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SPRING 2020 THE GREAT INFLUENZA: THE STORY OF THE GREATEST MODERN PANDEMIC AND ITS LESSONS FOR 2020 AND BEYOND The world now faces another major pandemic. While the death toll in the current pandemic is still but a fraction of the greatest modern pandemic of the 1918 Spanish flu, there are valuable lessons from a century ago that can put our current predicament in perspective. We explore.grease, bring the key issues to a simmer, and box up the topics for the reader to feast upon. Hold the pickles.
The Great Influenza:
The S tory of the Greatest Modern Pandemic and Its
Lessons for 2020 and Beyond
"I f anything kills over 10 million people in
the next few decades, it’s most likely to be
a highly infectious virus, rather than a war. Not
provide a few lessons from the Great Influenza,
its magnitude, its origins, its uncontrolled spread,
and some of its consequences. Pandemics are not
240–480 million deaths—simply staggering
and unfathomable. So, the first lesson is that
the tragedy now unfolding is NOT the Great
missiles, but microbes.”1 random events. Influenza (or the Black Death for that matter).
These prescient words were spoken in 2015 THE SHADOW OF 1918 In addition to the death toll, there was the speed
by none other than Bill Gates, the co-founder with which the destruction was inflicted on the
Although accounts vary, an estimated one-third
of Microsoft. In a TED Talk, Gates lamented population in 1918. The Great Influenza killed
of the world’s population, or roughly 500 million
humanity’s misplaced focus. While we have swiftly, often within hours of infection. One army
people, were infected during the 1918–1920
invested heavily in nuclear deterrents, he opined, report from 1918 described it as “fulminating
“Great Influenza” pandemic (See Did You Know?
we have invested very little to stop a pandemic. pneumonia, with wet hemorrhagic lungs” that
The Spanish Flu Misnomer). The pandemic was
He concluded, “We’re not ready for the next proved “fatal in 24 to 48 hours.”
not your regular seasonal flu—the illness was far
epidemic.”2
more severe than the average seasonal flu variety. An estimated two-thirds of total deaths occurred
Gates was right. A pandemic has now enveloped Total death estimates range from 50 million to in just 24 weeks in 1918, “and more than half of
the world, roiled financial markets, brought the 100 million of the global population at the time.3 those deaths occurred” in less than three months,
global economy to its knees—and caught almost A comparable death toll today implies around from mid-September to early December. In sum,
everyone unprepared. As we go to press, SARS- the “Great Influenza” took more lives than the
CoV-2, the virus that causes COVID-19, has ongoing, decades-long AIDS epidemic—in a
already surpassed the 2009 H1N1 pandemic in «AN ESTIMATED manner of mere weeks.
terms of case count and global deaths (see Figure ONE-THIRD OF THE
WORLD’S POPULATION, Frightening? It gets worse. Typically, the flu
1). The current pandemic could rival the 1957
befalls the very old and the very weak. With the
and 1968 episodes when all is said and done. OR ROUGHLY 500
Great Influenza, young adults, aged 20–40 years,
Rare events pose particular challenges for
MILLION PEOPLE, WERE fared the worst, accounting for nearly half of all
investors. Are they just random occurrences? INFECTED DURING deaths. Furthermore, an estimated 47% of all
How do we put current events into the proper THE 1918–1920 “GREAT deaths in the United States in 1918–1919—that
perspective? Our response is that history teaches INFLUENZA” PANDEMIC» includes all deaths from everything from cancer
those who inquire with an open mind. We to accidents—were due to the influenza.
fig. 1
A RARE EVENT OR HISTORY REPEATING ITSELF? SELECTED
PANDEMICS SINCE 165 AD
Millions of Deaths*
0 10 20 30 40 50 60 70 80
Antonine Plague, 165 - 180 5.0
Plague of Justinian, 541 - 542 30.0
Black Death, 1347 - 1352 75.0
New World smallpox, 1520 25.0
Italian Plague, 1629 - 1631 1.0
Great Plague of London, 1665 0.08 The Black Death was the deadliest
Third Plague, 1885 pandemic in recorded history, wiping
12.0
out 30-60% of Europe's population
Russian flu, 1889 - 1890 1.0
Pandemic, Year
Yellow Fever, 1895 0.15
The Great Influenza, 1918 - 1920 50.0
Asian flu, 1957 - 1958 1.0
Hong Kong flu, 1968 - 1970 1.0
HIV/AIDS, 1981-Present 35.0
SARS, 2002 - 2003 0.001
Ebola, 2014 - 2016 0.011
MERS, 2015 0.001
Swine Flu (H1N1), 2009 - 2020 0.20
COVID-19, 2020 - ? 0.29
Source: Washington Post *For some pandemics, there was a range of values and we chose to plot the lower end of the estimates.
