing the people.

My father and his younger sister both had the flu in Glasgow in 1919. He survived, his sister died. He never had the flu again, and I have never had it…I’m 81 now. I’ve been told I am immune and have never had the flu shot. There is an area south of Glasgow/northern England that has been studied because there is are a number of people there who are also immune. J. Wilson Saville

To keep this thread (article) in check and updated I’d like to add that there was hope of a slow down. However, the desire for normalcy has in turn resulted in a resurgence of the virus. Hospitals are now getting brunt of the aged ill. Some retirement homes are nearly at 75% plus positive to the virus, whereas; the nurses are infected as well and even though now overtaken by the virus are capable of working. In my opinion, this will continue for another year. I hope the timeframe is less, but the end result will likely be another depression. Our country needs to prepare and seek aid from other countries to prepare for this. The USA are the worlds leading consumers and I dint believe the rest of the world could take a financial hit like a US collapse.

Well, vaccines are on the way. Half of America is still crazy. I guess you could say we started “rounding the corner” on Nov. 3rd. Hopefully things back to normal this time next year.

Very good and informative article. Thank you

The Spanish fly and the COVID -19 are are bit similar

When roll out to massive vaccinate happens worldwide we will heal. It reminds me of the World War 2 armament. Once we got the ball rolling we were successful.

I was always strong never in the hospital because of illness. October 2020 came , and despite all my efforts to avoid COVID-19 I landed in the local hospital, and spent the month of October in the covid unit. The infectious disease specialists went to work with what was available, and saved my life. I was on oxygen until March, or April, and I was doing rehab at home until I could walk again. Thank God my wife and I were able to get our COVID-19 shots. Please get yours, everyone!!!

History have already repeating it self In a bad way and we did not learn anything at all ! .

The covid -19 or coronavirus in 2020

Life expectancy dropped by 12 years during the Spanish flu. The virus continued until 1957. Some believe a lack of nutrition played a part in the mortality rate at the time Life expectancy for COVID 19 is the same as normal life expectancy (around 78). Like the Spanish flu our body should adapt to the coming variations. Like the Spanish flu it may last decades.

Why was there a 37 year absence of flu pandemic between 1920 & 1957; yet subsequent to 1957 they have appeared more frequently?

@Sumeyo, I think you mean “The Spanish Flu” 😉

people did not learn about the requirements for this😑. I mean really!

Good info and everything but could had added more info

The article was worded very well and fairly informative. And that leads me to bring up a part of the Article that most people tend to over look. The flu started in the military and spread rapidly. When i was six years old i had very similar symptoms of the Spanish flue and I compared the symptoms of covid 19 and what I had when it was six was actually worse. Im 55 yrs old now and I haven’t had a flu shot in 36 years now and I have no intentions of getting another one with all the Chemical war fair going on in the world.

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A Smithsonian magazine special report

History | April 13, 2020

What We Can Learn From 1918 Influenza Diaries

These letters and journals offer insights on how to record one’s thoughts amid a pandemic

Meilan Solly

Associate Editor, History

When Dorman B.E. Kent , a historian and businessman from Montpelier, Vermont, contracted influenza in fall 1918, he chronicled his symptoms in vivid detail. Writing in his journal , the 42-year-old described waking up with a “high fever,” “an awful headache” and a stomach bug.

“Tried to get Dr. Watson in the morning but he couldn’t come,” Kent added. Instead, the physician advised his patient to place greased cloths and a hot water bottle around his throat and chest.

“Took a seidlitz powder”—similar to Alka-Seltzer—“about 10:00 and threw it up soon so then took two tablespoons of castor oil,” Kent wrote. “Then the movements began and I spent a good part of the time at the seat.”

The Vermont historian’s account, housed at the state’s historical society, is one of countless diaries and letters penned during the 1918 influenza pandemic , which killed an estimated 50 to 100 million people in just 15 months. With historians and organizations urging members of the public to keep journals of their own amid the COVID-19 pandemic, these century-old musings represent not only invaluable historical resources, but sources of inspiration or even diversion.

“History may often appear to our students as something that happens to other people,” writes Civil War historian and high school educator Kevin M. Levin on his blog , “but the present moment offers a unique opportunity for them to create their own historical record.”

The work of a historian often involves poring through pages upon pages of primary source documents like diaries—a fact that puts these researchers in a position to offer helpful advice on how prospective pandemic journalers might want to get started.

First and foremost, suggests Lora Vogt of the National WWI Museum and Memorial , “Just write,” giving yourself the freedom to describe “what you’re actually interested in, whether that’s your emotions, [the] media or whatever it is that you’re watching on Netflix.”

Nancy Bristow , author of American Pandemic: The Lost Worlds Of The 1918 Influenza Epidemic , advises writers to include specific details that demonstrate how “they fit into the world and … the pandemic itself,” from demographic information to assessment of the virus’ impact in both the public and personal spheres. Examples of relevant topics include the economy; political messaging; level of trust in the government and media; and discussion of “what’s happening in terms of relationships with family and friends, neighbors and colleagues.”

Other considerations include choosing a medium that will ensure the journal’s longevity (try printing out entries written via an electronic journaling app like Day One , Penzu or Journey rather than counting on Facebook, Twitter and other social media platforms’ staying power, says Vogt) and defying the sense of pressure associated with the need to document life during a “historic moment” by simply writing what comes naturally.

Journaling “shouldn’t be forced,” says Levin. “There are no rules. It’s really a matter of what you take to be important.”

If all else fails, look to the past: specifically, the nine century-old missives featured below. Though much has changed since 1918, the sentiments shared in writings from this earlier pandemic are likely to resonate with modern readers—and, in doing so, perhaps offer a jumping-off point for those navigating similar situations today.

Many of these journalers opted to dedicate space to seemingly mundane musings: descriptions of the weather, for instance, or gossip shared by friends. That these quotidian topics still manage to hold our attention 100 years later is a testament to the value of writing organically.

State historical societies are among the most prominent record-keepers of everyday people’s journals and correspondence, often undertaking the painstaking tasks of transcribing and digitizing handwritten documents. The quotes featured here—drawn in large part from local organizations’ collections—are reproduced faithfully, with no adjustments for misspelling or modern usage.

Edith Coffin (Colby) Mahoney

From the massachusetts historical society.

Between 1906 and 1920, Edith Coffin (Colby) Mahoney of Salem, Massachusetts, kept “ three line-a-day diaries ” featuring snippets from her busy schedule of socializing, shopping and managing the household. Most entries are fairly repetitive, offering a simple record of what Mahoney did and when, but, on September 22, 1918, she shifted focus to reflect the pandemic sweeping across the United States.

Fair & cold. Pa and Frank here to dinner just back from Jefferson Highlands. Rob played golf with Dr. Ferguson and Mr. Warren. Eugene F. went to the hospital Fri. with Spanish influenza. 1500 cases in Salem. Bradstreet Parker died of it yesterday. 21 yrs old.

Four days later, Mahoney reported that Eugene had succumbed to influenza. “Several thousand cases in the city with a great shortage of nurses and doctors,” she added. “Theatres, churches, gatherings of everykind stopped.”

Mahoney’s husband, Rob, was scheduled to serve as a pallbearer at Eugene’s September 28 funeral, but came down with the flu himself and landed “in bed all day with high fever, bound up head and aching eye balls.”

By September 29—a “beautiful, mild day,” according to Mahoney—Rob was “very much better,” complaining only of a “husky throat.” The broader picture, however, remained bleak. Another acquaintance, 37-year-old James Tierney, had also died of the flu, and as the journal’s author noted, “Dr says there is no sign of epidemic abating.”

Franklin Martin

From the national library of medicine, via research by nancy bristow.

In January 1919, physician Franklin Martin fell ill while traveling home from a postwar tour of Europe. His record of this experience, written in a journal he kept for his wife , Isabelle, offers a colorful portrait of influenza’s physical toll.

Soon after feeling “chilly all day,” Martin developed a 105-degree fever.

About 12 o'clock I began to feel hot. I was so feverish I was afraid I would ignite the clothing. I had a cough that tore my very innards out when I could not suppress it. It was dark; I surely had pneumonia and I never was so forlorn and uncomfortable in my life. … Then I found that I was breaking into a deluge of perspiration and while I should have been more comfortable I was more miserable than ever.

Added the doctor, “When the light did finally come I was some specimen of misery—couldn't breathe without an excruciating cough and there was no hope in me.”

Martin’s writing differs from that of many men, says Bristow, in its expression of vulnerability. Typically, the historian explains, men exchanging correspondence with each other are “really making this effort to be very brave, … always apologizing for being sick and finding out how quickly they’ll be back at work, or [saying] that they’re never going to get sick, that they’re not going to be a victim of this.”

