1918 flu pandemic
1918 flu pandemic (January 1918 – December 1920) was an
unusually deadly influenza pandemic, the first of the two pandemics
H1N1 influenza virus. It infected 500 million people
around the world, including people on remote Pacific islands and in
the Arctic, and resulted in the deaths of 50 to 100 million
(three to five percent of the world's population), making it one of
the deadliest natural disasters in human history.
Disease had already greatly limited life expectancy in the early 20th
century. In the first year of the pandemic, life expectancy in the
United States dropped by about 12 years. Most influenza
outbreaks disproportionately kill juvenile, elderly, or already
weakened patients; in contrast, the 1918 pandemic predominantly killed
previously healthy young adults.
There are several possible explanations for the high mortality rate of
the 1918 influenza pandemic. Some research suggests that the specific
variant of the virus had an unusually aggressive nature. One group of
researchers recovered the virus from the bodies of frozen victims, and
found that transfection in animals caused a rapid progressive
respiratory failure and death through a cytokine storm (overreaction
of the body's immune system). It was then postulated that the strong
immune reactions of young adults ravaged the body, whereas the weaker
immune systems of children and middle-aged adults resulted in fewer
deaths among those groups.
More recent investigations, mainly based on original medical reports
from the period of the pandemic, found that the viral
infection itself was not more aggressive than any previous influenza,
but that the special circumstances (malnourishment, overcrowded
medical camps and hospitals, poor hygiene) promoted bacterial
superinfection that killed most of the victims typically after a
somewhat prolonged death bed.
Historical and epidemiological data are inadequate to identify the
pandemic's geographic origin. It was implicated in the outbreak of
encephalitis lethargica in the 1920s.
To maintain morale, wartime censors minimized early reports of illness
and mortality in Germany, the United Kingdom, France, and the United
States. Papers were free to report the epidemic's effects in
neutral Spain (such as the grave illness of King Alfonso XIII).
This created a false impression of Spain as especially hard hit,
thereby giving rise to the pandemic's nickname, Spanish Flu.
1.1 Hypotheses about source
2.1 Around the globe
2.2 Patterns of fatality
2.3 Deadly second wave
2.4 Devastated communities
2.5 Less-affected areas
2.6 Aspirin poisoning
2.7 End of the pandemic
2.8 Long-term impact
4 Spanish flu research
5 In popular culture
7 See also
9 Further reading
10 External links
Hypotheses about source
Alfred W. Crosby recorded that the flu originated in the
U.S. state of Kansas, and popular writer John Barry echoed Crosby
in describing Haskell County, as the point of origin although
already in late 1917 there had been a first wave in at least 14 US
Investigative work in 1999 by a British team led by virologist John
St Bartholomew's Hospital
St Bartholomew's Hospital and the Royal London Hospital
identified the major troop staging and hospital camp in Étaples,
France, as being the center of the 1918 flu pandemic. In late 1917,
military pathologists reported the onset of a new disease with high
mortality that they later recognized as the flu. The overcrowded camp
and hospital — which treated thousands of victims of chemical
attacks and other casualties of war — was an ideal site for the
spreading of a respiratory virus; 100,000 soldiers were in transit
every day. It also was home to a live piggery, and poultry was
regularly brought in from surrounding villages. Oxford and his team
postulated that a significant precursor virus, harbored in birds,
mutated so it could migrate to pigs that were kept near the
Earlier hypotheses of the epidemic's origin have varied. Some
hypothesized the flu originated in East Asia. Claude Hannoun, the
leading expert on the 1918 flu for the Pasteur Institute, asserted the
former virus was likely to have come from China, mutating in the
United States near
Boston and spreading to Brest, France, Europe's
battlefields, Europe, and the world using Allied soldiers and sailors
as main spreaders. He considered several other hypotheses of
origin, such as Spain, Kansas, and Brest, as being possible, but not
Andrew Price-Smith published data from the
Austrian archives suggesting the influenza had earlier origins,
beginning in Austria in early 1917.