1Roman writer Varro (116–26 B.C.) speculated
«YOUNG ADULTS, AGED about tiny invisible germs, but scientists didn’t « YOU ARE UNDOUBTEDLY
20–40 YEARS, FARED THE see a virus under a microscope until the 1930s. SURROUNDED BY PLENTY
WORST, ACCOUNTING OF VIRUSES RIGHT NOW—
FOR NEARLY HALF OF ALL WE AREN’T IN KANSAS ANYMORE
DON’T TOUCH YOUR
DEATHS.» Aside from not being able to see the enemy, FACE!»
humanity in 1918 was also blind to its origins.
However, the worst part of all is that, amid the Again, speculation abounds, and the science and the virus has a chance to survive and replicate,
pandemic, scientists didn’t even know the enemy remains unsettled, but one plausible theory is to humans. AIDS and influenza are examples of
at hand. “No one could find the guilty bug, no one that the Great Influenza began, not in Spain, these “zoonoses”—and, indeed, most viruses we
could see it, no one could name it or comprehend despite the moniker, but in Kansas. know of infect humans through such an avenue.
it, because virology itself had scarcely begun to The jump was possibly made in Haskell.
exist. The virus responsible, which turned out to Yes, Kansas. Haskell, Kansas.
be a variant of H1N1, wasn’t precisely identified ALL THAT WAS NEEDED WAS A SPARK
What was so special about Haskell? Well, for
until …2005!”4 Humanity was in the dark.
starters, a man named Loring Miner. A doctor, he
If Kansas was indeed the epicenter, the virus
wasted little time in spreading across the world.
DID YOU KNOW?
It was the rapid buildup of U.S. involvement in
The Spanish Flu Misnomer World War I that provided the perfect kindling
for a pandemic. Public health took a backseat
According to the author John Barry, Spain is unfairly pinned with the Spanish flu name due
to politics (shocking, we know!). President
to happenstance. Spain had few cases but was a neutral nation in World War I, one of the Wilson made no statements on the influenza, in
few countries with a free press. Whereas other countries suppressed influenza stories so as public or, it seems, in private, and the federal
not to stoke fears, Spanish papers reported on the disease, and the Spanish King, Alfonso government focused on mobilizing for war.
XIII, fell ill. For this piece, we adopt Barry’s nomenclature and refer to the episode as the
With the benefit of hindsight, by the fall of 1918,
Great Influenza. 5
little more than a month remained in the conflict.
However, the U.S. was determined to ramp
up troops for the war. From Funston, troops
went to other army bases and then off to France.
VIRUSES: WAIT, WHAT ARE THEY? saw many patients in early 1918 suffering from Influenza cases sprung up in the following weeks
a worrisome illness and alerted the U.S. Public in Georgia, and then twenty-four of the thirty-
Viruses have been around on Earth for billions
Health Service on his findings of “influenza of the six largest army camps experienced an influenza
of years, meaning the viruses on Earth today are
severe type.” His reports were the only influenza outbreak that spring.
formidable foes as “only the fittest have survived.”
mentions from anywhere in the world at that
We tend to imagine large predators as our primary
early point in the outbreak.
competitors for survival, such as the lions of the
Serengeti, but tiny terrors lurk everywhere. You Haskell was also close to a military camp: «PUBLIC HEALTH TOOK A
are undoubtedly surrounded by plenty of viruses Camp Funston, Kansas. The frigid winter of BACKSEAT TO POLITICS
right now—don’t touch your face! 1917–1918 forced recruits to huddle together (SHOCKING, WE
For millennia, humans were surrounded by
in makeshift tents and overcrowded barracks, KNOW!)»
awaiting dispatch to Europe and World War I.
viruses, yet ignorant of them. Why? First, viruses
As people with influenza can transmit the virus
were not likely an issue for humans until modern
before symptoms appear, close quarters provide
cities allowed for dense enough populations to Further, thirty of the fifty largest cities in the
ripe conditions for a viral outbreak.
sustain a virus and promote its spread to plenty country, most of them adjacent to military
of nearby victims. For most of human history, our Influenza’s high infectivity preceded symptoms, facilities, also suffered an April spike in “excess
hunter-gatherer brethren roamed about; only a characteristic that probably helped account for mortality” from influenza, most of which were
very recently (~2,000 years) have we humans not realized at the time.
