By Ivo Kokić
The early 2020s were marked by the coronavirus pandemic. The topic of the Spanish flu suddenly became relevant again. It is essential to draw clear conclusions from both of these plagues so that we can respond properly if such a thing ever happens again—because there is no guarantee that it won’t.
True, this time it should be easier for us since the U.S. Secretary of Health is Robert F. Kennedy Jr., although he will not hold that position forever. It would be good if he remained in office as long as possible, since no one has devoted themselves so much to fighting the pharmaceutical mafia as he has. In any case, if we fail to draw clear conclusions, we risk repeating the same mistakes from the past.
This text (below) is a review of the book Pale Rider, which deals with the Spanish flu. The conclusion (the last two paragraphs) of that review refer to the then-ongoing coronavirus pandemic. The review was previously published in Historijski zbornik, vol. LXXV, no. 2, February 2023, and is reprinted here with permission from the journal’s editorial board. You can read the original version [HERE], on pages 413–420.
Laura Spinney. Pale Rider: How the Spanish Flu of 1918 Changed the World
Zagreb: V. B. Z., 2019, 281 pages
Laura Spinney (b. 1971) is one of Britain’s most prominent contemporary science journalists. She graduated in Natural Sciences from Durham University (UK). She has written for Nature, National Geographic, and other scientific journals. As a foreign correspondent, she reported for two months in 2019 from the Max Planck Institute in Berlin. Spinney is the author of numerous scientific articles and several books, such as The Doctor (2001) and Rue Centrale (2013). Her most complex work is considered to be Pale Rider (2017).
In this monograph, Spinney examines the Spanish flu from its outbreak, through attempts to contain it and perceptions of its deadliness, to the lessons learned from the disease. The Spanish flu is one of her central research interests because it claimed more lives than the First World War and is often treated in historiography as a side event near the war’s end and in its aftermath.
This plague was extremely virulent, infecting around half a billion people (one-third of the world’s population at the time) and taking between 50 and 100 million lives. The first recorded case appeared on March 4, 1918, and the last in March 1920. Despite these enormous human losses, the Spanish flu did not enter collective memory, nor were monuments erected to its victims (as they were for war heroes). Thus, the work explores a largely forgotten global phenomenon, and the author delves “beneath the surface,” moving into the sphere of the history of everyday life.
It is difficult to compare the Spanish flu with other fearsome diseases, as it spread much faster due to airborne transmission than modern deadly outbreaks such as Ebola. However, the recent coronavirus pandemic gives the book renewed contemporary relevance.
Spinney approaches the topic from the perspective of social history. The central research question of the book focuses on how the disease was perceived by ordinary people and how states responded to its spread. She draws on works of similar themes, online sources, Vatican documents, Hippocratic writings, medical reports of the time, unpublished letters, disease prevention guidelines, diaries of contemporaries, inspection reports, archival materials, personal correspondence with historians, reports from the Alaska Native Commission, and even a letter by Tagore to a friend.
The book is organized chronologically but aims more to analyze specific aspects of the Spanish flu than to simply list events. It includes an introduction, eight parts (each divided into smaller sections except the last), an epilogue, and acknowledgments. Before the introduction, there is a map showing the global spread of the Spanish flu during its second wave (1918).
Chapter One: The City Without Walls (pp. 23–43) is divided into two parts, discusses the historical conditions that enabled the spread of influenza and its perception in antiquity and modern times. By analyzing historical descriptions of plague symptoms in ancient times, Spinney identifies the first possible description of influenza among the inhabitants of Perinthos in ancient Greece in 412 BC.
Although it is impossible to pinpoint the virus’s exact origin, Spinney believes the turning point came about 12,000 years ago, when humans began living in closer communities. Before that, the influenza virus could not spread effectively due to its short transmission range (just a few meters). Interestingly, before Hippocrates, the term “epidemic” referred to anything that spread among people—rumors or wars, for example. Hippocrates narrowed the definition to diseases, focusing on how they spread rather than only on symptoms.