In 2014, historian Mark Humphries of the Memorial University of
Newfoundland in St. John's stated that newly unearthed records
confirmed that one of the side stories of the war, the mobilization of
96,000 Chinese laborers to work behind the British and French lines on
World War I's western front, might have been the source of the
pandemic. In the report, Humphries found archival evidence that a
respiratory illness that struck northern China in November 1917 was
identified a year later by Chinese health officials as identical to
the "Spanish" flu. A report published in 2016 in the Journal
Chinese Medical Association found no evidence that the 1918
virus was imported to Europe via Chinese and Southeast Asian soldiers
and workers. It found evidence that the virus had been circulating in
the European armies for months and possibly years before the 1918
When an infected person sneezes or coughs, more than half a million
virus particles can be spread to those close by. The close
quarters and massive troop movements of
World War I
World War I hastened the
pandemic, and probably both increased transmission and augmented
mutation; the war may also have increased the lethality of the virus.
Some speculate the soldiers' immune systems were weakened by
malnourishment, as well as the stresses of combat and chemical
attacks, increasing their susceptibility.
A large factor in the worldwide occurrence of this flu was increased
travel. Modern transportation systems made it easier for soldiers,
sailors, and civilian travelers to spread the disease.
In the United States, the disease was first observed in Haskell
County, Kansas, in January 1918, prompting local doctor Loring Miner
to warn the U.S. Public Health Service's academic journal. On 4 March
1918, company cook Albert Gitchell reported sick at Fort Riley, an
American military facility that at the time was training American
troops during World War I, making him the first recorded victim of the
flu. Within days, 522 men at the camp had reported sick.
By 11 March 1918, the virus had reached Queens, New York. Failure
to take preventive measures in March/April was later criticised.
In August 1918, a more virulent strain appeared simultaneously in
Brest, France; in Freetown, Sierra Leone; and in the U.S. in Boston,
Massachusetts. The Spanish flu also spread through Ireland, carried
there by returning Irish soldiers. The Allies of
World War I
World War I came to
call it the Spanish flu, primarily because the pandemic received
greater press attention after it moved from France to Spain in
November 1918. Spain was not involved in the war and had not imposed
Around the globe
The difference between the influenza mortality age-distributions of
the 1918 epidemic and normal epidemics – deaths per 100,000
persons in each age group, United States, for the interpandemic years
1911–1917 (dashed line) and the pandemic year 1918 (solid line)
Three pandemic waves: weekly combined influenza and pneumonia
mortality, United Kingdom, 1918–1919
The global mortality rate from the 1918/1919 pandemic is not known,
but an estimated 10% to 20% of those who were infected died. With
about a third of the world population infected, this case-fatality
ratio means 3% to 6% of the entire global population died.
Influenza may have killed as many as 25 million people in its
first 25 weeks. Older estimates say it killed 40–50 million
people, while current estimates say 50–100 million people
worldwide were killed.
This pandemic has been described as "the greatest medical holocaust in
history" and may have killed more people than the Black Death. It
is said that this flu killed more people in 24 weeks than AIDS killed
in 24 years, and more in a year than the
Black Death killed in a
century. However, a 2016 article in
The Atlantic states that the
Black Death, over the course of the decade of the 1340s, killed more
than 10% of the world population whereas the
1918 flu pandemic
1918 flu pandemic killed
less than half this percentage.
The disease killed in every corner of the globe. As many as
17 million died in India, about 5% of the population. The
death toll in India's British-ruled districts alone was 13.88
In Japan, of the 23 million people who were affected, 390,000
died. In the
Dutch East Indies
Dutch East Indies (now Indonesia), 1.5 million were
assumed to have died among 30 million inhabitants. In
of the population died during only a month. Similarly, in
Samoa 22% of
the population of 38,000 died within two months.