confined ourselves to dense cities.6
«ONE PLAUSIBLE The virus then ripped around the globe, from
Once in close contact, humans, and viruses have
THEORY IS THAT THE Portugal to Greece, back to England, Scotland,
been at war. History is punctuated by repeated,
GREAT INFLUENZA and Wales, then Calcutta, Madras, and Rangoon
devastating epidemics. In China alone, records after Bombay, and on to Karachi. Shanghai
show that “between 37 A.D. and 1718 A.D., BEGAN, NOT IN SPAIN,
and Sydney followed. It’s worth noting that the
234 outbreaks were severe enough to count as DESPITE THE MONIKER,
global spread occurred in an era long before
plagues—that’s one every seven years!”7 Figure BUT IN KANSAS.» the hyperconnected travel and trade networks
1 shows the most devastating tolls in recorded that now define the global economy. The mere
global history. presence of a mail carrier seemed to be enough
Second, the direct human-to-human spread was the scale of worldwide misery and death during to spread the virus city-by-city.
not always observed, so scientists remained in the the Great Influenza.
The bad news continued, though. Many are
dark about transmission. Malaria, for example,
Haskell added one other vital ingredient to already talking about a “second wave” of the
spreads from person-to-person via mosquito
the story: animals (it was an agricultural area). coronavirus in 2020. The Great Influenza
bites, not direct human contact.
Scientists now use the term “spillover” to designate hibernated over the summer of 1918 and
And, third, humankind did not yet have the the moment a pathogen jumps from a host or returned with a vengeance in the fall when it did
scientific tools to discover viruses. Viruses are reservoir species—say, birds or pigs—where the most of its killing.
small. Much smaller than the average bacteria. The genetic backdrop is similar enough to humans,
2fig. 2
SAVING LIVES TO (EVENTUALLY) SAVE THE ECONOMY? AMERICAN CITIES' SOCIAL
DISTANCING MEASURES AND MANUFACTURING SECTOR EMPLOYMENT GROWTH
AROUND THE 1918 PANDEMIC
Less Restrictive Measures* More Restrictive Measures Linear Trend
120% Seattle Cities that implemented harsh social distancing and saw lower
Employment Growth Between 1914 and 1919
Oakland mortality also saw their employment bounce back faster
100%
Portland Omaha
80%
Los Angeles
60%
Indianapolis
Spokane San Francisco Syracuse Birmingham
Toledo Cleveland
40% Columbus Denver
Minneapolis Rochester Buffalo Newark
Dayton Kansas City Baltimore
Milwaukee Cambridge Worcester Nashville
Grand Rapids St. Louis Richmond
20% Chicago New Haven
Albany Louisville Pittsburgh
Saint Paul Providence Washington New Orleans
New York Lowell Boston Philadelphia
0% Cincinnati Fall River
200 400 600 800 1000 1200
Deaths Per 100,000
Source: Sergio Correia, Stephan Luck, and Emil Verner, “Fight the Pandemic, Save the Economy: Lessons from the 1918 Flu,” Federal Reserve Bank of New York Liberty Street Economics, March 27, 2020
*The paper uses measures of non-pharmeceutical interventions (e.g. social distancing, mask wearing) established in Markel et. al. (2007)
discovered that certain cities that implemented to overwhelming ignorance. While denser
stricter interventions (like social distancing) saw populations build up a resistance to familiar
«IT’S WORTH NOTING
lower mortality rates and better employment viruses, they are vulnerable to “novel” ones.
THAT THE GLOBAL outcomes during the pandemic (see Figure Given enough time and proximity to nature,
SPREAD OCCURRED IN 2). Such findings present hope for our novel viruses will make the leap into humans
AN ERA LONG BEFORE present predicament, in which we see a global, again. Aside from the ever-present threat of the
THE HYPERCONNECTED synchronized use of social distancing measures influenza virus, we have now experienced three
TRAVEL AND TRADE to stem the virus. coronavirus outbreaks in the last 20 years: SARS-
NETWORKS THAT NOW CoV-1 in 2003–2004, MERS in 2015, and now
BETTER OFF TODAY SARS-CoV-2.