The physician’s journal, with its “blow-by-blow [treatment] of what it was like to actually get sick,” represents a “really unusually profound” and “visceral” point of view, according to Bristow.

Violet Harris

Violet Harris was 15 years old when the influenza epidemic struck her hometown of Seattle. Her high school diaries, recounted by grandniece Elizabeth Weise in a recent USA Today article, initially reflect a childlike naivete. On October 15, 1918, for example, Harris gleefully reported:

It was announced in the papers tonight that all churches, shows and schools would be closed until further notice, to prevent Spanish influenza from spreading. Good idea? I’ll say it is! So will every other school kid, I calculate. … The only cloud in my sky is that the [School] Board will add the missed days on to the end of the term.

Before long, however, the enormity of the situation sank in. The teenager’s best friend, Rena, became so sick she “could hardly walk.” When Rena recovered, Harris asked her “what it felt like to have the influenza, and she said, ‘Don’t get it.’”

Six weeks after Seattle banned all public gatherings, authorities lifted restrictions, and life returned to a semblance of normal. So, too, did Harris’ tone of witty irreverence. Writing on November 12, she said:

The ban was lifted to-day. No more .... masks. Everything open too. 'The Romance of Tarzan' is on at the Coliseum [movie theater] as it was about 6 weeks ago. I’d like to see it awfully. .... School opens this week—Thursday! Did you ever? As if they couldn’t have waited till Monday!

N. Roy Grist

Fort Devens , a military camp about 40 miles from Boston, was among the sites hardest hit by the 1918 influenza epidemic. On September 1, some 45,000 soldiers waiting to be deployed to France were stationed at the fort; by September 23, according to the New England Historical Society , 10,500 cases of the flu had broken out among this group of military men.

Physician N. Roy Grist described the devastation to his friend Burt in a graphic September 29 letter sent from Devens’ “Surgical Ward No. 16.”

These men start with what appears to be an attack of la grippe or influenza, and when brought to the hospital they very rapidly develop the most viscous type of pneumonia that has ever been seen. Two hours after admission they have the mahogany spots over the cheek bones, and a few hours later you can begin to see the cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves.

On average, wrote the doctor, around 100 patients died each day.

Grist’s letter is “a remarkably distinct and accurate description of what it was like to be in the midst of this,” says Bristow. “And then it goes on to talk about how difficult it is to be a doctor, … this sense of not being able to do as much as one might like and how exhausting it all is.”

Toward the end of the letter, Grist notes how much he wishes Burt, a fellow physician, was stationed at Fort Devens with him.

It’s more comfortable when one has a friend about. ... I want to find some fellow who will not ‘talk shop’ but there ain’t none, no how. We eat it, sleep it, and dream it, to say nothing of breathing it 16 hours a day. I would be very grateful indeed if you would drop me a line or two once in a while, and I promise you that if you ever get into a fix like this, I will do the same for you.

Clara Wrasse

From the national wwi museum and memorial.

In September 1918, 18-year-old Clara Wrasse wrote a letter to her future husband , Reid Fields, an American soldier stationed in France. Though her home city of Chicago was in the midst of battling an epidemic, influenza was, at best, a secondary concern for the teenager, who reported:

About four hundred [people] died of it at the Great Lakes … quite a number of people in Chi are suffering with it too. Mother thought that I had it when I wasn’t feeling good, but I am feeling fine now.

Quickly moving on from this mention of disease, Wrasse went on to regale her beau with stories of life in Chicago, which she deemed “to be the same old city, altho there are lots of queer things happening.”

Signing off with the lines “hoping you feel as happy as you did when we played Bunco together,” Wrasse added one last postscript: “Any time you haven’t got anything to do, drop me a few lines, as I watch for a letter from you like a cat watches a mouse.”

Vogt of the National World War I Museum cites Wrasse’s letters as some of her favorites in the Kansas City museum’s collections.

“It's so clear how similar across the ages teenagers are and what interests them,” she says, “and that … they’re kind of wooing each other in these letters in a way that a teenager would.”

Leo Baekeland

From the smithsonian’s national museum of american history.

Inventor Leo Baekeland , creator of the world’s first commercialized plastic, “documented his life prolifically” in diaries, laboratory notebooks, photographs and correspondence, according to the museum’s archives center , which houses 49 boxes of the inventor’s papers.

Baekeland’s fall 1918 journal offers succinct summaries of how the epidemic affected his loved ones. On October 24, he reported that a friend named Albert was sick with influenza; by November 3, Albert and his children were “better and out of bed, but now [his] wife is sick with pneumonia.” On November 10, the inventor simply stated, “Albert’s wife is dead”—a to-the-point message he echoed one week later, when he wrote that his maid, Katie, was “buried this morning.”

Perhaps the most expressive sentiment found among Baekeland’s entries: “From five who had influenza, two deaths!”

Dorman B.E. Kent

From the vermont historical society.

From the age of 11 to his death at 75 in 1951, Dorman B.E. Kent recorded his life in diaries and letters. These papers—now held by the Vermont Historical Society , where Kent served as a librarian for 11 years—document everything from his childhood chores to his views on Franklin Delano Roosevelt’s New Deal and his sons’ career progress.

Of particular interest is Kent’s fall 1918 diary , which contains vivid descriptions of his own bout with influenza. On September 24, he wrote (as mentioned above):

Awoke at 7:00 [a.m.] sick, sick, sick. Didn’t get up or try to. Had a high fever an awful headache every minute all day and was sick to my stomach also. Tried to get Dr. Watson in the morning but he couldn’t come. Told us instead what to do. Greased cloths with inflamacene all day and put around throat and chest and held a bottle of hot water at throat most of the time. Took a seidlitz powder about 10.00 and threw it up soon so then took two tablespoons of castor oil. Then the movements began and I spent a good part of the time at the seat … There is a tremendous lot of influenza in town.

Kent recovered within a few days, but by the time he was able to resume normal activities, his two sons had come down with the flu. Luckily, all three survived the illness.

In early October, Kent participated in a door-to-door census count of the disease’s toll. Surveying two wards in Montpelier on October 2, he and his fellow volunteers recorded 1,237 sick in bed, 1,876 “either ill or recovered,” and 8 dead in one night. The following day, Kent reported that “25 have died in Barre today & the conditions are getting worse all the while. … Terrible times.”

Donald McKinney Wallace

From the wright state university special collections and archives, partially transcribed by lisa powell of dayton daily news.

Donald McKinney Wallace , a farmer from New Carlisle, Ohio, was serving in the U.S. Army when the 1918 pandemic broke out. The soldier’s wartime diary detailed conditions in his unit’s sick bay—and the Army’s response to the crisis. On September 30, Wallace wrote:

Layed in our sick ward all day but am no better, had a fever all day. This evening the Doctor had some beef broth brought down to us which was the first I had eaten since last Fri. Our ward was fenced off from rest of the barrack by hanging blankets over a wire which they stretched clear across the ceiling.

On October 4, the still-ailing farmer added, “Not a bit well yet but anything is better than going over to the hospital. 2 men over there have Spanish Influenza bad and are not expected to live. We washed all windows and floors with creoline solution tonight.”

Wallace survived his illness (and the war), dying in 1975 at age 78.

Though Wallace’s writings don’t reference the situation in his hometown, Bristow notes that many soldiers expressed concern for their families in correspondence sent from the front.

“You get these letters from soldiers who are so worried about their families at home,” she says, “and it’s not what anyone had expected. Their job was to go off soldiering, and the family would worry about them. And now, suddenly, the tables are turned, and it’s really unsettling.”

Helen Viola Jackson Kent

From utah state university’s digital history collections.

When Helen Viola Jackson Kent’ s children donated her journals to Utah State University, they offered an apt description of the purpose these papers served. Like many diary writers, Kent used her journal to “reflect her daily life, her comings and goings, her thoughts, her wishes, her joys, and her disappointments.”

On November 1, 1918 , the lifelong Utah resident wrote that she “[h]ad a bad head ache all day and did not accomplish much. Felt very uneasy as I found out I was exposed to the ‘flu’ Wed. at the store.”

Kent escaped the flu, but her husband, Melvin—called “Mell” in her diary—was not so lucky. Still, Melvin managed to make a full recovery, and on November 18 , his wife reported:

Mell much better and dressed today. Almost worn out with worry and loss of sleep. So much sickness and death this week, but one great ray of light and hope on the outcome of the war as peace came this past [11th].

