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THE NEXT PANDEMIC A Smithsonian magazine special report

How the Horri�c 1918 Flu Spread Across America The toll of history’s worst epidemic surpasses all the military deaths in World War I and

World War II combined. And it may have begun in the United States

John M. Barry

November 2017

HISTORY

An emergency hospital at Camp Funston, Kansas, 1918. “Of the 12 men who slept in my squad room, 7 were ill at one time,” a soldier recalled. New Contributed Photographs Collection / otis historical Archives / National Museum of Health and Medicine

Haskell County, Kansas, lies in the southwest corner of the state, near Oklahoma and Colorado. In 1918 sod

houses were still common, barely distinguishable from the treeless, dry prairie they were dug out of. It had been

cattle country—a now bankrupt ranch once handled 30,000 head—but Haskell farmers also raised hogs, which is

one possible clue to the origin of the crisis that would terrorize the world that year. Another clue is that the county

sits on a major migratory �yway for 17 bird species, including sand hill cranes and mallards. Scientists today

understand that bird in�uenza viruses, like human in�uenza viruses, can also infect hogs, and when a bird virus

and a human virus infect the same pig cell, their di�erent genes can be shu�ed and exchanged like playing cards,

resulting in a new, perhaps especially lethal, virus.

We cannot say for certain that that happened in 1918 in Haskell County, but we do know that an in�uenza

outbreak struck in January, an outbreak so severe that, although in�uenza was not then a “reportable” disease, a

local physician named Loring Miner—a large and imposing man, gru�, a player in local politics, who became a

doctor before the acceptance of the germ theory of disease but whose intellectual curiosity had kept him abreast

of scienti�c developments—went to the trouble of alerting the U.S. Public Health Service. The report itself no

longer exists, but it stands as the �rst recorded notice anywhere in the world of unusual in�uenza activity that

year. The local newspaper, the Santa Fe Monitor, con�rms that something odd was happening around that time:

“Mrs. Eva Van Alstine is sick with pneumonia...Ralph Lindeman is still quite sick...Homer Moody has been reported

quite sick...Pete Hesser’s three children have pneumonia ...Mrs J.S. Cox is very weak yet...Ralph Mc-Connell has

      ⎙ ✉

been quite sick this week...Mertin, the young son of Ernest Elliot, is sick with pneumonia,...Most everybody over the

country is having lagrippe or pneumonia.”

Several Haskell men who had been exposed to in�uenza went to Camp Funston, in central Kansas. Days later, on

March 4, the �rst soldier known to have in�uenza reported ill. The huge Army base was training men for combat in

World War I, and within two weeks 1,100 soldiers were admitted to the hospital, with thousands more sick in

barracks. Thirty-eight died. Then, infected soldiers likely carried in�uenza from Funston to other Army camps in

the States—24 of 36 large camps had outbreaks—sickening tens of thousands, before carrying the disease

overseas. Meanwhile, the disease spread into U.S. civilian communities.

The in�uenza virus mutates rapidly, changing enough that the human immune system has di�culty recognizing

and attacking it even from one season to the next. A pandemic occurs when an entirely new and virulent in�uenza

virus, which the immune system has not previously seen, enters the population and spreads worldwide. Ordinary

seasonal in�uenza viruses normally bind only to cells in the upper respiratory tract—the nose and throat—which is

why they transmit easily. The 1918 pandemic virus infected cells in the upper respiratory tract, transmitting easily,

but also deep in the lungs, damaging tissue and often leading to viral as well as bacterial pneumonias.

Although some researchers argue that the 1918 pandemic began elsewhere, in France in 1916 or China and

Vietnam in 1917, many other studies indicate a U.S. origin. The Australian immunologist and Nobel laureate

Macfarlane Burnet, who spent most of his career studying in�uenza, concluded the evidence was “strongly

suggestive” that the disease started in the United States and spread to France with “the arrival of American

troops.” Camp Funston had long been considered as the site where the pandemic started until my historical

research, published in 2004, pointed to an earlier outbreak in Haskell County.

