Flu: how Britain coped in the 1918 epidemic

If you want to know what matters to people, you have only to listen to their children. In towns across England in 1918, a new nursery rhyme was heard in school playgrounds.

Britain and the rest of Europe had suffered a gruelling war and after four years of struggle, the nation was looking forward to peace. But for the young, far from distant battlefields, there was something else on their minds, something whose effects they witnessed. As they skipped rope they sang:

I had a little bird
Its name was Enza
I opened the window,
And in-flu-enza.

As the Great War was ending, a threat emerged that was even more lethal than the fighting that had brutally cut down so many young men. The influenza pandemic of 1918-19 claimed the lives of between 20 and 40 million people around the world, at least three times the number killed in the war. More died in a single year than were killed in the four years of the Black Death from 1347-51. Today, as the world prepares for the next influenza pandemic which England's chief medical officer, Sir Liam Donaldson, says is now inevitable, there are clues from the earlier catastrophe that demonstrate what we may face.

Although the world has changed beyond recognition in 85 years, and people are stronger, better nourished and better housed, with better-equipped hospitals and drugs to fight the coming infection, and if the pandemic is as serious as experts say it could be, we will still rely heavily on many of the measures used then for our survival.

In the spring of 1918, the disease emerged in pockets across the globe and at first seemed as benign as the common cold. Soldiers in the trenches in France became ill with what was known as la grippe. They complained of sore throats, headaches and a loss of appetite. Although the illness was highly infectious, and the primitive, crowded conditions made rapid spread inevitable, recovery was swift and doctors at first called it "three-day fever".

But they swiftly realised this was no ordinary flu. Glasgow was the first British city to be affected, in May 1918, and within weeks the illness had spread south, reaching London by June. During the next few months, 228,000 people died in Britain.

About a fifth of those infected developed pneumonia or septicaemia. Often this progressed to heliotrope cyanosis, a lavender hue of the skin that signalled shortage of oxygen and imminent death. Onset was devastatingly quick. Those hale and hearty at breakfast could be dead by tea-time.

In 1920, a Ministry of Health report noted that unlike ordinary seasonal flu, which was worst in the elderly, weak and sick, the new illness disproportionately struck those aged 20 to 30. Young adults with the strongest immune systems were, unexpectedly, the most vulnerable.

In a letter dated 29 September 1918, published in the British Medical Journal in 1979, Professor Roy Grist, a Glasgow physician, described the deadly impact of the infection.

"It starts with what appears to be an ordinary attack of la grippe. When brought to the hospital, [patients] very rapidly develop the most vicious type of pneumonia that has ever been seen. Two hours after admission, they have mahogany spots over the cheek bones, and a few hours later you can begin to see the cyanosis [blueness due to 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 and it is simply a struggle for air until they suffocate. It is horrible."

London, like other British cities, was ill-equipped to cope with the epidemic. The war had cost the country most of its fortune, industry was disrupted, there was damage to public services and millions were dead, missing or wounded. And ships were bringing soldiers back from the front carrying the virus to their homes and communities.

Hospitals were overwhelmed, and doctors and nurses worked to breaking point, although there was little they could do. Medical schools closed their third- and fourth-year classes and students helped in the wards. There were no treatments against the flu and no antibiotics to treat complications such as pneumonia.

In many towns, theatres, dance halls, churches and other public-gathering places were shut, some for months. Streets were sprayed with chemicals and people wore anti-germ masks. Some factories relaxed no-smoking rules believing that cigarettes would help prevent infection.

On 3 November 1918, the News of the World suggested ways to combat the epidemic which are equally relevant today:

"Wash inside nose with soap and water each night and morning; force yourself to sneeze night and morning, then breathe deeply. Do not wear a muffler; take sharp walks regularly and walk home from work; eat plenty of porridge." Possibly, the porridge may be optional. Armistice Day on 11 November, called to mark the end of the war, set off a second wave of infection. As people gathered to celebrate, the virus swept through them. Parties and parades turned to disaster.