Interestingly, Kent also noted that the celebrations held to mark the end of World War I had sparked an inadvertent uptick in illness.

“On account of the rejoicing and celebrating,” she wrote, “this disease of influenza increased everywhere.”

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Meilan Solly is Smithsonian magazine's associate digital editor, history.

The Spanish Flu of 1919

Written by: David Pietrusza, Independent Historian

By the end of this section, you will:.

• Explain the causes and effects of international and internal migration patterns over time

Suggested Sequencing

Use this Narrative at the beginning of Chapter 11 to explore the Spanish flu’s effect on the United States.

Mercifully, many of the diseases that once plagued humanity, such as polio, tuberculosis, and smallpox, have been brought under better control or even eradicated through innovative science. One disease – influenza or “the flu” – still flares periodically, but in 1918 it really was a plague, a raging pandemic called the Spanish flu that killed tens of millions worldwide in just a few months.

The world had plenty of trouble in 1918. World War I had raged since August 1914. Between nine million and 11 million soldiers died in the conflict, millions more were taken captive, and five million to six million civilians perished. Yet those numbers paled in comparison to the toll of the influenza pandemic. Between 50 and 100 million people died worldwide about 5 percent of the world’s population and the equivalent of more than 400 million based on today’s higher population levels. It was the worst pandemic since the Middle Age’s bubonic plague (“the Black Death”) killed 30 to 60 percent of Europe’s population in the 1300s.

The Spanish flu hit some areas such as the Pacific Islands, Iran, and India far harder than others. More than a quarter of the U.S. population became sick, and at least half a million Americans died in a population of fewer than 100 million. Men, women, and children wore surgical masks on the streets to avoid infection, and movie theaters and vaudeville houses closed. In Canada, the Stanley Cup hockey championship playoff was cancelled. Fear stalked every school, factory, and home.

Police officers in Seattle wore face masks provided by the Red Cross to help protect against the flu epidemic of 1918.

In New York, the cities of Rochester and Buffalo closed schools, theaters, pool halls, and saloons. The city of Buffalo went into the coffin business. On October, 10, 1918, Philadelphia was particularly hard hit 528 persons died in a single day. A doctor travelling 12 miles to his home each day reported seeing no people or cars on the road. As author A. A. Hoehling wrote of conditions in that city: “The dead lay sometimes for more than a day besides the gutters, and yet longer in half-abandoned, chill rooming houses. A mixed fear and revulsion had frustrated calls for stretcher-bearers and gravediggers.” An anonymous army doctor at Fort Devens near Boston observed that “it takes special trains to carry away the dead. For several days there were not enough coffins and the bodies piled up something fierce.” Dr. Victor C. Vaughan, former president of the American Medical Association and head of the Army’s Division of Communicable Disease, warned, “If the epidemic continues its mathematical rate of acceleration, civilization could easily have disappeared from the face of the earth within a matter of a few more weeks.”

The strain of flu that raged in 1918 is still known as the Spanish flu for a couple of reasons. First, it infected (but did not kill) the Spanish king, Alfonso XIII – a very high-profile victim. Second, Spain was one of the very few neutral nations in World War I. Wartime censorship was not in force, and developments there, including the spread of flu, could be more freely revealed than where the war raged.

Ordinary flu is painful and weakens people, but it is not usually deadly. The Spanish flu was amazingly harsh. High fevers caused hallucinations. People coughed violently and suffered excruciating pain. They turned black. They bled – not just from the mouth and nose but also from the ears and even, rarely, the eyes. Lungs became so weakened that they crackled when flu victims turned over in their beds. A person could be perfectly healthy in the morning and dead that night.

The worst flu mortality rates usually occur among the very young and the very old, whereas healthy young adults are best able to produce natural antibodies to fight the disease and survive fairly easily. That was not the case in 1918. Very young children did suffer a great deal. In the two years that the Spanish flu raged, the excess deaths for children one to four years of age equaled the normal number of such dead over 20 years. But those 65 years and older suffered an increase of less than 1 percent in excess mortality. Shockingly, more than half the dead were in what was normally the safest group: healthy young adults aged 18 to 45 years. One of the possible reasons is that these flu victims produced far too many antibodies, which overwhelmed not only the flu virus but their own bodies, causing death. If this is true, nature’s “cure” was truly worse than the disease.

Dorothy Deming, a nurse at New York City’s Columbia Presbyterian Hospital, observed that “until the epidemic, death had seemed kindly, coming to the very old, the incurably suffering, or striking suddenly without the knowledge of its victims. Now, we saw death clutch cruelly and ruthlessly at vigorous, well-muscled young women in the prime of Life. Flu dull[s] their resistance, choke[s] their lungs, swamp[s] their hearts. . . . There was nothing but sadness and horror to this senseless waste of human life”.

Nurses at the Red Cross Emergency Ambulance Station in Washington, DC, demonstrated how to help victims of the Spanish flu. Note the face masks they wear.

The Spanish flu pandemic was not entirely understood at the time. Its origin was unclear, as were the reasons it was so hard to treat and so deadly. Some believed the flu began at the U.S. Army’s huge base at Fort Riley, Kansas. Some said it originated abroad. But wherever it came from, it spread like wildfire. The war only worsened matters, given that soldiers from America, Asia, and Europe, all with different immune systems, had fought side by side in Europe. They lived in close quarters in tents, in barracks, on ships, and in the trenches of France’s western front. They were weakened from the stress of living under fire, and some had lung damage from the poison gas enemy forces lobbed at each other. And, of course, the same ships and trains that carried men and women across the country and around the world in record numbers also transported the microbes that transmitted this deadly strain of disease. In France, the U.S. 88th division counted 444 dead from the flu, but just 90 were killed, wounded, or captured in combat.

“The conditions cannot be visualized by anyone who has not actually seen them,” wrote Colonel E. W. Gibson of Vermont’s 57th Pioneer Division, who witnessed the worsening situation on the troopship Leviathan . “Pools of blood from severe nasal hemorrhages of many patients were scattered throughout the compartments, and the attendants were powerless to escape tracking through the mess, because of the narrow passages between the bunks. The decks became wet and slippery, groans and cries of the terrified added to the confusion of the applicants clamoring for treatment, and altogether a true Inferno reign[ed] supreme.”

Wartime censorship complicated the crisis. In 1918, Woodrow Wilson and Congress enacted an amendment to the 1917 Espionage Act (known as the Sedition Act), which decreed that “whoever, when the United States is at war, shall willfully utter, print, write, or publish any disloyal, profane, scurrilous, or abusive language about the form of government of the United States . . . shall be punished by a fine of not more than $10,000 or imprisonment for not more than twenty years, or both.” This Act made fighting the disease even more difficult because it choked off much honest conversation (and even reporting) about the situation.

As Chicago’s Public Health Commissioner John Dill Robertson stated, “It is our duty to keep the people from fear. Worry kills more people than the epidemic.” Actually, people had good reason for fear. At Chicago’s Cook County Hospital, 40 percent of all influenza patients died.

Eventually, the deadly pandemic ran its course and life returned to normal. A similar pandemic may return to wreak havoc on humanity, particularly with the frequency of international travel. And if it does, censorship will not help the situation any more than it did in 1918.

Review Questions

1. The 1918 Spanish flu outbreak was the worst pandemic since

• smallpox in the nineteenth century
• the bubonic plague in the fourteenth century
• polio in the nineteenth century
• tuberculosis in the eighteenth century

2. As the Spanish flu progressed across the United States, a unique characteristic that emerged was that the disease

• seemed to be without symptoms until the end
• killed a disproportionate number of women
• struck a disproportionate number of people in New England
• killed mostly young, healthy adults

3. A major effect of the Spanish flu on U.S. society was

• the collapse of the economy
• an immediate demand that immigration be halted
• a temporary closure of schools and businesses
• a decline in the medical industry

4. The quote “it is our duty to keep the people from fear. Worry kills more people than the epidemic” from Chicago Public Health Commissioner John Dill Robertson is related to what policy of the U.S. government?

• Wartime censorship of news concerning the Spanish flu
• The need for the medical profession to bring an end to the epidemic
• Encouragement of accurate reporting regarding the epidemic
• Temporary halting of migration

5. The passage of the Sedition Act made it even more difficult to fight the flu pandemic because

• it stifled honest discussion and reporting of the disease
• it allowed the arrest of many of the health-care workers fighting the disease
• it increased immigration and thus the flow of disease carriers into the United States
• it reopened schools and businesses that had been closed to control the contagion

Free Response Questions

• Explain the impact of Spanish influenza on commerce in the United States.
• Analyze the role that censorship of free speech played in the nation’s ability to fight the Spanish flu pandemic.
• Compare society’s response to the Spanish flu pandemic in 1919 with the COVID-19 pandemic of 2020. What similarities do you notice?