He was innovative for introducing diagnosis and therapy and for suggesting that diseases could have biological rather than spiritual causes—attributing them to an imbalance of the four bodily humors. Spinney traces how perceptions of disease causes evolved from antiquity to modernity, though human coexistence with influenza remained constant.
She also notes differing social views of influenza strains—for instance, the interpretation that Edvard Munch’s painting The Scream was inspired by psychosis caused by the Russian flu outbreak at the end of the 19th century.
In the 20th century, science defeated many mass diseases but also fostered the illusion that infectious diseases could be eradicated altogether. The germ theory of disease (that microorganisms cause illness) raised such hopes. Improved hygiene and water purification did indeed yield significant results in fighting epidemics.
Spinney also explains how Darwin’s ideas about natural selection influenced the rise of eugenics—a pseudo-science claiming that “stronger” races would survive while “weaker” ones would perish. Eugenics was widely accepted in the early 20th century, even in Japan, though American eugenicists viewed the Japanese as inferior. This ideological context is vital to understand since medicine—when it should have been fighting the Spanish flu—was also shaped by such discriminatory theories.
Although industrial, cultural, and scientific modernization was underway, only a thin layer of society benefited from its fruits.
Facts about Spanish flu
Chapter Two: Anatomy of a Pandemic (pp. 45–65) provides information about the beginning and course of the Spanish flu, its symptoms, and its influence on the First World War. The pandemic is said to have begun when army cook Albert Gitchell at Camp Funston, Kansas, fell ill on March 4, 1918. Though this might not have been the true first case, it is considered the official starting point.
American soldiers carried the virus to the Western Front, spreading it across France, Britain, Italy, Spain, and Germany. The disease also appeared in North Africa, reached Bombay, and even northern China, though much of Africa remained untouched.
In Russia, the flu was likely introduced by former war prisoners released by Germany after the Brest-Litovsk peace treaty. Civil war and regional conflicts further accelerated its spread.
At first, there was little public panic during the first of four waves. Yet hospitals were overcrowded. By spring 1918, more than half of British troops and nearly three-quarters of French soldiers were infected. Governments even exploited the disease for propaganda—British planes dropped satirical leaflets over German cities mocking their epidemic losses.
Different countries were affected unequally; Brazil, for instance, faced only one wave late in 1918. Early on, most patients had mild symptoms, leading health systems to underestimate the danger. It was only when the virus returned in summer 1918 that it became clear this was no seasonal flu. The rise in deaths was largely due to pneumonia as a complication. Doctors described patients’ faces turning a reddish-brown hue—known as heliotrope cyanosis.
While many in Brazil dismissed the threat as exaggerated, authorities took precautions such as playing football matches without spectators. In Rio de Janeiro, nightlife on Avenida Rio Branco came to a halt.
Chapter Three: “Manhu”—What Is It? (pp. 67–91) discusses the etymology (origin of the name) and etiology (cause) of the Spanish flu. The naming of the disease reflected the chaos of the time: one newspaper in Freetown, Sierra Leone, proposed calling it “manhu,” meaning “what is it?” in Hebrew.
It eventually became known as the Spanish flu because Spain, being neutral in the war, had no press censorship, allowing its newspapers to report freely once the disease arrived in May 1918. Warring nations had suppressed information about the epidemic to avoid harming troop morale.
French military doctors internally called it maladie onze (“disease number 11”). Even after it got its name, confusion persisted: not all doctors agreed on what “influenza” actually meant.
A major scientific breakthrough came when it was discovered that Pfeiffer’s bacillus was not the true cause of influenza, overturning the first of Koch’s postulates (criteria for linking microbes to disease). Because viruses are about twenty times smaller than bacteria, they could not yet be seen under optical microscopes, making diagnosis extremely difficult. Some even thought the illness was typhus rather than flu.
