How the Spanish flu compares to COVID-19: Lessons learned, answers still being pursued

By | April 11, 2020

The learned experiences from a devastating flu pandemic 100 years that staggered the world don’t make it any easier this time around, says a historian and author who specializes in health and infectious disease.

While there are many similarities between how society is responding to COVID-19 and how it reacted to the Spanish flu of 1918-19, “there isn’t a playbook,” said Esyllt Jones, a professor of history at the University of Manitoba.

The Spanish flu first raged through the battlefields of the First World War before moving into other countries. (Library of Congress)

A century ago, health professionals faced an organism they didn’t know a lot about. The same holds true now.

COVID-19 and the Spanish flu both presented novel, or new, viruses — which means there are no treatments, no vaccines, and no one has been exposed before so there is no immunity, said Jones, author of the book Influenza 1918: Disease, Death, and Struggle in Winnipeg.

“Each outbreak is its own thing, in its own context, and there’s a lot about COVID-19 that’s completely unique. So people are really having to figure it out as they go.”

Three men, believed to be in Alberta, are shown wearing masks during the Spanish influenza pandemic. (Winnipeg Tribune Archives/University of Manitoba)

There is some greater scientific understanding now than in 1918, when viruses had not even been isolated yet, Jones said.

“But there is this underlying sense of not really knowing how the disease is behaving exactly.”

That results in confusion for people about which messages they need to listen to. There have been, for example, mixed messages about the benefits of masks and whether someone without symptoms should wear one.

Still others have resorted to thinking it’s just a bad cold and officials are overreacting, or that the pandemic is worse somewhere else and not a big concern locally.

Guidance on how to prevent Influenza, published in the Illustrated Current News, on Oct. 18, 1918. (National Library of Medicine)

That was the same thought in 1918.

In the late spring, as allied troops in Europe were battling the German army, word began to reach Canada that another invader was killing soldiers. A deadly flu was raging through the battlefields, causing fever and fatigue, pounding headaches and sore throats, before filling the lungs with fluid and choking the breath from its victims.

The flu started earlier in the year but the warring countries, not wanting to give information to the enemy, suppressed the news. Spain was a neutral country in the First World War, so the first uncensored news about the flu came from there, leading to the name.

The Manitoba Free Press announced the arrival of the Spanish flu on Oct. 1, 1918. (Manitoba Free Press)

Manitobans were initially shocked but not fearful — after all, Europe was an ocean away. If the flu did reach Canada’s shores, Manitoba was thousands of kilometres from any major port. There was a sense of immunity.

That came to a sudden end in the fall.

The flu arrived in Canada on the same ships that brought troops home. It then made its way across the country by rail, reaching Winnipeg in late September.

Returning soldiers at Union Station in Winnipeg. Troops coming home brought the deadly flu virus with them from the battlefields of Europe. (Archives of Manitoba)

As the death toll mounted, Winnipeggers faced long bouts of isolation in an effort to rein in the spread.

Churches and schools, along with entertainment venues such as movie theatres, billiard halls, dance halls, and public bathhouses, were shuttered.

Gatherings were banned and limits put on how many people could be on streetcars or in grocery stores.

Hospital visiting hours were abolished and personal care homes were closed to all visitors.

The Winnipeg Evening Tribune of Nov. 4, 1918, lists the methods the city took to try to contain the flu. (Winnipeg Tribune Archives/University of Manitoba)

People were urged to wash and a no-spitting bylaw was enforced for the first time in years.

Quarantine wards were set up in hospitals, and makeshift hospitals were created in available buildings as the regular facilities filled up.

A familiar story

Flash forward to 2019 and the story is much the same.

News surfaced in December about a flu outbreak in Wuhan, China. As  cases mounted, it swept into Italy, Iran, and South Korea.

Still, many people in Canada continued, unfazed, with regular plans — including travel. There was a sense of being cautious but not overly worried, even as the first death from the illness in Canada was reported March 9 in British Columbia.

Two days later, the World Health Organization declared COVID-19 a pandemic, pointing to 118,000 cases in 110 countries and territories, and thousands of deaths.

Spitting in Winnipeg, and in many cities around the world, was strictly banned and the laws were enforced during the Spanish flu pandemic. (Historical Medical Library of The College of Physicians of Philadelphia)

Nurses hold a casket outside Winnipeg’s Gardiner Funeral Home during the flu epidemic of 1918-1919. (L.B. Foote Collection/Archives of Manitoba)

From that point, the dominoes fell. Professional sports leagues cancelled their seasons and major events began to follow suit. Bans on gatherings led to schools, churches, cafes, shops, parks, playgrounds, and non-essential businesses being closed.

Many of those broad measures echo 1918-19, but there are some significant differences as well, Jones said.