Wherever it began, the pandemic lasted just 15 months but was the deadliest disease outbreak in human history,

killing between 50 million and 100 million people worldwide, according to the most widely cited analysis. An exact

global number is unlikely ever to be determined, given the lack of suitable records in much of the world at that

time. But it’s clear the pandemic killed more people in a year than AIDS has killed in 40 years, more than the

bubonic plague killed in a century.

The impact of the pandemic on the United States is sobering to contemplate: Some 670,000 Americans died.

In 1918, medicine had barely become modern; some scientists still believed “miasma” accounted for in�uenza’s

spread. With medicine’s advances since then, laypeople have become rather complacent about in�uenza. Today

we worry about Ebola or Zika or MERS or other exotic pathogens, not a disease often confused with the common

cold. This is a mistake.

We are arguably as vulnerable—or more vulnerable—to another pandemic as we were in 1918. Today top public

health experts routinely rank in�uenza as potentially the most dangerous “emerging” health threat we face. Earlier

this year, upon leaving his post as head of the Centers for Disease Control and Prevention, Tom Frieden was asked

what scared him the most, what kept him up at night. “The biggest concern is always for an in�uenza pandemic...

[It] really is the worst-case scenario.” So the tragic events of 100 years ago have a surprising urgency—especially

since the most crucial lessons to be learned from the disaster have yet to be absorbed.

**********

Initially the 1918 pandemic set o� few alarms, chie�y because in most places it rarely killed, despite the enormous

numbers of people infected. Doctors in the British Grand Fleet, for example, admitted 10,313 sailors to sick bay in

May and June, but only 4 died. It had hit both warring armies in France in April, but troops dismissed it as “three-

day fever.” The only attention it got came when it swept through Spain, and sickened the king; the press in Spain,

which was not at war, wrote at length about the disease, unlike the censored press in warring countries, including

the United States. Hence it became known as “Spanish �u.” By June in�uenza reached from Algeria to New

Zealand. Still, a 1927 study concluded, “In many parts of the world the �rst wave either was so faint as to be hardly

perceptible or was altogether lacking...and was everywhere of a mild form.” Some experts argued that it was too

mild to be in�uenza.

Yet there were warnings, ominous ones. Though few died in the spring, those who did were often healthy young

adults—people whom in�uenza rarely kills. Here and there, local outbreaks were not so mild. At one French Army

post of 1,018 soldiers, 688 were hospitalized and 49 died—5 percent of that population of young men, dead. And

some deaths in the �rst wave were overlooked because they were misdiagnosed, often as meningitis. A puzzled

Chicago pathologist observed lung tissue heavy with �uid and “full of hemorrhages” and asked another expert if it

represented “a new disease.”

A ravaged lung (at the National Museum of Health and Medicine) from a U.S. soldier killed by �u in 1918. Cade Martin

By July it didn’t seem to matter. As a U.S. Army medical bulletin reported from France, the “epidemic is about at an

end...and has been throughout of a benign type.” A British medical journal stated �atly that in�uenza “has

completely disappeared.”

In fact, it was more like a great tsunami that initially pulls water away from the shore—only to return in a towering,

overwhelming surge. In August, the a�iction resurfaced in Switzerland in a form so virulent that a U.S. Navy

intelligence o�cer, in a report stamped “Secret and Con�dential,” warned “that the disease now epidemic

throughout Switzerland is what is commonly known as the black plague, although it is designated as Spanish

sickness and grip.”

The second wave had begun.

**********

The hospital at Camp Devens, an Army training base 35 miles from Boston that teemed with 45,000 soldiers, could

accommodate 1,200 patients. On September 1, it held 84.

On September 7, a soldier sent to the hospital delirious and screaming when touched was diagnosed with

meningitis. The next day a dozen more men from his company were diagnosed with meningitis. But as more men

fell ill, physicians changed the diagnosis to in�uenza. Suddenly, an Army report noted, “the in�uenza...occurred as

an explosion.”

At the outbreak’s peak, 1,543 soldiers reported ill with in�uenza in a single day. Now, with hospital facilities

overwhelmed, with doctors and nurses sick, with too few cafeteria workers to feed patients and sta�, the hospital

ceased accepting patients, no matter how ill, leaving thousands more sick and dying in barracks.