As for its causes, some believed the fumes of unburied war corpses caused the disease; others thought it was biological warfare. Many saw it as divine punishment.
The Spanish town of Zamora, despite its medieval walls, could not shield itself: young soldiers quarantined in the local castle spread the disease to civilians when the isolation failed.
Chapter Four, The Instinct for Survival (pp. 93–148), in its three parts, explores humanity’s struggle to survive disease. One of the main methods of combating illness was quarantine — which, according to the author, was first introduced by the Venetians in the 15th century. However, this is incorrect, as quarantine actually originated in Dubrovnik in the 14th century. The author also notes that the idea of isolating a potentially sick person can be traced back to the Book of Leviticus in the Bible.
Discussing nations that prioritized public health over profit or warfare, she points out the challenges of effectively implementing measures to prevent the spread of infection. The difficulty lay not only in balancing the economy and national security with public health but also in overcoming human disobedience.
The author refers to the thesis of American influenza historian Alfred Crosby, who claimed that democracy was not helpful during a pandemic. The fear of public unrest was evident in France, where markets, churches, cinemas, and theatres were supposed to close — yet such measures were often poorly enforced. An especially interesting case is Japan, where public gatherings were not banned, while in its colony of Korea, all large gatherings, including religious ones, were strictly prohibited. The Spanish government, meanwhile, believed the disease was coming from Portugal. Before closing both its Portuguese and French borders, Spanish authorities detained passengers arriving from Portugal at the Medina del Campo railway hub, subjecting them to harsh disinfectants. The process could last up to eight hours, and any sign of revolt was punishable by fines or imprisonment.
Just as the disease spread through the port of Manila in the Philippines, New York — as a major hub — was highly exposed to infection. Yet U.S. President Woodrow Wilson did not order a halt to public transit. After eventually declaring a pandemic (with apparent delay), he shortened working hours in many industries, established cleaning stations and emergency centers in New York to care for patients and keep records. Most notably, however, he kept schools open. Wilson reasoned that children were easier to monitor, feed, and even treat when they remained in school.
Some journalists questioned how effective the measures could really be — it was unrealistic, they argued, to expect city dwellers not to use public transport or for the poor to afford healthy food. The government’s goal was to reduce gatherings and keep people apart, a policy that became known as “social distancing.” Given the wartime context, military language was ubiquitous: those who ignored government orders were labeled deserters. Newspaper censorship backfired, since the many corpses could not easily be hidden, meaning the public still knew the pandemic was ongoing. Except for Corporal Cesare Carella, public funerals in New York were banned.
Over time, people began gathering again and abandoned mask-wearing, worsening the situation in the healthcare system. Some New Yorkers turned to religion, while others relied on superstition to ward off illness. Spinney also discusses the placebo effect of certain medicines. She uses aspirin as an example: at the time, it was believed to cure the disease, whereas today we know it only alleviates symptoms like fever and pain. It is unsurprising that patients saw aspirin as a miracle drug — it gave them a false sense of relief. However, there are well-founded theories that some victims of the Spanish flu actually died from excessive doses of aspirin.
When it comes to the spread of infection, kindness and altruism are depicted as a double-edged sword. People generally did not stay isolated at home to protect themselves — instead, they selflessly helped one another with food and other necessities. Besides material assistance, this created a psychological effect of “collective resilience.” Thus, while achieving their goal of compassionate aid, they unintentionally contributed to the further spread of the Spanish flu.
Despite her thorough argumentation, the author could have consulted certain works in the sociology of religion, which might have deepened her understanding of the phenomena she only briefly touches upon — namely, people’s reliance on the supernatural. Furthermore, modern readers might be interested in concrete statistics showing how (in)effective closures were in combating the pandemic. Spinney might also have noted that the term “social distancing” is a misnomer, since “social” refers to societal interaction — therefore, the correct term would be “physical distancing.”