AP Practice Questions

A 1919 public health broadside provides information on the Spanish flu pandemic.

1. The information presented in the broadside at the provided link could be used to support which of the following conclusions?

• The government developed public policies for fighting the disease.
• Private business banned individuals on the basis of their health status.
• Censorship impeded the spread of information about the disease.
• Widespread panic set in because there was little understanding of the way the disease spread.

2. The publication of this broadside most likely indicates

• an expansion of the role of the federal government
• the widespread health concerns caused by the epidemic
• the national government’s concern about the effects of the epidemic on trade
• the ignorance of most citizens of the time about healthy habits

3. The situation that prompted the broadside can be best described as

• the Red Scare created a fear of socialism in America
• people feared America becoming involved in another European war if the United States joined the League of Nations
• the rebirth of the Ku Klux Klan led a fear that personal freedoms would be lost
• a devastating Spanish flu epidemic spread fear, misery, and death around the world

Primary Sources

Price, George M. “Influenza-Destroyer and Teacher: A General Confession by the Public Health Authorities of a Continent.” The Survey 41, no. 12 (1918): 367-369.

“Quarantine and Isolation in Influenza.” Journal of the American Medical Association 71, no. 15 (1918): 1220.

“Spanish Influenza the Way to Treat It and to Avoid It.” A Vicks VapoRub advertisement. Portland Morning Oregonian . January 8, 1919, p. 6. https://oregonnews.uoregon.edu/lccn/sn83025138/1919-01-08/ed-1/seq-6/

Suggested Resources

Barry, John M. The Great Influenza . New York: Viking, 2004.

Hoehling, A. A. The Great Epidemic . Boston: Little, Brown and Company, 1961.

Iezzoni, Lynette. Influenza 1918: The Worst Epidemic in American History . New York: TV Books, 1999.

Kolata, Gina. Flu: The Story of The Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It . New York: Farrar, Straus and Giroux, 1999.

Tucker, Spencer and Priscilla Mary Roberts (eds.). World War I: A Student Encyclopedia . Santa Barbara, CA: ABC-CLIO, 2006.

Withington, John. Disaster!: A History of Earthquakes, Floods, Plagues, and Other Catastrophes . New York: Skyhorse Publishing, 2010.

Related Content

Life, Liberty, and the Pursuit of Happiness

In our resource history is presented through a series of narratives, primary sources, and point-counterpoint debates that invites students to participate in the ongoing conversation about the American experiment.

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Spanish Flu: How America Fought a Pandemic a Century Ago

Science and medicine have come a long way since the 1918 outbreak.

by Aaron Kassraie, AARP , Updated September 21, 2021

National Archives

Nurses carry a patient in St. Louis, Missouri, during the Spanish Flu pandemic in 1918.

En español | Before scientists identified the influenza virus in 1933, the medical community had far less knowledge of how the flu passed from person to person and how to treat those infected. In 1918, as the world was nearing the end of the first world war, what became known as the Spanish flu was spreading rapidly among the soldiers who lived in close quarters. Some erroneously attributed the deadly pandemic that ultimately claimed an estimated 50 million to 100 million lives around the globe to everything from volcanic eruptions to bad Russian oats, according to Jeremy Brown, author of  Influenza: The 100-Year Hunt to Cure the Deadliest Disease in History .

Many countries censored news reports during World War I, especially information about the pandemic. Since Spain remained a neutral country, its press was free to report on the outbreak's relentless spread, leading to the name Spanish flu. Scientists are split over where the virus originated, with three possibilities being Kansas, France and China.

The Spanish flu killed about 675,000 people in the U.S. In September 2021, 18 months after the start of the coronavirus pandemic, American deaths attributed to COVID-19 hit 676,000, surpassing the toll of the influenza pandemic of 1918. Here are historical photos from the National Archives that show just how hard the Spanish flu hit America — and how Americans tried to avoid it, treat it and live with it.

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PHOTO BY: National Archives

Parades and other large public gatherings were common, contributing to the spread of the flu. Here munitions workers in Washington, D.C., line up for hot chocolate.

Convalescing soldiers were placed within arm's reach of each other in sick wards, separated by little more than a sheet, aiding the Spanish flu's spread. These patients were being housed at Eberts Field in Lonoke, Arkansas, because there was no room in the hospital.

Public health officials gathered in Chicago to address the epidemic, which at that point had already killed 400,000 people in three months. Experts agreed that whatever transmitted the disease could be found in mucus from the throat, nose and mouth. Gargling with salt water was recommended to military personnel as a preventive measure.

Hospitals were crowded and offered limited treatment options. Antibiotics to treat secondary bacterial infections that often accompany the flu had yet to be discovered. At Fort Porter in New York, beds were reversed so patients wouldn't breath in each other's faces.

Face masks made of gauze were widely used but offered little real protection. Nonetheless, these Red Cross workers in Boston assembled masks. “It is our duty to keep people from fear,” said Chicago's health commissioner. “Worry kills more people than the epidemic."

As disease spread, medical officers (above, at Love Field in Dallas) sprayed the mouths and throats of 800 healthy men daily with a solution of dichloramine-T, a disinfectant. But when they compared their influenza rates with 800 untreated men, they were disappointed to find that “over a period of twenty days the incidence in the two groups was the same,” according to a public health report.

It was thought that keeping windows open would deter the spread of the Spanish flu. This flyer in a trolley car in Cincinnati encouraged the practice, which was utilized nationwide.

Court officials in San Francisco held proceedings outside in hope that the open air would prevent infections.

It was a truly global epidemic; 100 American soldiers were buried in Devon, England, where they succumbed to the disease.

Editor's note: This story was updated with the latest numbers on COVID-19.

More on Politics & Society

• More states moving their primaries because of coronavirus
• Governors order coronavirus-related restrictions across America
• Will coronavirus impact the 2020 census?

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Economic Synopses

What can we learn from the spanish flu pandemic of 1918-19 for covid-19.

The COVID-19 pandemic has spurred intense efforts among researchers to estimate the likely course of the pandemic and its economic effects. Several studies have sought insights from global pandemics of the past, including the Spanish flu pandemic of 1918-19, which is thought to have infected some 500 million persons, or about one-third of the world's population, and killed anywhere from 50 to 100 million people. 1 Lessons from the Spanish flu pandemic are relevant and informative. Like COVID-19, the Spanish flu was highly contagious; it was also unusually lethal compared with a typical seasonal flu. As the flu became more widespread and its dangers apparent, many cities sought to contain the virus by imposing restrictions on social and economic interactions. These efforts can provide insights about the economic and public health impacts of government efforts to limit the spread of pandemic diseases. This essay discusses some recent research findings on the effects of the Spanish flu pandemic and measures that cities took to control it.

The Spanish flu pandemic came in three waves beginning in the spring of 1918. The second wave, in the fall of 1918, was the largest by far in terms of total infections and deaths. A third wave occurred in the spring of 1919. Overall, the pandemic is estimated to have infected about 25 percent of the U.S. population, or about 25 million people, and killed 675,000 for roughly a 3 percent mortality rate. 2 The pandemic began during World War I, and the virus is thought to have been introduced and spread throughout the United States by soldiers returning from Europe. By the end of 1918, some 45,000 U.S. soldiers had contracted and died from the disease, a number only modestly smaller than the 53,000 American combat deaths. 3 As with typical seasonal flu, young children and the elderly were particularly susceptible to the Spanish flu. However, the Spanish flu was especially lethal for young, "prime-age" adults, especially men. In 1918, the mortality rate from the flu and pneumonia among men 15 to 34 years of age was more than 20 times higher than in previous years, and throughout the pandemic, half of all flu deaths were among adults between 20 and 40 years of age. Furthermore, the absolute risk of death from the flu was higher among those younger than 65 years of age than those 65 or older, with those younger than 65 accounting for 99 percent of excess flu deaths in 1918-19. 4 The high fatality rate among young adults, especially young adult men, is striking in comparison with both typical seasonal flu and COVID-19, where the case fatality rate has been far higher among the elderly than among the young. These differences in age-related fatality rates are one reason the economic impacts of the COVID-19 and Spanish flu pandemics might differ. The high fatality rate among prime-age males during the Spanish flu pandemic reduced labor supply and boosted real wage rates in locations where the incidence of the disease was high (Garret, 2009, and Correia et al., 2020). Such an effect seems unlikely from the COVID-19 pandemic. 5

As the COVID-19 pandemic spread across the United States, most state and local governments imposed restrictions on economic activity, such as requiring certain non-­essential businesses to close or reduce their in-store services. Many firms have voluntarily reduced their operations to protect the health of their employees or because of weaker demand for their products. At the same time, many households have refrained from non-essential purchases and travel in an effort to protect themselves and to help limit the spread of the virus. To date these measures appear to have helped slow the pandemic and avoid overwhelming the health care system in most locations. However, aggregate economic activity and employment have declined sharply, leading many states and cities to ease restrictions even as COVID-19 cases and fatalities continue to rise. 