Roy Grist, a physician at the hospital, wrote a colleague, “These men start with what appears to be an ordinary

attack of LaGrippe or In�uenza, and when brought to the Hosp. they very rapidly develop the most vicious 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”—the term refers to a person turning blue from

lack of oxygen—“extending from their ears and spreading all over the face....It is only a matter of a few hours then

until death comes...It is horrible....We have been averaging about 100 deaths per day...For several days there were

no co�ns and the bodies piled up something �erce...”

Devens, and the Boston area, was the �rst place in the Americas hit by the pandemic’s second wave. Before it

ended, in�uenza was everywhere, from ice-bound Alaska to steaming Africa. And this time it was lethal.

**********

The killing created its own horrors. Governments aggravated them, partly because of the war. For instance, the

U.S. military took roughly half of all physicians under 45—and most of the best ones.

What proved even more deadly was the government policy toward the truth. When the United States entered the

war, Woodrow Wilson demanded that “the spirit of ruthless brutality...enter into the very �bre of national life.” So

he created the Committee on Public Information, which was inspired by an adviser who wrote, “Truth and

falsehood are arbitrary terms....The force of an idea lies in its inspirational value. It matters very little if it is true or

false.”

At Wilson’s urging, Congress passed the Sedition Act, making it punishable with 20 years in prison to “utter, print,

write or publish any disloyal, profane, scurrilous, or abusive language about the form of government of the United

State...or to urge, incite, or advocate any curtailment of production in this country of any thing or

things...necessary or essential to the prosecution of the war.” Government posters and advertisements urged

people to report to the Justice Department anyone “who spreads pessimistic stories...cries for peace, or belittles

our e�ort to win the war.”

Against this background, while in�uenza bled into American life, public health o�cials, determined to keep morale

up, began to lie.

Early in September, a Navy ship from Boston carried in�uenza to Philadelphia, where the disease erupted in the

Navy Yard. The city’s public health director, Wilmer Krusen, declared that he would “con�ne this disease to its

present limits, and in this we are sure to be successful. No fatalities have been recorded. No concern whatever is

felt.”

The next day two sailors died of in�uenza. Krusen stated they died of “old-fashioned in�uenza or grip,” not Spanish

�u. Another health o�cial declared, “From now on the disease will decrease.”

The next day 14 sailors died—and the �rst civilian. Each day the disease accelerated. Each day newspapers assured

readers that in�uenza posed no danger. Krusen assured the city he would “nip the epidemic in the bud.”

By September 26, in�uenza had spread across the country, and so many military training camps were beginning to

look like Devens that the Army canceled its nationwide draft call.

Philadelphia had scheduled a big Liberty Loan parade for September 28. Doctors urged Krusen to cancel it, fearful

that hundreds of thousands jamming the route, crushing against each other for a better view, would spread

disease. They convinced reporters to write stories about the danger. But editors refused to run them, and refused

to print letters from doctors. The largest parade in Philadelphia’s history proceeded on schedule.

The incubation period of in�uenza is two to three days. Two days after the parade, Krusen conceded that the

epidemic “now present in the civilian population was...assuming the type found in” Army camps. Still, he cautioned

not to be “panic stricken over exaggerated reports.”

He needn’t have worried about exaggeration; the newspapers were on his side. “Scienti�c Nursing Halting

Epidemic,” an Inquirer headline blared. In truth, nurses had no impact because none were available: Out of 3,100

urgent requests for nurses submitted to one dispatcher, only 193 were provided. Krusen �nally and belatedly

ordered all schools closed and banned all public gatherings—yet a newspaper nonsensically said the order was

not “a public health measure” and “there is no cause for panic or alarm.”

There was plenty of cause. At its worst, the epidemic in Philadelphia would kill 759 people...in one day. Priests

drove horse-drawn carts down city streets, calling upon residents to bring out their dead; many were buried in

mass graves. More than 12,000 Philadelphians died—nearly all of them in six weeks.

Across the country, public o�cials were lying. U.S. Surgeon General Rupert Blue said, “There is no cause for alarm

if precautions are observed.” New York City’s public health director declared “other bronchial diseases and not the

so-called Spanish in�uenza...[caused] the illness of the majority of persons who were reported ill with in�uenza.”

