Aftermath and afterthoughts 2 - The Grim Reaper

In today’s world, with blanket media coverage and social networking, bad news travels faster than ever and it seems as if the dangers of our existence are constantly increasing. In fact, in terms of armed conflicts, the world is safer than ever before. Yuval Harari’s exceptional book Homo Deus provides plentiful figures in support of this – our challenges today are not, by and large, how mankind can survive wars. 

But 1918? How would social media have dealt with a year that, for global mortality was the worst in history. Not only was it the year of terminal carnage in WW1, but it brought the Spanish Flu pandemic. For the warring nations the numbers dying were no more than a ghastly postscript to the four years of death and suffering. For non-combatant nations the 1918 flu pandemic was the worst event in their history. High profile epidemics of recent years such as SARS, AIDS, Ebola, Bird Flu barely register on the scale of the Spanish Flu. Accurate figures are impossible, but broad figures record that half a billion people - 1 in 3 of the world’s population - suffered from the deadly new H1N1 strain of the flu virus. The 50-100 million deaths worldwide exceeded deaths in both world wars – (probably) combined. Only the Black Death could lay claim to comparable effects on a global (and numerically much smaller) population.

The only redeeming statistic was the brevity of the pandemic. The first cases were reported in early 1918, with the last in early 1920, and within that relatively short time the majority of the deaths occurred in the weeks between mid-September and mid-December 1918. By comparison the Black Death took four years to afflict all of Eurasia.

So how and why was the Spanish Flu so virulent?

Influenza and its periodic epidemics had been known about for centuries before the era of virology (1933 saw discovery of the influenza virus), and the 1918 version. When a disease, such as the flu or smallpox is present continuously in relatively small numbers in communities it is referred to as endemic. Occasional waves of high numbers that affect communities and populations are epidemics, and when an epidemic goes global it becomes a pandemic. In the case of influenza 'Flu', we now know that major epidemics occur when there is a significant mutational change in the virus. This is a process termed antigenic ‘shift’, as opposed to the more gradual antigenic ‘drift’ that happens year on year, enabling the population to develop resistance to its worst effects. With antigenic shift, the flu virus is able to sweep through the host defences, killing the most vulnerable victims, usually by pneumonia or just overwhelming sepsis. This, of course, is what happened in spades with the Spanish Flu.

It would be wrong to apportion any responsibility for the disaster to Spain. The mutant virus probably originated in the Far East, but is generally reckoned to have started its trail of destruction from military camps in the USA in 1917 (Kansas seemingly the main suspect), crossing the Atlantic in troop carrying ships, and landing in Europe at the French ports.

The ideal conditions for rapid spread of an epidemic existed across the theatres of war, particularly the Western Front. These included increased mobility of populations; densely packed communities of soldiers and refugees; people malnourished and physically and mentally weakened by four years of war. Medical services, already overwhelmed, had little with which they could treat people, and public health advice was virtually non-existent. In fact, press censorship tended to suppress information about the early phases of the epidemic and its effects on the suffering masses at the front. It was only when King Alfonso of neutral Spain became a prominent victim that newspaper reports created the soubriquet ‘Spanish Flu’.

Can we assess its impact on the outcome of the war? Probably marginal. There were two waves of the flu amongst the troops on the Western Front. The first wave in the summer months of 1918 was a milder version*. Men were ill for 7-10 days then generally ready to resume action. Mortality was low, but higher amongst the poorly nourished Germans. In military terms it was one more factor in the tipping of the balance against the Germans after the efforts of their final offensives. 

Behind the lines, and in the two months after the Armistice, the impact of the flu was much greater. As the disease spread around via the ports of the world the impact on civilian populations was enormous. Inevitably the weakest individuals (and populations, Germany, Austria-Hungary (RIP) and eastern Europe) were hardest hit, although paradoxically there was also a peak in those usually most resistant – young adults. The paradox was that their mode of death, a fulminating bloody pneumonia, was created by the toxins (cytokines storm) from the stronger immune defence they were able to put up.

Millions of poignant individual cases occurred across Europe of soldiers, sailors and civilians who had survived through four years of war, only to die of flu in days, sometimes hours after its end. Men taken ill on the ferry home across the channel; men recovering in military hospitals taken as the flu swept through the area; families becoming victims just as their men arrived home. My own grandmother died of flu on Armistice day.

Japan - 30 million cases - 'only'
200,000 deaths

Finally, as if the Grim Reaper was temporarily sated, the deaths began to fall - at first slowly and then with increasing rapidity. It may have been better prevention and treatment strategies that contributed; it may be that the virus reverted rapidly to a milder strain. However the number of cases fell as rapidly as the numbers of deaths. Around the world the pandemic had petered out by the end of 1919. All continents except Antarctica had been decimated. Some islands escaped, and some nations suffered relatively mildly – in Japan the mortality rate was ten times lower than surrounding countries, but there were still over 200,000 deaths. Very few communities escaped the visitation. An overall fatality ratio of 10-20% means that up to 5% of the world’s population died, dwarfing the 1.1% figure for WW1 deaths.

And yet, from a European and North American the Spanish Flu epidemic will always be seen as that final cruel blow inflicted on a world that had already suffered enough. Such is the scarring legacy of the First World War. I have attempted to be there in spirit these past four years, but we are all lucky not to have been there.