A short documentary
In the two sections of Chapter Five, Post Mortem (pp. 149–168), the author discusses efforts to uncover the origins of the Spanish flu pandemic and the scale of its mortality. She notes that U.S. Army captain James Joseph King, already in the first year of the pandemic, proposed a theory that the flu originated in China, citing a similar epidemiological situation in Harbin in 1910 during a pneumonic plague outbreak. On the other hand, since the first recorded case appeared in the U.S., it is possible that the disease started there.
However, these assumptions remain unproven — some New York residents had similar symptoms as early as February 1918, suggesting that American soldiers may have brought the disease back from France. Spinney concludes that the only (almost) certain fact today is that the Spanish flu did not come from Spain — yet it is still unknown whether it began in China, the U.S., or France. If it did start in China, that would significantly alter one of the core perceptions of the Spanish flu.
Although the pandemic spread rapidly — largely because people’s immune systems were weakened by the war, which allowed for complications and higher mortality — a Chinese origin would imply that the outbreak was not solely a consequence of the Great War.
Immediately after the pandemic, it was clear that the Spanish flu represented an unprecedented event in social and medical history. Early estimates suggested around 20 million deaths. Of course, determining an exact number is difficult, especially on a regional scale. It is particularly hard to make estimates for China, where epidemics occurred routinely every year. Since the Spanish flu struck between two pneumonic plague outbreaks (all three diseases appearing between December 1917 and December 1918), it is nearly impossible to determine who died from which illness.
Modern research estimates the total number of deaths at around 50 million — 30 million of them in Asia, including 18 million in India alone — though the true toll may have reached as high as 100 million people, many dying from complications caused by the Spanish flu.
The three sections of Chapter Six, Science’s Redeemed Face (pp. 169–202), discuss the biological research surrounding this plague. The author finds it fascinating that the cause of the Spanish flu was identified as H1N1, which strongly resembles the arbitrary name “Disease No. 11,” coined by military doctors in France. Scientists from a laboratory in Atlanta, Georgia, succeeded in 2005 in recreating the exact virus that caused the Spanish flu. Furthermore, a 2014 study revealed that seven of the eight genes of the Spanish flu virus were very similar to those found in avian influenza viruses in North America. While this is not a definitive answer to the question of its origin, it is certainly a strong indicator of where it began. That virus killed at least 2.5% of confirmed cases, whereas ordinary influenza complications kill about 0.1%. On the other hand, most survivors experienced symptoms only slightly worse than those of seasonal flu.
Spinney devotes significant attention to the human factor. Drawing a parallel with the much more recent swine flu, she notes that it did not originate in pigs but rather in humans — with pigs serving merely as intermediaries in transmission to other humans. Various factors influenced mortality rates among specific social groups. A higher social status provided better access to healthcare; living conditions and hygiene affected immunity; a higher standard of living ensured better nutrition; and even genetics played a role in resistance. Naturally, eugenicists attributed the lower mortality rates in Northern Europe compared to Africa solely to genetic differences, using this to reinforce their racial theories.
Chapter Seven, The World After the Flu (pp. 203–257), the longest in the book (with six sections), explores the consequences of the Spanish flu. According to one interpretation, recovery began as soon as the initial shock and panic subsided. However, the author provides a complex view, showing that some Indigenous communities in North America never fully recovered and still feel the long-term effects of the pandemic. She then examines the misuse of scientific theories for unscientific ideas. For instance, spiritualists invoked Einstein’s theory of the fourth dimension of time, claiming that spirits inhabit undiscovered dimensions. Eugenicists, meanwhile, used the concept of natural purity as an argument for the “cleansing” of humanity.
One of the most important legacies of the Spanish flu in the field of healthcare was the increased push for medical care equally available to all. Although such ideas existed before the pandemic and were not immediately realized afterward, the flu acted as a catalyst. For example, Britain’s National Health Service (NHS) was founded only in 1948, but the Spanish flu helped set the stage for it. Spinney draws a parallel between the struggle for health and the struggle for political rights. In India, organizations tied to the independence movement helped the government contain the disease, which contributed to Mahatma Gandhi’s rise as a leader of the movement for independence from Britain.