The Los Angeles public health chief said, “If ordinary precautions are observed there is no cause for alarm.”

For an example of the press’s failure, consider Arkansas. Over a four-day period in October, the hospital at Camp

Pike admitted 8,000 soldiers. Francis Blake, a member of the Army’s special pneumonia unit, described the scene:

“Every corridor and there are miles of them with double rows of cots ...with in�uenza patients...There is only death

and destruction.” Yet seven miles away in Little Rock, a headline in the Gazette pretended yawns: “Spanish

in�uenza is plain la grippe—same old fever and chills.”

People knew this was not the same old thing, though. They knew because the numbers were staggering—in San

Antonio, 53 percent of the population got sick with in�uenza. They knew because victims could die within hours of

the �rst symptoms—horri�c symptoms, not just aches and cyanosis but also a foamy blood coughed up from the

lungs, and bleeding from the nose, ears and even eyes. And people knew because towns and cities ran out of

co�ns.

People could believe nothing they were being told, so they feared everything, particularly the unknown. How long

would it last? How many would it kill? Who would it kill? With the truth buried, morale collapsed. Society itself

began to disintegrate.

In most disasters, people come together, help each other, as we saw recently with Hurricanes Harvey and Irma.

But in 1918, without leadership, without the truth, trust evaporated. And people looked after only themselves.

In Philadelphia, the head of Emergency Aid pleaded, “All who are free from the care of the sick at home... report as

early as possible...on emergency work.” But volunteers did not come. The Bureau of Child Hygiene begged people

to take in—just temporarily—children whose parents were dying or dead; few replied. Emergency Aid again

pleaded, “We simply must have more volunteer helpers....These people are almost all at the point of death. Won’t

you...come to our help?” Still nothing. Finally, Emergency Aid’s director turned bitter and contemptuous: “Hundreds

of women...had delightful dreams of themselves in the roles of angels of mercy...Nothing seems to rouse them

now...There are families in which the children are actually starving because there is no one to give them food. The

death rate is so high and they still hold back.”

Philadelphia’s misery was not unique. In Luce County, Michigan, a couple and three children were all sick together,

but, a Red Cross worker reported, “Not one of the neighbors would come in and help. I ...telephoned the woman’s

sister. She came and tapped on the window, but refused to talk to me until she had gotten a safe distance away.”

In New Haven, Connecticut, John Delano recalled, “Normally when someone was sick in those days [people] would

bring food over to other families but...Nobody was coming in, nobody would bring food in, nobody came to visit.”

In Perry County, Kentucky, the Red Cross chapter chairman begged for help, pleaded that there were “hundreds of

cases...[of] people starving to death not from lack of food but because the well were panic stricken and would not

go near the sick.”

Red Cross workers carried a stretcher in 1918; names �ll an Army hospital ledger. Hollie Chastain

In Goldsboro, North Carolina, Dan Tonkel recalled, “We were actually almost afraid to breathe...You were afraid

even to go out...The fear was so great people were actually afraid to leave their homes...afraid to talk to one

another.” In Washington, D.C., William Sardo said, “It kept people apart...You had no school life, you had no church

life, you had nothing...It completely destroyed all family and community life...The terrifying aspect was when each

day dawned you didn’t know whether you would be there when the sun set that day.”

An internal American Red Cross report concluded, “A fear and panic of the in�uenza, akin to the terror of the

Middle Ages regarding the Black Plague, [has] been prevalent in many parts of the country.”

Fear emptied places of employment, emptied cities. Shipbuilding workers throughout the Northeast were told they

were as important to the war e�ort as soldiers at the front. Yet at the L.H. Shattuck Co. only 54 percent of its

workers showed up; at the George A. Gilchrist yard only 45 percent did; at Freeport Shipbuilding only 43 percent;

at Groton Iron Works, 41 percent.

Fear emptied the streets, too. A medical student working in an emergency hospital in Philadelphia, one of the

nation’s largest cities, encountered so few cars on the road he took to counting them. One night, driving the 12

miles home, he saw not a single car. “The life of the city had almost stopped,” he said.

