A Tale of Two Pandemics: The 1918 Flu and COVID-19

**By Chris Baliga, MD, and David Wilma**

“We’re in unprecedented times.” During the COVID-19 pandemic, we hear variations of this statement on repeat. While current times are heartbreaking and incredibly trying, there is, in fact, a precedent.

As an infectious disease specialist here at Virginia Mason, I was curious about historical similarities and differences between the 1918 influenza pandemic and the current COVID-19 pandemic.

I checked in with David Wilma, author and historian, to help answer some questions many people have related to what we are experiencing now compared to what happened more than a century ago.

Chris Baliga, MD (CB): What did the early days of the 1918 influenza pandemic look like?

David Wilma (DW): First, let’s discuss the 1918 pandemic’s commonly used name, the “Spanish flu.” It’s entirely a misnomer. The name “Spanish flu” mainly spread far and wide because Spanish public health officials were the first to report an influenza epidemic in 1918. But the virus did not originate in Spain.

Due to wartime censorship during World War I, reports of severe influenza-like illnesses from several years earlier in army camps in France were suppressed. Because Spain had been the first to publicly declare an epidemic of influenza, the world latched onto that association.

CB: So, if not Spain, where did the influenza of 1918 originate?

DW: There are a few theories. One posits the virus transferred to humans from birds in China. Thousands of Chinese people were recruited by the British Army as laborers, sailed across the Pacific Ocean and were transported by trains across Canada, where the first known infections were recorded. Then, these recruits and additional passengers boarded ships and returned back across the Atlantic Ocean, subsequently infecting armies in France.

Another theory places the first outbreak in Kansas in February 1918. But, it’s possible that outbreak was the result of the virus returning with travelers from France. An unfortunate reality is that the likely origin and means of transmission have never been established and will never be known.

CB: What did the influenza pandemic of 1918 look like in Seattle and our region?

DW: The first influenza infections in Seattle occurred aboard a trainload of Navy recruits arriving from Philadelphia in early October 1918. Statewide containment measures were not rolled out until Nov. 3, 1918. Still, there was no state authority over local governments, and bans on public gatherings were spotty and irregular.

Hospital 1920

Virginia Mason Hospital in 1920

In Seattle, public gatherings resumed on Nov. 11, 1918, to celebrate Armistice Day, only to prove that the city was not ready to return to “normal.” Infections increased again, resulting in a total of 1,441 deaths in Seattle and more than 5,000 deaths across Washington state, of which more than half of victims were between 20 and 39 years of age.

At the time, Seattle had a population of three hundred thousand, making it the largest city in the state. Inadequate hospital beds in the city forced a dormitory at the University of Washington to be pressed into service for the sick and dying.

The shortage of good hospital care in Seattle prompted the Virginia Mason founders to consider a new hospital built around a team of specialists. As a result, Virginia Mason Hospital opened in 1920 in direct response to the 1918 flu pandemic.

CB: What are we seeing with COVID-19 that is similar to the influenza pandemic in 1918?

 DW: First, both the 1918 flu and COVID-19 are caused by a virus. Both highly contagious, the viruses also share similar transmission between humans by contact with infected air particles. Transmission is exacerbated by travel. Though ships and trains back then were physically slower than airplanes travelling internationally today, they were still just as effective in moving passengers around and contributing to disease spread. During both pandemics, seaport and airport cities were home to the earliest infections, largely due to the volume of travelers through the area. For many people in 1918, the notion that influenza came from “somewhere else” outside their own country in combination with wartime tensions contributed to harmful xenophobic, racist ideas and scapegoating of foreign populations. We’ve unfortunately seen similar reactions to the coronavirus.

And as influenza and COVID-19 arrived in and spread throughout cities, they’ve affected Native, Hispanic and African-American populations more than other populations.

In both pandemics, the virus alone is not the sole cause of fatalities. Rather, it’s the escalation of symptom severity that can become a problem. Influenza and the coronavirus can rapidly contribute to severe, often fatal complications like pneumonia.

As we analyze various government responses and containment efforts directed at COVID-19, it’s important to remember what we saw during the 1918 influenza pandemic. Intentional, thorough and well-implemented containment measures are likely to be most effective in virus control. In fact, during the 1918 pandemic and COVID-19 today, countries and cities that imposed contact restriction measures early and kept those measures in place experience fewer fatalities overall. Acting early is an important lesson for all of us to learn, as well as ensuring a thorough response and not returning to normal operations too quickly.

CB: How is our current response to COVID-19 different from how we experienced and handled the influenza pandemic in 1918?

DW: Perhaps the most significant determinant of the 1918 influenza response was the limited medical understanding and technology at the time.

Our lack of understanding of viruses and their behavior meant we were never able to respond to the 1918 influenza pandemic properly. The particular strain of influenza was not even identified as a virus until 1930, and no vaccine was ever developed to combat the disease. The pandemic only really calmed down after infection rates declined in waves in the late winter of 1918. Wartime censorship limited our understanding of the ongoing pandemic and early outbreaks on the battlefields. Potential drug treatments like Tamiflu simply did not exist at the time.

Recordkeeping practices in 1918 also posed a challenge, and reports of influenza were likely overlooked. We know that the 1918 flu infected populations across the board – hitting the youngest, the oldest, men and women. But contact tracing and tracking the disease’s spread in real time was minimal. Wartime record suppression, lack of reporting requirements and health authorities’ conflation of data among deaths from influenza and pneumonia all contributed to inaccurate data.

Around 100 years later, we have a much greater understanding of viruses, their behavior, effective treatments and the capabilities of health care workers and medical systems overall. We’ve been here before, and we’ll get through this now, by all working together.


Baliga, ChrisChristopher Baliga, M.D. is board-certified by the American Academy of Internal Medicine in infectious diseases and internal medicine. He practices at Virginia Mason Seattle Medical Center. Dr. Baliga specializes in infectious diseases, HIV/AIDS care and travel health issues.


David WilmaDavid Wilma is a writer and author of history books and historical fiction. He is based in the Pacific Northwest.

 

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