The covid-19 pandemic one year on: parallels and lessons from Spanish flu

On 11 March 2020, the Director General of the WHO declared the outbreak of covid-19 infections to be a “global pandemic.” One year on, as the total cases have surpassed 100 million, we look to history and to another pandemic with devastating effects: the influenza of 1918-1919, or “Spanish flu.” Parallels to our current situation abound. 

The Spanish flu arrived in Europe in March 1918. It came in three major waves: a mild first one in the spring of 1918, the next and most devastating one in October-November 1918, and the last moderate one in early 1919. At its onset and for many months, it was not recognized as a major threat. In July of 1918, it was still being compared to previous flu outbreaks from the 1880s (“clinically very similar to other epidemics in former years”,1 and even “identical with that of the last pandemic of 1889″.2) The tone of English physicians remained moderate and anti-alarmist3 throughout what would prove to be the most catastrophic pandemic in history. 

Society faced challenges not unlike our own: economic disruption, crowded public transportation as people continued going to work, having to disinfect surfaces widely, the ever controversial issue of wearing masks4 (one physician suggested nose plugs5 as an alternative), and lack of compliance with recommendations. Management was restricted to preventative and supportive measures. There was no cure. 

One year on, by March 1919, the popular mood was fluctuating between despair and hope. Some physicians expressed optimism that the pandemic would subside;6 others declared that “the epidemic cannot be stopped”.7 One deplored that “a human strain capable of withstanding the evil influences of unventilated rooms has not so far been evolved.8 Treatments were following, at best, the “primum non nocere” principle. Rest and sleep were paramount; active measures included salicin,9 compresses (“fomentations”) with turpentine10 to reduce fever, or “stimulants” such as “fresh air and oxygen, brandy or whisky.”11

The question as to cause of death also preoccupied physicians, mirroring current debates on “dying from Covid versus dying with Covid.”12 Then as now, underlying conditions were decisive:13 “for the most part the older patients with lungs already diseased-adherent, emphysematous, bronchitic”, would usually die of “acute asphyxiating bronchiolitis or by bronchopneumonia”14 blamed usually on the Pfeiffer bacillus.

In October 1918 a controversial vaccine recipe emerged: a mixture of the bacteria most commonly found in the sputum of sick patients, including the Pfeiffer bacillus, streptococci and pneumococci.15 The “vaccine” was explicitly targeted at the secondary infections, such as pneumonia, with a goal to reducing overall mortality. Subsequent small-scale tests16 were hopeful but inconclusive because of one key element: The primary causative pathogen remained unknown.17

The advancement of science is what sets the current situation apart. We now know that the 1918 outbreak was caused by a virus which was only identified in the 1990s. Our forefathers fruitlessly tried to discover the cause, which they presumed to be an airborne bacterium transmitted through droplets from person to person:18 hence the need for public health measures. Some, however, realized that the real culprit must be evading detection: a so-called “filter-passer”,19 “possibly beyond the present range of microscopic vision.”20 They were right, yet lacked the means to prove it. The electron microscope would not arrive until 1931.21 But the pandemic did finally subside in the spring of 1919, as most people either acquired immunity or died.

In short, physicians in 1918 and 1919 faced many of the same challenges as we do, while being poorly equipped to tackle them. Treatments were rarely effective and often unsafe. The ability to test vaccines on large numbers did not exist and drug regulation, a largely 20th century innovation, was still in its infancy during the Spanish flu pandemic. Undoubtedly, mental health issues and the distress associated with bereavement were present then as now, compounded and overshadowed by losses due to the recent war.

More than a century later, we are better prepared in our own struggle with covid-19. Living standards, at least in the Western world, have improved; modern medicine is able to save an increasing proportion of the affected; better communication channels enable homeworking and the dissemination of health advice. Following genomic sequencing, several vaccines with high thresholds of efficacy are now being rolled out having passed stringent safety testing and peer review. Yet challenges remain. Public health measures continue to be crucial in mitigating further waves of infection and the threat of new variants. The lesson of the “Spanish flu” suggests we may have to brace ourselves for another year of uncertainty and mostly virtual interaction. While we now have the tools of 21st century medicine to predict virus behaviour, it remains our responsibility to adapt our own behaviour, as much as humanely possible, in accordance with what science tells us. 