A similar pattern played out during the Spanish flu pandemic. In an effort to stem the pandemic, many cities adopted measures such as closing schools and churches, prohibiting large gatherings of people, shutting down theaters and other entertainment venues, and temporarily closing non-essential businesses. 6 Several studies examine the effects of such non-pharmaceutical interventions (NPIs) on flu incidence and mortality rates. A general finding is that cities that put NPIs in place earlier or took more aggressive action had lower excess mortality rates, later peaks in caseloads and mortality, and, to a lesser extent, fewer total fatalities than cities that moved slowly or adopted fewer measures. 7 The experiences of Philadelphia and St. Louis are often compared. Philadelphia was slow to implement measures to stem the pandemic and experienced a surge in cases following a large parade in support of a Liberty Loan drive. St. Louis, by contrast, canceled a similar parade and took other measures soon after the first cases were reported. Philadelphia had among the highest mortality rates of any of the U.S. cities, with a peak weekly excess mortality rate of 250 deaths per 100,000 persons and a total pandemic mortality rate of 748 deaths per 100,000 persons. St. Louis had among the lowest rates of all major cities, with a peak weekly excess mortality rate of just 30 deaths per 100,000 persons and a total mortality rate of 358 deaths per 100,000 persons (Markel et al., 2007). 

Most cities relaxed their measures after just a few weeks when flu deaths began to recede. However, many cities faced a surge in cases when measures were eased, which resulted in a second peak—often higher than the first—that led to reactivation of some NPIs (Bootsma and Ferguson, 2007, and Markel et al., 2007). The experience of St. Louis is a case in point. St. Louis's authorities moved quickly to close schools, churches, saloons, theaters, and other entertainment venues when the city's first cases appeared in early October. Businesses and factories were permitted to remain open, but business hours were reduced and police were dispatched to keep shoppers from lingering in stores. On November 9, the health commissioner ordered all non-­essential stores and factories closed for four days, and cases peaked within days. Businesses were permitted to reopen on November 13 and schools opened on November 14. Flu cases continued to decline for the next two weeks but then began to climb sharply. The city closed schools again and reinstated a ban on all public gatherings. The second peak in cases—with a higher excess mortality rate than the first peak—was reached in December. Cases then began to decline and the city lifted all restrictions on businesses on December 28 and reopened schools on January 2. 8

The economic impacts of the flu pandemic and NPIs implemented to contain it are somewhat less clear than the epidemiological effects. Perhaps surprisingly, given the widespread incidence of illness and many deaths, the pandemic did not trigger a major contraction in aggregate economic activity. A mild recession began in September 1918 and continued to March 1919. Federal spending on the war effort might explain why the aggregate economy did not slow appreciably: "[T]he never-ending demand for coal, steel, machinery, textiles, and other products needed for the war effort largely offset the effects of such a severe pandemic on aggregate economic activity" (Benmelech and Frydman, 2020). Industrial production did fall sharply but recovered quickly. Retail sales appear to have been little affected by the pandemic, perhaps because of a surge in consumer purchases after Armistice on November 11, and neither business failures nor other forms of financial distress increased significantly. 9 The pandemic did have a large impact on some sectors, however—notably manufacturing. Correia et al. (2020) estimate that the pandemic caused an 18 percent decline in manufacturing output and a 23 percent decline in manufacturing employment, in part because several cities with large manufacturing industries were among those with the highest flu fatality rates. 

Some NPIs, such as temporary closures of non-essential businesses, clearly impose direct economic costs on affected firms and households. However, widespread illness or deaths can also be economically costly, suggesting that, conceivably, the economic benefits of containing a pandemic might outweigh the direct costs imposed on owners and employees of firms that are required to close. During the Spanish flu pandemic, cities with lower excess flu mortality rates had smaller declines in some measures of economic activity, suggesting that the direct cost of NPIs might have been offset at least to some extent by stronger economies. Moreover, there is evidence that cities that imposed NPIs earlier and more rigorously during the pandemic had higher growth in manufacturing output and employment for up to four years after the pandemic. Correia et al. (2020) use a dynamic difference-in-difference regression approach to examine the impact of NPIs on manufacturing across cities. Their model controls for various pre-crisis state and local characteristics, such as total population, urbanization, manufacturing share of employment, and growth of manufacturing output and employment from 1909 to 1914. The study finds that implementing NPIs earlier in the pandemic and using them more intensely produced significantly higher rates of growth in manufacturing output and employment from 1919 to 1923 than did slower activation or less intense use of NPIs. Estimates from the study's base model indicate that a one standard deviation increase in the speed of adopting NPIs (8 days) is associated with 4 percent higher growth of employment after the pandemic, while a one standard deviation increase in NPI intensity leads to 6 percent higher employment growth. The authors estimate several models with different sets of controls, and though not all show a statistically significant impact of NPIs on growth or employment, none indicate that NPIs reduced economic activity. 10  

Clearly, there are limits to the applicability of the Spanish flu episode to the COVID-19 pandemic. In particular, the unusually high fatality rate among young, working-age men suggests that the flu pandemic might have had a larger economic impact, particularly on labor-intensive industries, than will COVID-19. The structure of the U.S. economy and distribution of the population are also very different today than in 1918, which could affect how either a pandemic or the NPIs imposed to contain it affect public health or the economy. For example, because pandemic mortality is strongly associated with population density, increased urbanization suggests that NPIs might have more public health benefit today than in 1918. On the other hand, the substantial increase over time in employment in the service sector suggests that the direct costs of mandatory business closures, which tend to fall more heavily on retail establishments and other service industries, could be higher today than in 1918. 11 Still, insights from the Spanish flu and other pandemics should not be dismissed entirely. So long as we remain cognizant of the environmental features in which they occurred, the pandemics of the past can provide useful data points for helping to forecast how the COVID-19 and future pandemics are likely to play out, and in particular for addressing such questions as whether NPIs are likely to be the sole source of economic disruptions in a pandemic, or whether a pandemic would cause an economic downturn in the absence of interventions to slow its spread.

1 Johnson and Mueller (2002) estimate 50 million deaths worldwide and provide estimates for several countries. Jorda et al. (2020) report an estimate of 100 million deaths, as well as mortality estimates for other pandemics since the fourteenth century with at least 100,000 deaths.

2 Taubenberger and Morens (2006). See also Garrett (2008) and references therein for data and other information about the origins and spread of the pandemic in the United States.

3 Eric Durr, "Worldwide Flu Outbreak Killed 45,000 American Soldiers During World War I"; https://www.army.mil/article/210420/worldwide_flu_outbreak_killed_45000_american_soldiers_during_world_war_i .

4 Taubenberger and Morens (2006).

5 In a study of 15 major pandemics since the fourteenth century, Jorda, Singh, and Taylor (2020) find that real wages are typically elevated for several years after pandemics, while the returns to capital are low, likely because of widespread deaths among the working-age population. 

6 Detailed information about the use of NPIs by 50 cities during the pandemic is available from the University of Michigan Center for the History of Medicine; http://chm.med.umich.edu/research/1918-influenza-digital-archive/ .

7 See Barro (2020), Correia et al. (2020), Bootsma and Ferguson (2007), Hatchett et al. (2007), and Markel et al. (2007). Barro (2020) notes that the mean duration of NPIs across 43 cities was 4-6 weeks and suggests that a duration of 12 weeks would have produced a substantially lower total death rate.

8 University of Michigan Center for the History of Medicine; https://www.influenzaarchive.org/cities/city-stlouis.html.

9 Velde (2020) examines a variety of high-frequency economic time series data during the pandemic and concludes that the pandemic had only modest impact on economic activity. Barro et al. (2020) examine the impact of the pandemic across countries and attempt to control for differences in war intensity using data on combat deaths. The study finds that the flu pandemic caused a 6.2 percent decline in GDP in a typical country and a decline of about 1.5 percent in the United States.