The author also highlights changes in literature and art following the pandemic. Artists lost their faith in scientific progress as the sole path forward, disillusioned by the devastation of war, while the feeling of helplessness — intensified by the Spanish flu — deeply influenced their creative expression.
The big lesson from history
Chapter Eight, Roscoe’s Legacy (pp. 259–269), contains no sub-sections. It discusses the possibility of a new pandemic, which the author considers highly realistic and dependent on numerous factors — particularly climatic ones. She cites a 2016 report from the U.S. National Academy of Medicine stating that there is roughly a 20% chance of at least four pandemics occurring in the next hundred years. One of them, the report suggests, is likely to be caused by influenza.
The author notes that health protection measures are most effective when they are voluntary. However, learning from the Spanish flu, the U.S. Centers for Disease Control and Prevention (CDC) declared in 2007 that mandatory measures may be used once a disease’s mortality rate exceeds 1%. Spinney misses an opportunity to engage in intellectual debate with this stance. For illnesses similar to influenza, it is impossible to determine the “true” mortality rate. Assuming the state can provide hospital treatment to everyone who needs it, only the mortality rate among confirmed cases can be known. The actual mortality is likely much lower, since many people who recovered at home never reported their illness. In poor countries, the opposite may occur — people may die without their disease ever being confirmed due to a lack of medical capacity.
However, when developed nations apply certain measures to their populations, there is a risk of falling into the trap of falsely elevated mortality rates, because the government has no data on the many individuals who survived the illness but were never included in official statistics.
Despite certain criticisms raised in this analysis, it must be acknowledged that the author has made a significant contribution to a topic that has long been neglected. It is commendable that Spinney, despite relying on a large number of sources, clearly states which conclusions she cannot reach with certainty.
We can conclude that the public perception of the Spanish flu was far from uniform — it varied according to culture, environment, and social circumstances. Some advocated strict measures to stop the spread of infection, while others opposed them. Many focused instead on identifying the “guilty nation” from which the virus supposedly originated. There was also a wide range of beliefs about the cause of the disease — from rotting corpses to divine punishment.
Governments initially sought to conceal the spread of the disease, and when that became impossible, they tried to exploit it for wartime purposes. Common countermeasures included restricting mobility and gatherings within a country, as well as closing borders. Yet the overall picture was far more complex — for example, the Japanese government spared its own citizens from such restrictions but imposed them in occupied Korea.
Ultimately, valuable lessons can be drawn for the current COVID-19 pandemic. Naturally, there are key differences. The Spanish flu was compounded by wartime conditions; there was no specific treatment or vaccine; and it lasted two years. In contrast, the coronavirus pandemic lacked such a burden — in fact, governments initially imposed lockdowns to limit the spread — yet, despite the existence of a vaccine, it has lasted more than two years.
Nevertheless, certain conclusions remain consistent. First, governments tend to portray crises to their own advantage, whatever the circumstances. Second, infection and death statistics can easily be manipulated. During the Spanish flu, governments downplayed the numbers to maintain wartime morale. But if a government’s goal is to instill fear, the manipulation can go the other way.
The Spanish flu demonstrated that science should not be followed blindly — as shown by the breakdown of Koch’s first postulate, once accepted as absolute truth. Moreover, patients and doctors alike placed misplaced faith in the supposedly miraculous aspirin, which likely contributed to some of the deaths. Thus, we should avoid glorifying any medical product simply because it is currently considered desirable — future discoveries may reveal hidden dangers.
Finally, there is an enriching insight in the wise decision of U.S. President Woodrow Wilson (without entering into other aspects of his politics) as an example of effective crisis management. His decision not to close schools serves as an inspiring reminder that, no matter how difficult or dangerous a situation becomes, certain boundaries must never be crossed — and maintaining education in schools is one of them.