In Iran, the impact was enormous and according to an estimate, between
902,400 and 2,431,000 or 8.0% and 21.7% of the total population
In the U.S., about 28% of the population became infected, and 500,000
to 675,000 died. Native American tribes were particularly hard
hit. In the
Four Corners area alone, 3,293 deaths were registered
among Native Americans. Entire village communities perished in
Alaska. In Canada 50,000 died. In Brazil 300,000 died,
including president Rodrigues Alves. In Britain, as many as
250,000 died; in France, more than 400,000. In West Africa an
influenza epidemic killed at least 100,000 people in Ghana. Tafari
Makonnen (the future Haile Selassie, Emperor of Ethiopia) was one of
the first Ethiopians who contracted influenza but survived,
although many of his family's subjects did not; estimates for the
fatalities in the capital city, Addis Ababa, range from 5,000 to
10,000, or higher. In
British Somaliland one official estimated
that 7% of the native population died.
This huge death toll was caused by an extremely high infection rate of
up to 50% and the extreme severity of the symptoms, suspected to be
caused by cytokine storms. Symptoms in 1918 were so unusual that
initially influenza was misdiagnosed as dengue, cholera, or typhoid.
One observer wrote, "One of the most striking of the complications was
hemorrhage from mucous membranes, especially from the nose, stomach,
Bleeding from the ears and petechial hemorrhages in the
skin also occurred". The majority of deaths were from bacterial
pneumonia, a common secondary infection associated with
influenza, but the virus also killed people directly, by causing
massive hemorrhages and edema in the lung.
The unusually severe disease killed up to 20% of those infected, as
opposed to the usual flu epidemic mortality rate of 0.1%.
Patterns of fatality
The pandemic mostly killed young adults. In 1918–1919, 99% of
pandemic influenza deaths in the U.S. occurred in people under 65, and
nearly half in young adults 20 to 40 years old. In 1920, the
mortality rate among people under 65 had decreased sixfold to half the
mortality rate of people over 65, but still 92% of deaths occurred in
people under 65. This is unusual, since influenza is normally most
deadly to weak individuals, such as infants (under age two), the very
old (over age 70), and the immunocompromised. In 1918, older adults
may have had partial protection caused by exposure to the 1889–1890
flu pandemic, known as the Russian flu. According to historian
John M. Barry, the most vulnerable of all – "those most likely, of
the most likely", to die – were pregnant women. He reported that in
thirteen studies of hospitalized women in the pandemic, the death rate
ranged from 23% to 71%. Of the pregnant women who survived
childbirth, over one-quarter (26%) lost the child.
Another oddity was that the outbreak was widespread in the summer and
autumn (in the Northern Hemisphere); influenza is usually worse in
Modern analysis has shown the virus to be particularly deadly because
it triggers a cytokine storm, which ravages the stronger immune system
of young adults.
In fast-progressing cases, mortality was primarily from pneumonia, by
virus-induced pulmonary consolidation. Slower-progressing cases
featured secondary bacterial pneumonias, and there may have been
neural involvement that led to mental disorders in some cases. Some
deaths resulted from malnourishment.
A study – conducted by He et al. – used a mechanistic modelling
approach to study the three waves of the 1918 influenza pandemic. They
tried to study the factors that underlie variability in temporal
patterns, and the patterns of mortality and morbidity. Their analysis
suggests that temporal variations in transmission rate provide the
best explanation and the variation in transmission required to
generate these three waves is within biologically plausible
Another study by He et al. used a simple epidemic model, to
incorporate three factors including school opening and closing,
temperature changes over the course of the outbreak, and human
behavioral changes in response to the outbreak to infer the cause of
the three waves of the 1918 influenza pandemic. Their modelling
results showed that all three factors are important but human
behavioral responses showed the largest effects.
Deadly second wave
American Expeditionary Force
American Expeditionary Force victims of the flu pandemic at U.S. Army
Camp Hospital no. 45 in Aix-les-Bains, France, in 1918
The second wave of the 1918 pandemic was much deadlier than the first.