10 The base specification controls include measures of urbanization, pre-crisis population, manufacturing employment share, and flu mortality in 1917, as well as state-level agricultural employment share. Additional control variables in other specifications include the growth in manufacturing output and employment from 1909 to 1914, census region fixed effects, longitude, WWI servicemen mortality rate, and health and total public spending per capita in 1917. 

11 In 1918, the U.S. population was split evenly between urban and rural areas in 1918, whereas today the urban population is five times the rural population. Moreover, in 1918, 33 percent of the labor force was employed in agriculture and 28 percent was employed in manufacturing, compared with 2 percent and 8 percent, respectively, today (Velde 2020). As of 2018, some 80 percent of the U.S. labor force was employed in service industries. See https://www.bls.gov/emp/tables/employment-by-major-industry-sector.htm.

Barro, Robert J. "Non-Pharmaceutical Interventions and Mortality in U.S. Cities During the Great Influenza Pandemic, 1918-1919." NBER Working Paper 27049, April 2020.

Barro, Robert J.; Ursua, Jose F. and Weng, Joanna. "The Coronavirus and the Great Influenza Pandemic—Lessons from the 'Spanish Flu' for the Coronavirus's Potential Effects on Mortality and Economic Activity." NBER Working Paper 26866, March 2020.

Benmelech, Efraim and Frydman, Carola. "The 1918 Influenza Did Not Kill the US Economy." VOX CEPR Policy Portal, April 29, 2020.

Bootsma, Martin C.J. and Ferguson, Neil M. "The Effect of Public Health Measures on the 1918 Influenza Pandemic in U.S. Cities." Proceedings of the National Academy of Sciences , May 2007, 104 (18), pp. 7588-93.

Correia, Sergio; Luck, Stephan and Verner, Emil. "Pandemics Depress the Economy, Public Heath Interventions Do Not: Evidence from the 1918 Flu." SSRN Working Paper No. 3561560, April 10, 2020.

Garrett, Thomas A. "Pandemic Economics: The 1918 Influenza and Its Modern-­Day Implications." Federal Reserve Bank of St. Louis Review , March/April 2008, pp. 75-93.

Garrett, Thomas A. "War and Pestilence as Labor Market Shocks: U.S. Manufacturing Wage Growth 1914-1919." Economic Inquiry , October 2009, 47 (4), pp. 711-25.

Hatchett, Richard J.; Mecher, Carter E. and Lipsitch, Marc. "Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic." Proceedings of the National Academy of Sciences , May 2007, 104 (18), pp. 7582-87.

Johnson, Niall P.A.S. and Mueller, Juergen. "Updating the Accounts: Global Mortality of the 1918-1920 'Spanish' Influenza Pandemic." Bulletin of the History of Medicine , Spring 2002, 76 (1), pp. 105-15.

Jorda, Oscar; Singh, Sanjay R. and Taylor, Alan M. "Longer-Run Economic Consequences of Pandemics." Federal Reserve Bank of San Francisco Working Paper 2020-09, March 2020.

Markel, Howard; Lipman, Harvey B.; Navarro, J. Alexander; Sloan, Alexandra; Michalsen, Joseph R.; Stern, Alexandra Minna and Cetron, Martin S. "Nonpharmaceutical Interventions Implemented by U.S. Cities During the 1918-1919 Influenza Pandemic." Journal of the American Medical Association , 2007, 298 (6), pp. 644-54.

Taubenberger, Jeffery K. and Morens, David M. "1918 Influenza: the Mother of All Pandemics." Emerging Infectious Diseases , January 2006, 12 (1), pp. 15-22.

Velde, Francois R. "What Happened to the U.S. Economy During the 1918 Influenza Pandemic? A View Through High-Frequency Data." Federal Reserve Bank of Chicago Working Paper 2020-11, April 2020.

© 2020, Federal Reserve Bank of St. Louis. The views expressed are those of the author(s) and do not necessarily reflect official positions of the Federal Reserve Bank of St. Louis or the Federal Reserve System.

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Guest Essay

Some Words Feel Truer in Spanish

By Natalia Sylvester

Ms. Sylvester is the author of the forthcoming children’s book “A Maleta Full of Treasures” (“La Maleta de Tesoros”).

My earliest relationship with language was defined by rules. As an immigrant who came to this country from Peru at age 4, I spent half of my days in kindergarten occupied with learning the rules of the English language. There was the tricky inconsistency of pronunciation to navigate and, once I learned to speak it, the challenge of translating what I’d learned into reading skills.

At home, my mom would often create games to help my sister and me preserve our Spanish and improve our grammar. Driving around our neighborhood in Miami, she’d point at a traffic light, hold up four fingers and say, “Se-ma-fo-ro — on which syllable do you put the accent?”

Each language had its defined space: English in school, Spanish at home. But as my parents became more fluent (and my sister and I more dominant) in English, the boundaries became blurred. Being bilingual empowered us to break barriers beyond the rules and definitions attached to words. Some things were simply untranslatable, because they spoke to this new space we were living in — within, between and around language. We were making a new home here, same as so many immigrants who end up shaping language as much as it shapes us.

It became evident as the phrase “Cómo se dice?” or “How do you say?” became a constant in my home. Sometimes, it’d be my parents who asked, “How do you say” followed by a word like “sobremesa” or “ganas.” It seemed simple enough in theory, but proved nearly impossible for us to translate without elaborating using full sentences or phrases. After all, to have a word to describe a long conversation that keeps you at the table and extends a meal, you’d have to value the concept enough to name it. Some ideas are so embedded in Latin American and Spanish cultures that they exist implicitly. Of course “ganas” can be something you feel but also give, and be at once more tame yet more powerful than “desire.” (If you know, you know.)

Other times, it’d be my sister and I who were curious about a word’s Spanish counterpart. Was there really no differentiating in Spanish between the fingers (dedos) on our hands, and those on our feet we call toes? When we wanted to say we were excited about something, the word “emocionada” seemed to fall short of capturing our specific, well, emotion. Sometimes we would blank on a word. But sometimes, we would find that the perfect word isn’t necessarily in the language we’re speaking.

What I’m describing, of course, has its own word: code switching. The act of shifting from one language or dialect to another, particularly based on social context, is often framed as something that so-called minorities do to fit into more mainstream spaces. It’s true that code switching can be a form of assimilation, a way of shielding ourselves from the prejudices rooted in racism, classism and xenophobia that can arise when we freely express our culture and language in spaces not designed to embrace them. But what I seldom see discussed is how code switching isn’t solely a reactionary response to feeling unwelcome. Within our own communities, it can signal comfort and belonging.

Take the Spanish word “maleta,” or “suitcase” in English. This year, I was at a writing conference and met up with two Mexican American authors, one of whom brought her suitcase to the venue because she had already checked out of the hotel. We walked the halls and offered to help with her maleta, making several jokes and references to it, but never once using the word “suitcase,” despite speaking mainly in English.

This was an entirely natural and unspoken decision. There are some words that simply feel truer in Spanish than they do in English. I call these home words and heart words because I associate them with the place I most grew up using them: at home, among family. Though the words might share a literal definition with their translation, one version carries emotional depth that enriches its meaning. To code switch this way among friends implies we share not only a language, but an intimate understanding of where we come from.

A suitcase is for clothes and possessions when someone travels, but to me, a maleta meant family had arrived from Peru, carrying flavors, textures and memories of my birthplace. Language is rooted in context, which is another way of saying that language is driven by memory. In this way, what we do or don’t choose to translate is another way of telling stories about our past.

Last year, a study on the specific way that Miamians use direct Spanish translations to form English phrases called the practice an emerging dialect. It’s a form of borrowing between languages that results in what is known as calques. For decades, expressions like “get down from the car” and “super hungry,” which are translated from Spanish, have made their way into regional speech, even in the case of non-Spanish speakers.

When I shared the article on social media, my DMs were flooded by friends and family — not only in Miami but also in the Rio Grande Valley in Texas and in Southern California — who joked that they’ve been using these phrases since they were children, and their parents had, too. The novelty was not in their usage but in their validation (whether or not we sought that validation). My friends and I grew up being told to speak a certain way and respect the rules of both languages. We, in turn, didn’t so much break the rules as we simply played with them, swirling bits of English and Spanish together until it resembled something new yet familiar, our fingerprints proudly planted in its mess.

This is one of my greatest joys as a writer. I love language not only for all it can do but also for all it can’t and all the space it leaves in the gaps for creation. It is empowering that something as supposedly fixed as the meaning of a word or phrase is actually alive and evolving. It means we don’t have to lose parts of ourselves to assimilation; we can expand language to include the full breadth of our experiences.

Words are just sounds and letters until we collectively give them meaning through story. When we use language to connect, it’s one of the most beautiful things that makes us human.

