During the final year of the Great War, pandemic influenza affected and debilitated circa 25 percent of the global population, typically resulting in the mortality of between 2 and 4 percent of those afflicted. Death typically resulted from influenza-induced hemorrhaging or suffocation, or from secondary pneumonic or tubercular co-infections.2 In the United States, flu-induced morbidity was circa 25 million, with an estimated mortality of 675,000. According to the medical historian Hans Zinsser, the epidemic exerted a dramatic (if rather brief) negative effect on average US life expectancy, resulting in a significant decline of 12 years in 1918.3
"The pandemic," Alfred Crosby concludes, affected history in general in the way that the random addition of a poison to some of the refreshments served at the 1918 West Point commencement celebrations would have affected the military history of World War II; i.e. it had enormous influence but one that utterly evades logical analysis and that has been completely ignored by all commentators on the past. On the level of organizations and institutions—the level of collectivities—the Spanish flu had little impact. It did not spur great changes in the structure and procedures of governments, armies, corporations, or universities. It had little influence on the course of political and military struggles because it usually affected all sides equally.4
Crosby's argument is based on a reading of US mortality data; however, the data presented below indicate that the pandemic did not affect all the protagonists equally. The balance of evidence indicates that the virus generated differential mortality across the spectrum of affected societies. The very fact that mortality varied so greatly across cultures leads to the conclusion that the pandemic had differential impacts on the various combatants involved in the war. A second point is that there was considerable temporal variation in the waves of pandemic influenza that circulated the world in 1918-19, and that it struck and debilitated the Central Powers before it struck the Allies.
The first evidence to challenge Crosby's assertion that all sides were affected equally by the pathogen comes from the medical historian W. H. Frost, who used the rates of mortality in mid-size to large population centers to document the degree to which influenza swept the United States in 1918. Importantly, Frost's data clearly indicate differential rates of morbidity across US population centers, ranging from 15 percent in Louisville to 53 percent in San Antonio.5 Reinforcing this finding that flu-induced mortality was not uniform, but rather ranged along a continuum within societies, the medical historian Edgar Sydenstricker estimated that US national mortality rates ranged from 2.76 percent to
4.6 percent.6 Considering this estimate in terms of rates, Crosby noted that (according to US Public Health Service surveys conducted at the time) 280 per thousand US citizens contracted pandemic influenza in 1918-19. Crosby extrapolates to conclude that over 25 percent of the US population was infected and debilitated by the contagion.7
Given that influenza-induced morbidity and mortality appears to have ranged along a continuum within societies, one might expect to observe considerable variance between sovereign states. The data bear out this supposition, as certain countries (e.g., Japan) exhibited exceptionally low mortality rates, whereas other countries exhibited exceptional to catastrophic levels of mortality (the worst case being Samoa). The medical demographers G. Rice and E. Palmer analyzed Japanese medical archives to compile data on influenza-related morbidity and mortality, and determined that Japan witnessed 2,168,398 cases (morbidity) and 257,363 deaths (mortality). "The case rate," they write, "was therefore 370 per thousand, or just over one-third of the whole population, which was rather higher than that of the United States. However, the influenza-induced crude death rate was rather minute, at 4.5 per thousand."8 Other societies were not so fortunate. Data collected by Colin Brown indicate that Indonesia's mortality rate was approximately 17.7 per thousand.9 Furthermore, approximately 3 percent of Sierra Leone's indigenous population died as a direct result of influenza by late 1918,10 and Patterson has established that flu-induced mortality in African societies ranged from 30 to 40 per thousand.11
Attempts to quarantine Australia and New Zealand were partially successful; they only delayed the onset of the contagion, and Rice notes that New Zealand's Maori population exhibited a mortality rate of 43 per thousand.12 Mills has established that India suffered to an even greater extent from the virus, with a mortality rate ranging from 46 to 67 per thousand, again varying by region.13 The highest death rates appear to have occurred among the isolated and immunologically naive populations of islands such as Western Samoa, which exhibited a staggering mortality rate of 220 per thousand, resulting in the destruction of over 20 percent of its population base over the duration of the pan-demic.14 (See figure 3.1.)
Initial estimates of deaths induced by pandemic influenza placed aggregate global mortality at circa 21 million. However, recent epidemiologi-cal investigations have revealed that flu-induced mortality in South Asia
Japan Indonesia Sierra New India Samoa
Leone Zealand (Maori)
Influenza: comparative crude death rate per thousand, 1918-19.
alone (particularly in India) exceeded 17 million. Therefore, conservative revised estimates of mortality currently approach 50 million,15 and liberal estimates are as high as circa 100 million.16 For the purposes of this inquiry it seems prudent to adopt the figure of 50 million.
During typical manifestations of the pathogen, influenza is a killer of those at the two tails of the demographic distribution of a society: the very young and the elderly. Yet the 1918 epidemic displayed an unusual penchant for the destruction of healthy and productive individuals in the prime of their lives. Specifically, during the 1918 pandemic, the mortality distribution associated with infection exhibited the form of a W, with pronounced mortality in the 15-45-year age range, accompanied by the expected high mortality in the elderly and young.17 Flu-induced mortality seems to have affected females and males in equal fashion, although the pathogen apparently generated exceptional mortality in pregnant mothers.18 Why would the pathogen affect so many healthy young adults in the prime of their lives? It is reasonable to speculate that the influenza generated a profound overreaction by the body's immune system, and that the cytokines (endogenous toxins) released by the body destroyed the fragile tissues of the lungs during the immune system's attempt to combat the virus.19 It would seem, then, that those with stronger immune systems were, as a perverse consequence, more vulnerable to the pathogen.
Beyond the influenza, various pathogens exhibited a pronounced and deleterious effect on the German population during World War I. One reasonable explanation for such declines in German public health is that the embargo on the shipment of foodstuffs to the Central Powers during this period would have severely compromised the base health of the average German citizen, increasing the probability of colonization of the human host by the pathogen. Indeed, male civilian deaths in Germany peaked in 1918 at 566,077, with female mortality in the same year reaching a zenith of 644,163 even though females were non-combatants. Compare such figures with postwar baseline civilian mortality of 429,741 for males and 426,263 for females in the year 1923.20 Note that this post-conflict baseline may be rather inflated relative to prewar data, owing to the fact that the war generated attenuated negative impacts on human health, ranging from immunosuppression and secondary infection to mental illness.21
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