The first wave had resembled typical flu epidemics; those most at risk
were the sick and elderly, while younger, healthier people recovered
easily. But in August, when the second wave began in France, Sierra
Leone and the United States, the virus had mutated to a much
deadlier form. As the American Experience
Influenza 1918 episode says,
October 1918 was the deadliest month of the whole pandemic.[citation
This increased severity has been attributed to the circumstances of
the First World War. In civilian life, natural selection favors a
mild strain. Those who get very ill stay home, and those mildly ill
continue with their lives, preferentially spreading the mild strain.
In the trenches, natural selection was reversed. Soldiers with a mild
strain stayed where they were, while the severely ill were sent on
crowded trains to crowded field hospitals, spreading the deadlier
virus. The second wave began and the flu quickly spread around the
world again. Consequently, during modern pandemics health officials
pay attention when the virus reaches places with social upheaval
(looking for deadlier strains of the virus).
The fact that most of those who recovered from first-wave infections
were now immune showed that it must have been the same strain of flu.
This was most dramatically illustrated in Copenhagen, which escaped
with a combined mortality rate of just 0.29% (0.02% in the first wave
and 0.27% in the second wave) because of exposure to the less-lethal
first wave. On the rest of the population it was far more deadly
now; the most vulnerable people were those like the soldiers in the
trenches – young previously healthy adults.
A chart of deaths in major cities, showing a peak in
Even in areas where mortality was low, so many were incapacitated that
much of everyday life was hampered. Some communities closed all stores
or required customers to leave orders outside. There were reports that
health-care workers could not tend the sick nor the gravediggers bury
the dead because they too were ill. Mass graves were dug by steam
shovel and bodies buried without coffins in many places.
Pacific island territories were particularly hard-hit. The
pandemic reached them from New Zealand, which was too slow to
implement measures to prevent ships carrying the flu from leaving its
ports. From New Zealand, the flu reached
Tonga (killing 8% of the
Nauru (16%) and
Fiji (5%, 9,000 people).
Worst affected was German Samoa, today the independent state of Samoa,
which had been occupied by New Zealand in 1914. 90% of the population
was infected; 30% of adult men, 22% of adult women and 10% of children
died. By contrast, the flu was kept away from American
John Martin Poyer
John Martin Poyer imposed a blockade. In New Zealand
itself, 8,573 deaths were attributed to the 1918 pandemic influenza,
resulting in a total population fatality rate of 0.74%. In
Ireland, the Spanish Flu accounted for 10% of the total deaths in
Data analysis revealed 6,520 recorded deaths in Savannah-Chatham
County, Georgia (population = 83,252) for the three-year period from
January 1, 1917, to December 31, 1919. Of these deaths, influenza was
specifically listed as the cause of death in 316 cases, representing
4.85 percent of all causes of death for the total time period.
In Japan, 257,363 deaths were attributed to influenza by July 1919,
giving an estimated 0.425% mortality rate, much lower than nearly all
other Asian countries for which data are available. The Japanese
government severely restricted maritime travel to and from the home
islands when the pandemic struck.
In the Pacific, American Samoa and the French colony of New
Caledonia also succeeded in preventing even a single death from
influenza through effective quarantines. In Australia, nearly 12,000
By the end of the pandemic, the isolated island of Marajó, in
Brazil's Amazon River Delta had not reported an outbreak.
Saint Helena also reported no deaths.
In a 2009 paper published in the journal Clinical Infectious Diseases,
Karen Starko proposed that aspirin poisoning contributed substantially
to the fatalities. She based this on the reported symptoms in those
dying from the flu, as reported in the post mortem reports still
available, and also the timing of the big "death spike" in October
1918 which happened right after the Surgeon General of the United
States Army, and the Journal of the American Medical Association both
recommended very large doses of 8 to 31 grams of aspirin per day.