“The main one being the closure of workplaces. In 1918-19 people continued to go to work every day if they could and probably often even when they couldn’t. They shouldn’t have been there when they were ill,” she said.

“Nobody seemed to take seriously the possibility that you would close down major sectors of the economy.”

A group of employees from the Canadian Bank of Commerce during the Spanish flu epidemic. (Glenbow Archives)

People forced themselves to go to work, for fear of losing their jobs and to make money so they could get treatment for family members who were ill. There was no universal health care and there were few unions.

“So that is very different now, as is the government’s willingness in Canada to economically support people during these times,” Jones said.

“So there have been some things that have fed into the response we’re seeing now.”

In this 1918 photo, made available by the Library of Congress, volunteer nurses from the American Red Cross tend to influenza patients in the Oakland Municipal Auditorium, used as a temporary hospital. (Edward A. ‘Doc’ Rogers/Library of Congress)

Another difference between 1918-19 and 2020 is that the global health system now crucial to the COVID-19 response did not exist a century ago, points out Michael Bresalier, a lecturer at Swansea University in the United Kingdom.

An expert in the history of disease — and a friend of Jones — Bresalier posted an article on the website History and Policy, noting the World Health Organization was not founded until 1948.

So nothing existed during the Spanish flu to advise governments, help them align their approaches, or facilitate the sharing of vital information and resources. Countries were left to piece together their own approaches. 

Headlines proclaim the impact of the Spanish flu in Winnipeg on Oct. 26, 1918. (Manitoba Free Press)

Homes where people were believed to have come in contact with the flu were ordered to place placards in the windows. Many people didn’t report their symptoms in order to avoid the stigma of having a sign. (Library of Congress)

An estimated one-third of the world’s population was infected with the Spanish flu, resulting in at a death toll estimated to have been at least 50 million, but possibly twice that. Government reporting was poor and there were many people who refused to see a doctor for fear of the stigma attached to having the virus.

Some deaths were recorded only by church parishes, not public health officials. And in some countries, no reporting was done at all.

IODE convalescent hospital at the corner of Broadway and Donald, where soldiers recuperating from Spanish flu were housed. (Archives of Manitoba)

One in six Canadians contracted the infection and some 55,000 died. In Winnipeg, there were more than 1,700 deaths out of a population of 183,000.  

The numbers for COVID-19 continue to climb across the world, but as of April 10, more than 1.6 million cases had been reported in 185 countries and territories, resulting in over 98,000 deaths, according to data from Johns Hopkins University.

More than 21,000 cases had been confirmed in Canada as of April 10, with more than 540 deaths.

Historical photo of the 1918 Spanish influenza ward at Camp Funston, Kansas, showing the many patients ill with the flu. (U.S. Army photographer/Wikimedia Commons)

A challenge that surfaced in 1918, and could again, is maintaining the strategies to slow the spread of the virus as the isolation drags on, said Jones.

During the Spanish flu, “the public health officer in Winnipeg faced a lot of pressure to end the closures because they were affecting the local economy in certain ways and they were certainly disrupting everyday life,” she said.

That officer has to negotiate a deluge of messages from the federal government and provincial government, the best scientific practices, the state of the public mindset, and pressure from the business sector, Jones said.

That pressure mounts when the number of new cases starts falling.

This 1918 poster, issued by the Alberta Provincial Board of Health, provides information on Spanish flu and instructions on how to make a mask. (Glenbow Archives)

Jones understands the impulse to get back to normal, to think things aren’t so bad, when that happens.

But a drop in new cases doesn’t necessarily mean the virus has weakened — it often means the measures put in place by government and health officials are working.

That makes it difficult for people understand the disease is still extremely dangerous.

“We just have to keep repeating the message,” Jones said. “I’m always reminded that with the [Spanish] flu pandemic there were measures that could have been taken that weren’t.”

A city health department map shows the number of cases and deaths from Spanish flu in Winnipeg’s neighbourhood wards. (City of Winnipeg Archives)

People also need to remember that beyond the battlefield, the Spanish flu hit the world in three waves.

The first, in spring of 1918, was generally mild and resulted in few deaths, The second, in the fall, was highly contagious and arrived with a vengeance. It led to death within just a few days, sometimes within hours, of someone showing symptoms.

The third wave occurred during the winter and into the spring of 1919, and was more lethal than the first, but less so than the second.

By summer of 1919, the pandemic nearly vanished — not because it was cured, but because those infected died or developed immunity.

Even then, some places in Canada experienced pockets of it into 1920, Jones said.

“So it really does become the question: Is that what this is going to look like and how can we plan for that? All of that is a big unknown for us now and unknowns are not comfortable for anyone,” she said.

“On the bright side, everyone working in public health right now is learning every day about the disease and ideally, they’re buying time, [so] should the disease return in a more serious way … they will have more tools in their tool box.”

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