On the other side of the globe, in Wellington, New Zealand, another man stepped outside his emergency hospital

and found the same thing: “I stood in the middle of Wellington City at 2 P.M. on a weekday afternoon, and there

was not a soul to be seen; no trams running; no shops open, and the only tra�c was a van with a white sheet tied

to the side with a big red cross painted on it, serving as an ambulance or hearse. It was really a city of the dead.”

Victor Vaughan, formerly the dean of the University of Michigan’s Medical School, was not a man to resort to

hyperbole. Now the head of the Army’s communicable disease division, he jotted down his private fear: “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.”

**********

Then, as suddenly as it came, in�uenza seemed to disappear. It had burned through the available fuel in a given

community. An undercurrent of unease remained, but aided by the euphoria accompanying the end of the war,

tra�c returned to streets, schools and businesses reopened, society returned to normal.

A third wave followed in January 1919, ending in the spring. This was lethal by any standard except the second

wave, and one particular case would have an exceptional impact on history.

On April 3, 1919, during the Versailles Peace Conference, Woodrow Wilson collapsed. His sudden weakness and

severe confusion halfway through that conference—widely commented upon—very possibly contributed to his

abandoning his principles. The result was the disastrous peace treaty, which would later contribute to the start of

World War II. Some historians have attributed Wilson’s confusion to a minor stroke. In fact, he had a 103 degree

temperature, intense coughing �ts, diarrhea and other serious symptoms. A stroke explains none of the

symptoms. In�uenza, which was then widespread in Paris and killed a young aide to Wilson, explains all of them—

including his confusion. Experts would later agree that many patients a�icted by the pandemic in�uenza had

cognitive or psychological symptoms. As an authoritative 1927 medical review concluded, “There is no doubt that

the neuropsychiatric e�ects of in�uenza are profound...hardly second to its e�ect on the respiratory system.”

After that third wave, the 1918 virus did not go away, but it did lose its extraordinary lethality, partly because many

human immune systems now recognized it and partly because it lost the ability to easily invade the lungs. No

longer a bloodthirsty murderer, it evolved into a seasonal in�uenza.

Scientists and other experts are still asking questions about the virus and the devastation it caused, including why

the second wave was so much more lethal than the �rst. Researchers aren’t certain, and some argue that the �rst

wave was caused by an ordinary seasonal in�uenza virus that was di�erent from the pandemic virus; but the

evidence seems overwhelming that the pandemic virus had both a mild and virulent form, causing mild as well as

severe spring outbreaks, and then, for reasons that remain unclear, the virulent form of the virus became more

common in the fall.

Another question concerns who died. Even though the death toll was historic, most people who were infected by

the pandemic virus survived; in the developed world, the overall mortality was about 2 percent. In the less

developed world, mortality was worse. In Mexico, estimates of the dead range from 2.3 to 4 percent of the entire

population. Much of Russia and Iran saw 7 percent of the population die. In the Fiji Islands 14 percent of the

population died—in 16 days. One-third of the population of Labrador died. In small native villages in Alaska and

Gambia, everyone died, probably because all got sick simultaneously and no one could provide care, could not

even give people water, and perhaps because, with so much death around them, those who might have survived

did not �ght.

The age of the victims was also striking. Normally, elderly people account for the overwhelming number of

in�uenza deaths; in 1918, that was reversed, with young adults killed in the highest numbers. This e�ect was

heightened within certain subgroups. For instance, a Metropolitan Life Insurance Company study of people aged

25 to 45 found that 3.26 percent of all industrial workers and 6 percent of all coal miners died. Other studies found

that for pregnant women, fatality rates ranged from 23 percent to 71 percent.

Why did so many young adults die? As it happens, young adults have the strongest immune systems, which

attacked the virus with every weapon possible—including chemicals called cytokines and other microbe-�ghting

toxins—and the battle�eld was the lung. These “cytokine storms” further damaged the patient’s own tissue. The

destruction, according to the noted in�uenza expert Edwin Kilbourne, resembled nothing so much as the lesions

from breathing poison gas.