Natalia Sylvester is the author of the forthcoming children’s book “A Maleta Full of Treasures” (“La Maleta de Tesoros”).

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What Can We Learn from the Spanish Flu Pandemic of 1918-19 for COVID-19?

This post first appeared May 18 as an Economic Synopses essay .

The COVID-19 pandemic has spurred intense efforts among researchers to estimate the likely course of the pandemic and its economic effects. Several studies have sought insights from global pandemics of the past, including the Spanish flu pandemic of 1918-19, which is thought to have infected some 500 million persons, or about one-third of the world's population, and killed anywhere from 50 to 100 million people. Johnson and Mueller (2002) estimate 50 million deaths worldwide and provide estimates for several countries. Jorda et al. (2020) report an estimate of 100 million deaths, as well as mortality estimates for other pandemics since the fourteenth century with at least 100,000 deaths. Lessons from the Spanish flu pandemic are relevant and informative. Like COVID-19, the Spanish flu was highly contagious; it was also unusually lethal compared with a typical seasonal flu. As the flu became more widespread and its dangers apparent, many cities sought to contain the virus by imposing restrictions on social and economic interactions. These efforts can provide insights about the economic and public health impacts of government efforts to limit the spread of pandemic diseases. This essay discusses some recent research findings on the effects of the Spanish flu pandemic and measures that cities took to control it.

The Spanish flu pandemic came in three waves beginning in the spring of 1918. The second wave, in the fall of 1918, was the largest by far in terms of total infections and deaths. A third wave occurred in the spring of 1919. Overall, the pandemic is estimated to have infected about 25 percent of the U.S. population, or about 25 million people, and killed 675,000 for roughly a 3 percent mortality rate.  Taubenberger and Morens (2006). See also Garrett (2008) and references therein for data and other information about the origins and spread of the pandemic in the United States. The pandemic began during World War I, and the virus is thought to have been introduced and spread throughout the United States by soldiers returning from Europe. By the end of 1918, some 45,000 U.S. soldiers had contracted and died from the disease, a number only modestly smaller than the 53,000 American combat deaths.  Eric Durr, " Worldwide Flu Outbreak Killed 45,000 American Soldiers During World War I ." As with typical seasonal flu, young children and the elderly were particularly susceptible to the Spanish flu. However, the Spanish flu was especially lethal for young, "prime-age" adults, especially men. In 1918, the mortality rate from the flu and pneumonia among men 15 to 34 years of age was more than 20 times higher than in previous years, and throughout the pandemic, half of all flu deaths were among adults between 20 and 40 years of age. Furthermore, the absolute risk of death from the flu was higher among those younger than 65 years of age than those 65 or older, with those younger than 65 accounting for 99 percent of excess flu deaths in 1918-19. Taubenberger and Morens (2006). The high fatality rate among young adults, especially young adult men, is striking in comparison with both typical seasonal flu and COVID-19, where the case fatality rate has been far higher among the elderly than among the young. These differences in age-related fatality rates are one reason the economic impacts of the COVID-19 and Spanish flu pandemics might differ. The high fatality rate among prime-age males during the Spanish flu pandemic reduced labor supply and boosted real wage rates in locations where the incidence of the disease was high (Garret, 2009, and Correia et al., 2020). Such an effect seems unlikely from the COVID-19 pandemic.  In a study of 15 major pandemics since the fourteenth century, Jorda, Singh, and Taylor (2020) find that real wages are typically elevated for several years after pandemics, while the returns to capital are low, likely because of widespread deaths among the working-age population.

As the COVID-19 pandemic spread across the United States, most state and local governments imposed restrictions on economic activity, such as requiring certain non-essential businesses to close or reduce their in-store services. Many firms have voluntarily reduced their operations to protect the health of their employees or because of weaker demand for their products. At the same time, many households have refrained from non-essential purchases and travel in an effort to protect themselves and to help limit the spread of the virus. To date these measures appear to have helped slow the pandemic and avoid overwhelming the health care system in most locations. However, aggregate economic activity and employment have declined sharply, leading many states and cities to ease restrictions even as COVID-19 cases and fatalities continue to rise.

A similar pattern played out during the Spanish flu pandemic. In an effort to stem the pandemic, many cities adopted measures such as closing schools and churches, prohibiting large gatherings of people, shutting down theaters and other entertainment venues, and temporarily closing non-essential businesses.  Detailed information about the use of NPIs by 50 cities during the pandemic is available from the University of Michigan Center for the History of Medicine . Several studies examine the effects of such non-pharmaceutical interventions (NPIs) on flu incidence and mortality rates. A general finding is that cities that put NPIs in place earlier or took more aggressive action had lower excess mortality rates, later peaks in caseloads and mortality, and, to a lesser extent, fewer total fatalities than cities that moved slowly or adopted fewer measures.  See Barro (2020), Correia et al. (2020), Bootsma and Ferguson (2007), Hatchett et al. (2007), and Markel et al. (2007). Barro (2020) notes that the mean duration of NPIs across 43 cities was 4-6 weeks and suggests that a duration of 12 weeks would have produced a substantially lower total death rate. The experiences of Philadelphia and St. Louis are often compared. Philadelphia was slow to implement measures to stem the pandemic and experienced a surge in cases following a large parade in support of a Liberty Loan drive. St. Louis, by contrast, canceled a similar parade and took other measures soon after the first cases were reported. Philadelphia had among the highest mortality rates of any of the U.S. cities, with a peak weekly excess mortality rate of 250 deaths per 100,000 persons and a total pandemic mortality rate of 748 deaths per 100,000 persons. St. Louis had among the lowest rates of all major cities, with a peak weekly excess mortality rate of just 30 deaths per 100,000 persons and a total mortality rate of 358 deaths per 100,000 persons (Markel et al., 2007).

Most cities relaxed their measures after just a few weeks when flu deaths began to recede. However, many cities faced a surge in cases when measures were eased, which resulted in a second peak—often higher than the first—that led to reactivation of some NPIs (Bootsma and Ferguson, 2007, and Markel et al., 2007). The experience of St. Louis is a case in point. St. Louis's authorities moved quickly to close schools, churches, saloons, theaters, and other entertainment venues when the city's first cases appeared in early October. Businesses and factories were permitted to remain open, but business hours were reduced and police were dispatched to keep shoppers from lingering in stores. On November 9, the health commissioner ordered all non-­essential stores and factories closed for four days, and cases peaked within days. Businesses were permitted to reopen on November 13 and schools opened on November 14. Flu cases continued to decline for the next two weeks but then began to climb sharply. The city closed schools again and reinstated a ban on all public gatherings. The second peak in cases—with a higher excess mortality rate than the first peak—was reached in December. Cases then began to decline and the city lifted all restrictions on businesses on December 28 and reopened schools on January 2. University of Michigan Center for the History of Medicine .

The economic impacts of the flu pandemic and NPIs implemented to contain it are somewhat less clear than the epidemiological effects. Perhaps surprisingly, given the widespread incidence of illness and many deaths, the pandemic did not trigger a major contraction in aggregate economic activity. A mild recession began in September 1918 and continued to March 1919. Federal spending on the war effort might explain why the aggregate economy did not slow appreciably: "[T]he never-ending demand for coal, steel, machinery, textiles, and other products needed for the war effort largely offset the effects of such a severe pandemic on aggregate economic activity" (Benmelech and Frydman, 2020). Industrial production did fall sharply but recovered quickly. Retail sales appear to have been little affected by the pandemic, perhaps because of a surge in consumer purchases after Armistice on November 11, and neither business failures nor other forms of financial distress increased significantly.  Velde (2020) examines a variety of high-frequency economic time series data during the pandemic and concludes that the pandemic had only modest impact on economic activity. Barro et al. (2020) examine the impact of the pandemic across countries and attempt to control for differences in war intensity using data on combat deaths. The study finds that the flu pandemic caused a 6.2 percent decline in GDP in a typical country and a decline of about 1.5 percent in the United States. The pandemic did have a large impact on some sectors, however—notably manufacturing. Correia et al. (2020) estimate that the pandemic caused an 18 percent decline in manufacturing output and a 23 percent decline in manufacturing employment, in part because several cities with large manufacturing industries were among those with the highest flu fatality rates.