These levels will produce hyperventilation in 33% of patients, as well
as lung edema in 3% of patients. Starko also points out that many
early deaths showed "wet," sometimes hemorrhagic lungs, whereas late
deaths showed bacterial pneumonia. She suggests that the wave of
aspirin poisonings was due to a "perfect storm" of events: Bayer's
patent on aspirin expired, so that many companies rushed in to make a
profit and greatly increased the supply; this coincided with the flu
pandemic; and the symptoms of aspirin poisoning were not known at the
As an explanation for the universally high mortality rate, this
hypothesis was questioned in a letter to the journal published in
April 2010 by Andrew Noymer and Daisy Carreon of the University of
California, Irvine, and Niall Johnson of the Australian Commission on
Safety and Quality in Health Care. They questioned this universal
applicability given the high mortality rate in countries such as
India, where there was little or no access to aspirin at the time
compared to the rate where aspirin was plentiful. They concluded
that "the salicylate [aspirin] poisoning hypothesis [was] difficult to
sustain as the primary explanation for the unusual virulence of the
1918–1919 inﬂuenza pandemic". In response, Starko pointed to
anecdotal evidence of aspirin use in India and argued that even if
aspirin over-prescription had not contributed to the high Indian
mortality rate, it could still have been a factor for other high rates
in areas where other exacerbating factors present in India played less
of a role.
End of the pandemic
After the lethal second wave struck in late 1918, new cases dropped
abruptly – almost to nothing after the peak in the second
wave. In Philadelphia, for example, 4,597 people died in the week
ending 16 October, but by 11 November, influenza had almost
disappeared from the city. One explanation for the rapid decline of
the lethality of the disease is that doctors got better at preventing
and treating the pneumonia that developed after the victims had
contracted the virus, although John Barry stated in his book that
researchers have found no evidence to support this.
Another theory holds that the 1918 virus mutated extremely rapidly to
a less lethal strain. This is a common occurrence with influenza
viruses: there is a tendency for pathogenic viruses to become less
lethal with time, as the hosts of more dangerous strains tend to die
out (see also "Deadly Second Wave", above).
A 2006 study in the Journal of Political Economy found that "cohorts
in utero during the pandemic displayed reduced educational attainment,
increased rates of physical disability, lower income, lower
socioeconomic status, and higher transfer payments compared with other
See also: List of
1918 flu pandemic
1918 flu pandemic cases
American Red Cross
American Red Cross nurses tend to flu patients in temporary wards set
up inside Oakland Municipal Auditorium, 1918.
Andrew Price-Smith has made the argument that the virus
helped tip the balance of power in the later days of the war towards
the Allied cause. He provides data that the viral waves hit the
Central Powers before they hit the Allied powers, and that both
morbidity and mortality in Germany and Austria were considerably
higher than in Britain and France.
In the United States, Britain and other countries, despite the
relatively high morbidity and mortality rates that resulted from the
epidemic in 1918–1919, the Spanish flu began to fade from public
awareness over the decades until the arrival of news about bird flu
and other pandemics in the 1990s and 2000s. This has led some
historians to label the Spanish flu a "forgotten pandemic".
Various theories of why the Spanish flu was "forgotten" include the
rapid pace of the pandemic, which killed most of its victims in the
United States, for example, within a period of less than nine months,
resulting in limited media coverage. The general population was
familiar with patterns of pandemic disease in the late 19th and early
20th centuries: typhoid, yellow fever, diphtheria, and cholera all
occurred near the same time. These outbreaks probably lessened the
significance of the influenza pandemic for the public. In some
areas, the flu was not reported on, the only mention being that of
advertisements for medicines claiming to cure it.
In addition, the outbreak coincided with the deaths and media focus on
the First World War. Another explanation involves the age group
affected by the disease. The majority of fatalities, from both the war
and the epidemic, were among young adults. The deaths caused by the
flu may have been overlooked due to the large numbers of deaths of
young men in the war or as a result of injuries. When people read the
obituaries, they saw the war or postwar deaths and the deaths from the
influenza side by side. Particularly in Europe, where the war's toll
was extremely high, the flu may not have had a great, separate,
psychological impact, or may have seemed a mere extension of the war's
The duration of the pandemic and the war could have also played a
role. The disease would usually only affect a certain area for a month
before leaving, while the war, which most had initially expected to
end quickly, had lasted for four years by the time the pandemic
struck. This left little time for the disease to have a significant
impact on the economy.