**********

1 / 5

On October 16, 1918, a letter carrier in New York City makes his rounds wearing a mask for protection. National Archives

2 / 5

Corpsmen await patients on December 10, 1918, in the influenza ward at the U.S. Naval Hospital in Mare Island, California. U.S. Navy Medicine

3 / 5

Red Cross volunteers in Boston assemble gauze masks for hard-hit Camp Devens, a World War I Army training camp. National Archives

4 / 5

Stricken soldiers receive care in November 1918 in Mare Island. U.S. Navy Medicine

5 / 5

Seasonal in�uenza is bad enough. Over the past four decades it has killed 3,000 to 48,000 Americans annually,

depending on the dominant virus strains in circulation, among other things. And more deadly possibilities loom.

In recent years, two di�erent bird in�uenza viruses have been infecting people directly: the H5N1 strain has struck

in many nations, while H7N9 is still limited to China (see “The Birth of a Killer”). All told, these two avian in�uenza

viruses had killed 1,032 out of the 2,439 people infected as of this past July—a staggering mortality rate. Scientists

say that both virus strains, so far, bind only to cells deep in the lung and do not pass from person to person. If

either one acquires the ability to infect the upper respiratory tract, through mutation or by swapping genes with

an existing human virus, a deadly pandemic is possible.

Prompted by the re-emergence of avian in�uenza, governments, NGOs and major businesses around the world

have poured resources into preparing for a pandemic. Because of my history of the 1918 pandemic, The Great

In�uenza, I was asked to participate in some of those e�orts.

Public health experts agree that the highest priority is to develop a “universal vaccine” that confers immunity

against virtually all in�uenza viruses likely to infect humans (see “How to Stop a Lethal Virus”). Without such a

vaccine, if a new pandemic virus surfaces, we will have to produce a vaccine speci�cally for it; doing so will take

months and the vaccine may o�er only marginal protection.

During the autumn of 1918, the Red Cross ambulance station in Washington, D.C. was especially busy. Library of Congress

Another key step to improving pandemic readiness is to expand research on antiviral drugs; none is highly

e�ective against in�uenza, and some strains have apparently acquired resistance to the antiviral drug Tami�u.

Then there are the less glamorous measures, known as nonpharmaceutical interventions: hand-washing,

telecommuting, covering coughs, staying home when sick instead of going to work and, if the pandemic is severe

enough, widespread school closings and possibly more extreme controls. The hope is that “layering” such actions

one atop another will reduce the impact of an outbreak on public health and on resources in today’s just-in-time

economy. But the e�ectiveness of such interventions will depend on public compliance, and the public will have to

trust what it is being told.

That is why, in my view, the most important lesson from 1918 is to tell the truth. Though that idea is incorporated

into every preparedness plan I know of, its actual implementation will depend on the character and leadership of

the people in charge when a crisis erupts.

I recall participating in a pandemic “war game” in Los Angeles involving area public health o�cials. Before the

exercise began, I gave a talk about what happened in 1918, how society broke down, and emphasized that to

retain the public’s trust, authorities had to be candid. “You don’t manage the truth,” I said. “You tell the truth.”

Everyone shook their heads in agreement.

Next, the people running the game revealed the day’s challenge to the participants: A severe pandemic in�uenza

virus was spreading around the world. It had not o�cially reached California, but a suspected case—the severity of

the symptoms made it seem so—had just surfaced in Los Angeles. The news media had learned of it and were

demanding a press conference.

The participant with the �rst move was a top-ranking public health o�cial. What did he do? He declined to hold a

press conference, and instead just released a statement: More tests are required. The patient might not have

pandemic in�uenza. There is no reason for concern.

I was stunned. This o�cial had not actually told a lie, but he had deliberately minimized the danger; whether or

not this particular patient had the disease, a pandemic was coming. The o�cial’s unwillingness to answer

questions from the press or even acknowledge the pandemic’s inevitability meant that citizens would look

elsewhere for answers, and probably �nd a lot of bad ones. Instead of taking the lead in providing credible

information he instantly fell behind the pace of events. He would �nd it almost impossible to get ahead of them

again. He had, in short, shirked his duty to the public, risking countless lives.

And that was only a game.

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