Some NPIs, such as temporary closures of non-essential businesses, clearly impose direct economic costs on affected firms and households. However, widespread illness or deaths can also be economically costly, suggesting that, conceivably, the economic benefits of containing a pandemic might outweigh the direct costs imposed on owners and employees of firms that are required to close. During the Spanish flu pandemic, cities with lower excess flu mortality rates had smaller declines in some measures of economic activity, suggesting that the direct cost of NPIs might have been offset at least to some extent by stronger economies. Moreover, there is evidence that cities that imposed NPIs earlier and more rigorously during the pandemic had higher growth in manufacturing output and employment for up to four years after the pandemic. Correia et al. (2020) use a dynamic difference-in-difference regression approach to examine the impact of NPIs on manufacturing across cities. Their model controls for various pre-crisis state and local characteristics, such as total population, urbanization, manufacturing share of employment, and growth of manufacturing output and employment from 1909 to 1914. The study finds that implementing NPIs earlier in the pandemic and using them more intensely produced significantly higher rates of growth in manufacturing output and employment from 1919 to 1923 than did slower activation or less intense use of NPIs. Estimates from the study's base model indicate that a one standard deviation increase in the speed of adopting NPIs (8 days) is associated with 4 percent higher growth of employment after the pandemic, while a one standard deviation increase in NPI intensity leads to 6 percent higher employment growth. The authors estimate several models with different sets of controls, and though not all show a statistically significant impact of NPIs on growth or employment, none indicate that NPIs reduced economic activity. The base specification controls include measures of urbanization, pre-crisis population, manufacturing employment share, and flu mortality in 1917, as well as state-level agricultural employment share. Additional control variables in other specifications include the growth in manufacturing output and employment from 1909 to 1914, census region fixed effects, longitude, WWI servicemen mortality rate, and health and total public spending per capita in 1917.

Clearly, there are limits to the applicability of the Spanish flu episode to the COVID-19 pandemic. In particular, the unusually high fatality rate among young, working-age men suggests that the flu pandemic might have had a larger economic impact, particularly on labor-intensive industries, than will COVID-19. The structure of the U.S. economy and distribution of the population are also very different today than in 1918, which could affect how either a pandemic or the NPIs imposed to contain it affect public health or the economy. For example, because pandemic mortality is strongly associated with population density, increased urbanization suggests that NPIs might have more public health benefit today than in 1918. On the other hand, the substantial increase over time in employment in the service sector suggests that the direct costs of mandatory business closures, which tend to fall more heavily on retail establishments and other service industries, could be higher today than in 1918. In 1918, the U.S. population was split evenly between urban and rural areas in 1918, whereas today the urban population is five times the rural population. Moreover, in 1918, 33 percent of the labor force was employed in agriculture and 28 percent was employed in manufacturing, compared with 2 percent and 8 percent, respectively, today (Velde 2020). As of 2018, some 80 percent of the U.S. labor force was employed in service industries. See Bureau of Labor Statistics Employment Projections data . Still, insights from the Spanish flu and other pandemics should not be dismissed entirely. So long as we remain cognizant of the environmental features in which they occurred, the pandemics of the past can provide useful data points for helping to forecast how the COVID-19 and future pandemics are likely to play out, and in particular for addressing such questions as whether NPIs are likely to be the sole source of economic disruptions in a pandemic, or whether a pandemic would cause an economic downturn in the absence of interventions to slow its spread.

1 Johnson and Mueller (2002) estimate 50 million deaths worldwide and provide estimates for several countries. Jorda et al. (2020) report an estimate of 100 million deaths, as well as mortality estimates for other pandemics since the fourteenth century with at least 100,000 deaths.

2 Taubenberger and Morens (2006). See also Garrett (2008) and references therein for data and other information about the origins and spread of the pandemic in the United States.

3 Eric Durr, " Worldwide Flu Outbreak Killed 45,000 American Soldiers During World War I ."

4 Taubenberger and Morens (2006).

5 In a study of 15 major pandemics since the fourteenth century, Jorda, Singh, and Taylor (2020) find that real wages are typically elevated for several years after pandemics, while the returns to capital are low, likely because of widespread deaths among the working-age population.

6 Detailed information about the use of NPIs by 50 cities during the pandemic is available from the University of Michigan Center for the History of Medicine .

7 See Barro (2020), Correia et al. (2020), Bootsma and Ferguson (2007), Hatchett et al. (2007), and Markel et al. (2007). Barro (2020) notes that the mean duration of NPIs across 43 cities was 4-6 weeks and suggests that a duration of 12 weeks would have produced a substantially lower total death rate.

8 University of Michigan Center for the History of Medicine .

9 Velde (2020) examines a variety of high-frequency economic time series data during the pandemic and concludes that the pandemic had only modest impact on economic activity. Barro et al. (2020) examine the impact of the pandemic across countries and attempt to control for differences in war intensity using data on combat deaths. The study finds that the flu pandemic caused a 6.2 percent decline in GDP in a typical country and a decline of about 1.5 percent in the United States.

10 The base specification controls include measures of urbanization, pre-crisis population, manufacturing employment share, and flu mortality in 1917, as well as state-level agricultural employment share. Additional control variables in other specifications include the growth in manufacturing output and employment from 1909 to 1914, census region fixed effects, longitude, WWI servicemen mortality rate, and health and total public spending per capita in 1917.

11 In 1918, the U.S. population was split evenly between urban and rural areas in 1918, whereas today the urban population is five times the rural population. Moreover, in 1918, 33 percent of the labor force was employed in agriculture and 28 percent was employed in manufacturing, compared with 2 percent and 8 percent, respectively, today (Velde 2020). As of 2018, some 80 percent of the U.S. labor force was employed in service industries. See Bureau of Labor Statistics Employment Projections data .

Barro, Robert J. "Non-Pharmaceutical Interventions and Mortality in U.S. Cities During the Great Influenza Pandemic, 1918-1919." NBER Working Paper 27049, April 2020.

Barro, Robert J.; Ursua, Jose F. and Weng, Joanna. "The Coronavirus and the Great Influenza Pandemic—Lessons from the 'Spanish Flu' for the Coronavirus's Potential Effects on Mortality and Economic Activity." NBER Working Paper 26866, March 2020.

Benmelech, Efraim and Frydman, Carola. "The 1918 Influenza Did Not Kill the US Economy." VOX CEPR Policy Portal, April 29, 2020.

Bootsma, Martin C.J. and Ferguson, Neil M. "The Effect of Public Health Measures on the 1918 Influenza Pandemic in U.S. Cities." Proceedings of the National Academy of Sciences, May 2007, 104(18), pp. 7588-93.

Correia, Sergio; Luck, Stephan and Verner, Emil. "Pandemics Depress the Economy, Public Heath Interventions Do Not: Evidence from the 1918 Flu." SSRN Working Paper No. 3561560, April 10, 2020.

Garrett, Thomas A. "Pandemic Economics: The 1918 Influenza and Its Modern-­Day Implications." Federal Reserve Bank of St. Louis Review, March/April 2008, pp. 75-93.

Garrett, Thomas A. "War and Pestilence as Labor Market Shocks: U.S. Manufacturing Wage Growth 1914-1919." Economic Inquiry, October 2009, 47(4), pp. 711-25.

Hatchett, Richard J.; Mecher, Carter E. and Lipsitch, Marc. "Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic." Proceedings of the National Academy of Sciences, May 2007, 104(18), pp. 7582-87.

Johnson, Niall P.A.S. and Mueller, Juergen. "Updating the Accounts: Global Mortality of the 1918-1920 'Spanish' Influenza Pandemic." Bulletin of the History of Medicine, Spring 2002, 76(1), pp. 105-15.

Jorda, Oscar; Singh, Sanjay R. and Taylor, Alan M. "Longer-Run Economic Consequences of Pandemics." Federal Reserve Bank of San Francisco Working Paper 2020-09, March 2020.

Markel, Howard; Lipman, Harvey B.; Navarro, J. Alexander; Sloan, Alexandra; Michalsen, Joseph R.; Stern, Alexandra Minna and Cetron, Martin S. "Nonpharmaceutical Interventions Implemented by U.S. Cities During the 1918-1919 Influenza Pandemic." Journal of the American Medical Association, 2007, 298(6), pp. 644-54.

Taubenberger, Jeffery K. and Morens, David M. "1918 Influenza: the Mother of All Pandemics." Emerging Infectious Diseases, January 2006, 12(1), pp. 15-22.

Velde, Francois R. "What Happened to the U.S. Economy During the 1918 Influenza Pandemic? A View Through High-Frequency Data." Federal Reserve Bank of Chicago Working Paper 2020-11, April 2020.

© 2020, Federal Reserve Bank of St. Louis. The views expressed are those of the author(s) and do not necessarily reflect official positions of the Federal Reserve Bank of St. Louis or the Federal Reserve System.

David Wheelock is senior vice president and special policy advisor to the Bank president. Read more about his work .

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