Rich and poor were at risk; the virus spared no one. Katherine Garvin, daughter of James Garvin, editor of The Observer during the First World War, described going to London to join the Armistice Day celebrations with her mother, Cristina.

"I remember her crying and crying through all the rejoicing and saying, 'It is too late for me'. Nearly [two] months later she died, in her sleep, after a bad attack of influenza that had overrun England after the war. She was a war casualty. The doctor had been in the morning and said she was better. But at some time in the late afternoon of Christmas Eve, the eve of her 43rd birthday, her heart gave up and she went."

Katherine says her father, who had lost his son - her brother - at the Battle of Ypres in 1917 - was inconsolable after his wife's death, demonstrating how the flu piled tragedy upon tragedy. "He was totally incapable of dealing with a large family, house and kitchen, and he felt his loss more and more. Year after year, I saw him break into uncontrollable tears when he mentioned my mother. The grief became more intense with the years and not less. It was alarming to see him cry but I learned from it that the more manly, the larger the man, the more he can let his tears fall without false shame."

The pandemic circled the globe. No country was spared, except Australia which imposed strict quarantine rules. Entire Alaskan villages were overcome by the virus and Western Samoa, a small island in the Pacific, lost 20 per cent of its population. Worst-hit was India where an estimated 12 million people died. By the end of the pandemic, a fifth of the world's population had fallen sick. No one escaped its effects.

In the US, the first case was recorded on Monday, 11 March, 1918, at Fort Riley in Kansas, a military training camp. A cook, Albert Gitchell, reported to the hospital with a "bad cold". He was feverish, and complained of a sore throat, headache and muscular pains. By noon that day, 107 patients had been admitted with similar symptoms. Within five weeks, 1,127 men out of 26,000 in the camp, were infected.

The death rate was relatively low in this first outbreak but the second wave which started in Boston in the early autumn was much more severe. The virus appeared to have mutated over the summer. Philadelphia, hardest-hit of all US cities, was struck in October with 700 deaths in the first week, 2,600 by the second week and 12,162 by 2 November. Churches and schools were closed but the newspapers, as did those in Boston and other US cities, continued to devote their front pages to news from the battle front in Europe.

As flu deaths rose, cemetery keepers could not keep up. Families had to dig their own graves and there was a shortage of coffins. Louise Abruchezze, an Italian immigrant, said a neighbour became distressed at how the corpse of a family member was being treated and begged the undertaker: "Please, please, let me put him in a macaroni box." Wooden boxes were used at the time to hold 20lb of pasta.

The effect of the epidemic on the US was so severe that the average lifespan was cut by a decade. Some towns tried to restrict travellers or impose quarantine, with limited success. One banned shaking hands. Funerals were limited to 15 minutes and bodies piled up in warehouses. The pandemic peaked in the summer and autumn of 1918, as crops were ripening, but there were no field-hands to get the harvest in. "It was an agricultural disaster," one report said.

As the illness swept Europe, Spain was hardest hit, with an estimated eight million dead which led the BMJ to label the disease "Spanish flu", though it is thought to have originated in China. One of the earliest casualties was the King of Spain. Among others the flu killed were Egon Schiele, the Austrian artist, Guillaume Apollinaire, the French poet, and Felix Arendt, the American composer. A third wave of the pandemic struck in early 1919 but it died away swiftly, its force spent. The disease that had wreaked such havoc disappeared almost as quickly as it had come.

Forty million people had lost their lives. The death rate was 25 times higher than in a normal flu epidemic (2.5 per cent compared with 0.1 per cent). Which leaves us with the question: Will the next pandemic be as bad?

Some say modern standards of living and medical care means we have less to fear than our forebears in 1918. But that depends on the nature of the virus that emerges from the mixing of avian flu and human flu in the Far East that is expected to generate the next pandemic. It could happen next year or not for a decade. It could be mild or it could be more severe. There is no way of knowing until it strikes.