The 1918 influenza pandemic had a profound and, until recently, a largely unrecognized impact on the world.

For many of us, it was regarded as just a footnote to World War I. Only since its centennial two years ago (and the advent of COVID-19 six months ago) has there been much interest in the disease. Before 2018, about 80,000 books had been published about WWI – and only 400 about the 1918 pandemic.

It was called the Spanish flu even though it did not originate in Spain. The first reported outbreak occurred in the United States in March 1918. The first 100 cases were reported at Camp Funston in Fort Riley, Kansas, and quintupled within a week. Wartime censorship made it illegal to print anything considered detrimental to the war effort. Newspapers under-reported the rapid spread of the pandemic. And public health authorities followed suit.

Influenza news was suppressed in the U.S., France and Great Britain – but not in Spain, which remained neutral in WWI. Wire service reports of a flu outbreak in Madrid in spring 1918 led to the pandemic being called the “Spanish flu,” despite its known site of origin.

This suppression of news occurred mainly during the first wave of the disease. The 1918 flu started in March as a mild strain, highly contagious but less lethal. The virus died down during the summer, but in October 1918, a second, more virulent strain of the virus hit globally. In Durango, local cases were identified, and our first reported death was on the eighth of that month. By 1920, the strain did have surges, but became milder and more seasonal.

Unlike seasonal flu, which is most lethal to the very young and very old, many victims were between 20 and 40 years old.

The 1918 flu and COVID-19 are both considered “crowd” diseases. So are smallpox, measles and tuberculosis. A crowd disease is an infectious disease that burns through a population like a red hot iron but requires a pool of thousands of people to remain viable – one person infects another, who infects a couple of others, who infect a few others, who infect multiple others. Sustainability is dependent on a crowd of hosts. That’s why masking and social distancing are so important in stopping the spread, or flattening the curve, for all crowd diseases.

American draftees were at more than 30 military camps housing thousands of young men each. They may have been the cream of the crop. A half million of the 3.7 million draftees failed their physicals. At the time, life expectancy was only 50 years of age.

Soldiers and sailors were packed in railroad cars and sent for training around the nation. The military became an ideal breeding ground for respiratory and other infectious diseases. When the second wave of the pandemic struck in autumn 1918, it almost universally appeared in military populations before hitting civilian communities in the U.S.

Once awareness of the 1918 influenza became general knowledge, during the second more deadly wave of the pandemic, most communities enacted social-distancing measures. Local officials and health departments ordered theaters, movie houses, saloons, schools, churches and other public gathering places to close for the duration of the pandemic. Public gatherings were forbidden, and even burials were limited to immediate family and one member of clergy.

In Durango, saloons were among the last to close. In 2020, they were among the first closures for COVID-19. Grocery stores were considered essential services in 1918. In Durango, these small businesses had room for only two or three shoppers at a time. Only grocers handled supplies, removing them from the three walls of shelves behind their counters.

A 2007 study of the 1918 flu showed that public health measures, such as banning mass gatherings and wearing masks, cut the death toll from flu by up to 50% in some U.S. cities. In contrast to the response with our current pandemic, Americans were much better than their European counterparts at maintaining these measures. This was probably in large part because WWI was fought in Europe and there were competing health issues for the public. Why we are so badly behind the Europeans in this round is fiercely debated.

There is hope we will have an effective vaccine by the end of the year, or early next year, for our coronavirus pandemic. This was not the case in 1918 although multiple vaccines were tried.

Germ theory was well established by the time of the outbreak, and several vaccines were developed from bacterium. But influenza is a virus and viruses were unknown entities a century ago. They are much tinier than bacterium, only 1/20th the size, and invisible using the optical microscopes of the time.

There were scores of studies about lung tissue, and some bacteria was identified, but not the virus. The first organism misidentified as the causative agent was misnamed Haemophilus Influenza and was used in an early vaccine. Another was developed based on a mixture of killed pneumococcal, streptococcal and staphylococcal bacteria. Neither vaccine was effective for the flu, but may have prevented some secondary bacterial infections.

The electron microscope was developed well after the war, and the influenza virus was “seen” for the first time in 1943.

Many physicians and nurses left their communities to help with the war effort during WWI. There was no effective vaccine, no antibiotics for secondary infections like pneumonia, no ventilators and no portable oxygen supplies. Unmet nursing needs allowed largely untrained volunteers, like the Red Cross, to provide care to the ill, staff emergency hospitals, organize volunteers and assemble gauze face masks.

In Durango, the Red Cross not only did all of this, but took their care on the road by visiting Silverton by train, taking fresh soup and helping hands to the homes of the stricken. Some local physicians and morticians also traveled to the community that had the highest mortality rate per capita in the nation.

Physicians could throw the medicine cabinet at their patients, but it consisted of various untried concoctions and potentially lethal doses of aspirin and quinine. Other items in the medical arsenal included: arsenic, camphor oil, digitalis, mustard plasters, strychnine, Epsom salts, castor oil and iodine (given orally for disinfection – sound familiar?). Some returned to the good old days of blood-letting and others claimed inhaling cigarette smoke killed the germ.

Despite medical advances in the last century, simple things like social distancing and wearing masks, are known to be effective. Many crowd disease pandemics have lasted around three years, waning in virulence toward the end. Without a vaccine, despite our progress in medical care, there is no reason to think COVID-19 will be different.

Guy Walton is a retired nurse. He managed the Infection Prevention program at Mercy Regional Medical Center before retiring in 2016. He can be reached at blue52@frontier.net.