Regarding global economic effects, many businesses in the
entertainment and service industries suffered losses in revenue, while
the health care industry reported profit gains.
February 1918 drawing by
Marguerite Martyn of a visiting nurse in St.
Louis, Missouri, with medicine and babies
Historian Nancy Bristow has argued that the pandemic, when combined
with the increasing number of women attending college, contributed to
the success of women in the field of nursing. This was due in part to
the failure of medical doctors, who were predominantly men, to contain
and prevent the illness. Nursing staff, who were predominantly women,
felt more inclined to celebrate the success of their patient care and
less inclined to identify the spread of the disease with their own
In Spain, sources from the period explicitly linked the Spanish flu to
the cultural figure of Don Juan. The nickname for the flu, the "Naples
Soldier", was adopted from
Federico Romero and Guillermo Fernández
Shaw's operetta, The Song of Forgetting (La canción del olvido), the
protagonist of which is a stock
Don Juan type. Federico Romero, one of
the librettists, quipped that the play's most popular musical number,
Naples Soldier, was as catchy as the flu. Davis has argued the Spanish
Don Juan connection served a cognitive function, allowing
Spaniards to make sense of their epidemic experience by interpreting
it through a familiar template, namely the
Don Juan story.
Spanish flu research
Main article: Spanish flu research
An electron micrograph showing recreated 1918 influenza virions
Centers for Disease Control and Prevention
Centers for Disease Control and Prevention as Dr. Terrence Tumpey
examines a reconstructed version of the 1918 flu.
The origin of the Spanish flu pandemic, and the relationship between
the near-simultaneous outbreaks in humans and swine, have been
controversial. One hypothesis is that the virus strain originated at
Fort Riley, Kansas, in viruses in poultry and swine which the fort
bred for food; the soldiers were then sent from
Fort Riley around the
world, where they spread the disease. Similarities between a
reconstruction of the virus and avian viruses, combined with the human
pandemic preceding the first reports of influenza in swine, led
researchers to conclude the influenza virus jumped directly from birds
to humans, and swine caught the disease from humans.
Others have disagreed, and more recent research has suggested the
strain may have originated in a nonhuman, mammalian species. An
estimated date for its appearance in mammalian hosts has been put at
the period 1882–1913. This ancestor virus diverged about
1913–1915 into two clades (or biological groups), which gave rise to
the classical swine and human
H1N1 influenza lineages. The last common
ancestor of human strains dates to between February 1917 and April
1918. Because pigs are more readily infected with avian influenza
viruses than are humans, they were suggested as the original
recipients of the virus, passing the virus to humans sometime between
1913 and 1918.
An effort to recreate the 1918 flu strain (a subtype of avian strain
H1N1) was a collaboration among the Armed Forces Institute of
USDA ARS Southeast Poultry Research Laboratory and
Mount Sinai School of Medicine
Mount Sinai School of Medicine in New York City. The effort resulted
in the announcement (on 5
October 2005) that the group had
successfully determined the virus's genetic sequence, using historic
tissue samples recovered by pathologist
Johan Hultin from a female flu
victim buried in the Alaskan permafrost and samples preserved from
On 18 January 2007, Kobasa et al. (2007) reported that monkeys (Macaca
fascicularis) infected with the recreated flu strain exhibited classic
symptoms of the 1918 pandemic, and died from a cytokine
storm—an overreaction of the immune system. This may explain
why the 1918 flu had its surprising effect on younger, healthier
people, as a person with a stronger immune system would potentially
have a stronger overreaction.
On 16 September 2008, the body of British politician and diplomat Sir
Mark Sykes was exhumed to study the
RNA of the flu virus in efforts to
understand the genetic structure of modern
H5N1 bird flu. Sykes had
been buried in 1919 in a lead coffin which scientists hoped had helped
preserve the virus. The coffin was found to be split because of
the weight of soil over it, and the cadaver was badly decomposed.