DEFINE THE GLOBAL
ECONOMY.» Can a brief tour of history relieve any of our
present anxiety? The lesson of 1918 is that
humanity was largely in the dark. Ignorant of
« MICROBES, NOT
In the words of the Australian virologist Frank MISSILES, HAD
the virus, its origins, its piggyback spread on
Macfarlane Burnet, “It is convenient to follow
the waves of war, humanity was left extremely CAUSED MOST DEATHS
the story of influenza at this period mainly
in regard to the army experiences in America
vulnerable. Medical capacity was overrun quickly, THROUGHOUT
and Europe.”8 On September 29, a group
and scientists didn’t even catch their first glimpse RECORDED HUMAN
of 9,000 soldiers left for France on the USS
at a virus for more than a decade. HISTORY. WE ARE THE
Leviathan—2,000 died en route. And while there is much we still do not know LUCKY ONES WHO HAVE
about SARS-CoV-2, we do know the world is a LATELY GAINED THE
With nurses and doctors pressed into war much better place in 2020. Indeed, perhaps one UPPER HAND.»
service, cities and states left mostly to their own of the reasons we are so startled by the virus is
devices employed a wide array of strategies because we have become accustomed to dying
to arrest the virus. Some cities enforced strict of other things: heart disease, cancer, or just old Our best chance today and in the future is to
social distancing measures. Others, such as age. But that’s a modern luxury. In 1918, life push progress forward relentlessly. How do
Philadelphia, were much more lenient. In expectancy at birth did not exceed 50 in the U.S. we measure medical progress? One way is to
an analysis of 1914 and 1919 Census data, and Europe, with far worse prospects for the rest gauge the information sharing among scientists
researchers at the New York Federal Reserve of the globe. Microbes, not missiles, had caused collaborating to develop treatments and vaccines
most deaths throughout recorded human history. in real-time. A surge in science “preprints” in
We are the lucky ones who have lately gained the March and April 2020 (see Figure 3 on Page
«ON SEPTEMBER 29, 10) shows researchers are rushing to share
upper hand.
A GROUP OF 9,000 information with the world, with the growth
SOLDIERS LEFT FOR Seen in that light, we can’t treat the current rate in preprints more than doubling in the last
FRANCE ON THE USS pandemic as an isolated, random event, chalking two months.9 The efforts could yield results in a
it up to bad luck. Pandemics do not just happen. shorter timespan than ever before. Bill Gates, who
LEVIATHAN—2,000 DIED
Humanity has battled viruses for centuries— opened our story with a warning, closes it with
EN ROUTE. »
most of the time, with devastating results due
3fig. 3
INFORMATION SHARING IS AT ALL TIME HIGHS–
BIOMEDICAL PREPRINTS PER MONTH
Number of Preprints
2013 2014 2015 2016 2017 2018 2019 2020
Source: Zenodo.org
4. David Quammen. “Spillover: Animal Infections
and the Next Human Pandemic.” W.W. Norton &
«ASIDE FROM THE
Company, October 2012.
EVER-PRESENT THREAT
OF THE INFLUENZA 5. John Barry. “The Great Influenza: The Story of the
Greatest Pandemic In History.” New York: Penguin
VIRUS, WE HAVE
Books, 2005.
NOW EXPERIENCED
6. See for example our Point of View, “The Story
THREE CORONAVIRUS
of World History Through The Most Populous
OUTBREAKS IN THE LAST
Cities", Winter 2016, page 10, https://www.payden.
20 YEARS.» com/displayfile.aspx?fileloc=11
7. David P. Clark. “Germs, Genes, & Civilization.
a hint of optimism. “Although eighteen months How Epidemics Shaped Who We Are Today.” FT
[to a vaccine] might sound like a long time, this Press: Upper Saddle River, New Jersey, 2010.
would be the fastest scientists have created a new
8. Barry 120.
vaccine.”10 Perhaps never before in history has
9. Kai Kupferschmidt, “‘A completely new culture
humanity been so united in finding a solution.
of doing research.’ Coronavirus outbreak changes
Let’s count ourselves fortunate that the current how scientists communicate,” Science, February 26,
pandemic pales in comparison to the Great 2020.
Influenza—but let’s also use this opportunity to
10. Bill Gates, “What you need to know about the
learn how to prevent the next one—because it’s
COVID-19 vaccine,” GatesNotes, April 30, 2020.
inevitable.
SOURCES
1. “The New Outbreak? We’re Not Ready.” Bill Gates.
TedTalk. March 2015. https://www.ted.com/
talks/bill_gates_the_next_outbreak_we_re_not_
ready?language=en#t-62818
2. An epidemic is defined by Merriam-Webster as “an
outbreak of disease that spreads quickly and affects
many individuals at the same time.” A pandemic
is a type of epidemic (one with greater range and
coverage), an outbreak of a disease that occurs over
a wide geographic area and affects an exceptionally
high proportion of the population.
3. “1918 Influenza: the Mother of All Pandemics”,
Jeffery K. Taubenberger and David M. Morens,
Emerging Infectious Diseases. 2006 Jan; 12(1):
15–22. https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3291398/
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