Carmen Schmechel, medical historian and postdoctoral research fellow, Freie Universität, Germany

Lars Joensson, pharmaceutical professional and history student, University of Aachen, Germany

Sarah Stinnissen, freelance medical writer and editor, Germany

Steven Walker, director, Stgilesmedical, UK

Competing interests: none declared 


  1. Gotch, O. H., and H. E. Whittingham. “A REPORT ON THE ‘INFLUENZA’ EPIDEMIC OF 1918.” BMJ 2, no. 3004 (July 27, 1918): 82–85.
  2. “Bacteriology of The Influenza Pandemic.” The British Medical Journal 2, no. 3006 (August 10, 1918): 3.
  3. For a telling example, see “The Influenzal Pandemic,” The British Medical Journal 2, no. 3002 (July 13, 1918): 2.
  4. “Means for The Control of Influenza.” The British Medical Journal 1, no. 3035 (March 1, 1919): 3.
  5. Lucey, H.C. “The Nasal Plug as A Guard Against Influenza.” The British Medical Journal 1, no. 3037 (March 15, 1919): 2.
  6. “Influenza,” The British Medical Journal 1, no. 3037 (March 15, 1919),
  7. “Means for The Control of Influenza,” The British Medical Journal 1, no. 3035 (March 1, 1919): 3.
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  9. E.B. Turner, “Treatment of Influenza by Large Doses of Salicin,” The British Medical Journal 1, no. 3036 (March 8, 1919): 2
  10. Humphrey Davy, “Treatment of Influenza and Influenzal Pneumonia,” The British Medical Journal 1, no. 3035 (March 1, 1919): 2
  11. E. C. Cole, “Preliminary Report ON THE INFLUENZA EPIDEMIC AT BRAMSHOTT IN SEPTEMBER-OCTOBER, 1918,” BMJ 2, no. 3021 (November 23, 1918): 566–68,
  12. “‘Died from’ or ‘Died with’ COVID-19? We Need a Transparent Approach to Counting Coronavirus Deaths.” Accessed March 2, 2021.
  13. “The Pandemic of Influenza.” The British Medical Journal, July 27, 1918, 3.
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  15.  Leishman, W.B. “Vaccines for Influenza.” The British Medical Journal, October 26, 1918, 2.
  16. L. Armitage, “NOTE ON ‘INFLUENZA’ AND PNEUMONIA: FROM A FIELD HOSPITAL,” BMJ 1, no. 3036 (March 8, 1919): 272–74,
  17. “Whatever be the initial causative organism, there is no doubt that the infection quickly becomes a mixed one and that appearance of secondary infection is concomitant with graver symptoms. It is to be hoped that the etiology of the condition will soon be made clear.” – F. L. Armitage, “NOTE ON ‘INFLUENZA’ AND PNEUMONIA: FROM A FIELD HOSPITAL,” BMJ 1, no. 3036 (March 8, 1919): 272–74,
  18. Royal College of Physicians, “Memorandum – Prevention and Treatment of Influenza,” The British Medical Journal 2, no. 3020 (November 16, 1918): 2.
  19. “The Etiology Of Influenza,” The British Medical Journal 2, no. 3018 (November 2, 1918): 3.
  20. Royal College of Physicians, “Memorandum – Prevention and Treatment of Influenza,” The British Medical Journal 2, no. 3020 (November 16, 1918): 2.
  21. Mathys, Daniel, Zentrum für Mikroskopie, University of Basel: Die Entwicklung der Elektronenmikroskopie vom Bild über die Analyse zum Nanolabor, p. 8.