Nonetheless, samples of lung and brain tissue were taken through the
split, with the coffin remaining in situ in the grave during this
In December 2008, research by
Yoshihiro Kawaoka of the University of
Wisconsin linked the presence of three specific genes (termed PA, PB1,
and PB2) and a nucleoprotein derived from 1918 flu samples to the
ability of the flu virus to invade the lungs and cause pneumonia. The
combination triggered similar symptoms in animal testing.
In June 2010, a team at the
Mount Sinai School of Medicine
Mount Sinai School of Medicine reported
2009 flu pandemic vaccine
2009 flu pandemic vaccine provided some cross-protection against
1918 flu pandemic
1918 flu pandemic strain.
One of the few things known for certain about the influenza in 1918
and for some years after was that it was, out of the laboratory,
exclusively a disease of human beings.
In 2013, the AIR Worldwide Research and Modeling Group "characterized
the historic 1918 pandemic and estimated the effects of a similar
pandemic occurring today using the AIR
Pandemic Flu Model". In the
model, "a modern day "Spanish flu" event would result in additional
life insurance losses of between USD 15.3–27.8 billion in the United
States alone" with 188,000–337,000 deaths in the United States.
In popular culture
The 1995 film Outbreak, the 2011 film Contagion and the 2013 film
World War Z make reference to the pandemic.
Twentieth-century fiction includes at least three novels with the flu
pandemic as a major theme: Katherine Anne Porter's Pale Horse, Pale
Rider, Thomas Mullen's The Last Town on Earth, and Thomas Wolfe's Look
In the one-act play 1918 by
Horton Foote (part of his Orphans' Home
Cycle (1979)), the presence and threat of the flu (and the tragedy it
ultimately causes) is a major element of the plot. The play was made
into a film of the same title, released in 1985, which was
subsequently edited for broadcast by
PBS as the last part of the
miniseries "The Story of A Marriage".
American Red Cross
American Red Cross nurses demonstrating treatment practices during
the influenza pandemic of 1918.
Albertan farmers wearing masks to protect themselves from the flu.
Policemen wearing masks provided by the
American Red Cross
American Red Cross in Seattle,
A street car conductor in
Seattle in 1918 refusing to allow passengers
aboard who are not wearing masks
Red Cross workers remove a flu victim in St. Louis, Missouri (1918)
Influenza ward at Walter Reed Hospital during the Spanish flu pandemic
Burying flu victims,
North River, Newfoundland and Labrador
North River, Newfoundland and Labrador (1918)
1919 Tokyo, Japan
Japanese poster in 1919
Demonstration at the Red Cross Emergency Ambulance Station in
Washington, D.C., during the influenza pandemic of 1918
Cavalry memorial on the hill Lueg, memory of the Bernese cavalrymen
victims of the 1918 flu pandemic; Emmental, Bern, Switzerland
The Spanish flu as the Naples Soldier (Spain, 1918)
Spanish biologists and the flu microbe (Spain, 1918)
^ "La Grippe Espagnole de 1918" (in French). Institut Pasteur.
Archived from the original (Powerpoint) on 17 November 2015.
^ a b c d Taubenberger & Morens 2006.
^ "Historical Estimates of World Population". Retrieved 29 March
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^ a b Billings 1997.
^ Johnson & Mueller 2002.
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^ Brundage, John F.; Shanks, G. Dennis (2007). "What Really Happened
during the 1918
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^ Vilensky, Foley & Gilman 2007.
^ Valentine 2006.
^ Anderson, Susan (29 August 2006). "Analysis of Spanish flu cases in
1918–1920 suggests transfusions might help in bird flu pandemic".
American College of Physicians. Retrieved 2
^ Porras-Gallo & Davis 2014.
^ Barry 2004, p. 171.
^ Galvin 2007.
^ a b Crosby 2003.
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