“It would be impossible to relate all the sad and terrible scenes . . . all night long . . . witnessing death scenes, seeing weeping relatives and trying to take care of emergencies . . . “

A mother’s death remembered.

Litter carriers at Red Cross Emergency Ambulance Station in Washington, D.C., during influenza pandemic of 1918.

When my grandfather was six years old, his mother went to sleep one night and never woke up. She was one of the nearly 700,000 Americans who died during the 1918–1919 influenza pandemic, which killed an estimated 50 million people worldwide. The rest of her young family—my grandfather and his twin brother, their seven-year-old sister, and my great-grandfather—survived. The shock of losing his mother so suddenly was still evident when my grandfather talked about her 70 years later. She was 29 years old and healthy, and then she was gone.

High mortality, even among healthy young adults.

My family was not alone as it mourned. The CDC estimates that one-third of the world’s population was infected by what’s become known as the “Spanish flu.” (The origin of this name is unclear: some sources suggest it’s due to a misunderstanding about where the virus originated; others argue it’s related to wartime censorship, which was not as stringent in Spain, and thus the devastating effects of the flu there were more widely reported.) The flu was particularly deadly to children younger than age five, adults 20–40 years old, and the elderly. High mortality rates among healthy people, especially those in their 20s and 30s—like my great-grandmother—were a hallmark of this pandemic.

In the United States, the Spanish flu spread just as quickly through rural regions of Alaska as it did into dense urban areas. For some who succumbed, death quickly followed the first symptoms; others survived a few days. According to the National Archives, more people died from the 1918–1919 flu than in all of World War I, which claimed the lives of an estimated 16 million people and ended as the pandemic reached its peak.

Why so deadly?

When the first signs of the 1918 pandemic emerged, 100 years ago this spring, modern antibiotics and flu vaccines weren’t available. The two other flu pandemics of 20th century—in 1957 and 1968—weren’t as devastating as the Spanish flu (more than a million people died during each of those outbreaks). It’s believed this was partly due to the use of antibiotics to manage the secondary and often fatal bacterial infections that can arise from the flu. Yet researchers still don’t fully understand why the 1918 flu was so deadly, particularly among those who were young and healthy.

Current readiness.

The potential for a similarly devastating pandemic is especially concerning, given the speed at which any future outbreak can spread in a world that is much more connected than it was a century ago. Pandemic flu vaccines are thus essential to preparedness planning, but their effectiveness will depend both on their availability and on beliefs about flu vaccination.

Unfounded doubts and misinformation about the necessity, effectiveness, and safety of flu vaccination persist, even among health care providers and despite scientific evidence to the contrary, leading to uneven and sometimes low rates of annual vaccination. According to the California Department of Public Health, for instance, the overall flu vaccination rate among health care personnel in the state has been rising steadily for the past seven years—reaching 83% during the 2016–2017 season—but rates at individual hospitals were as low as 37% last year.

Nurses who were there.

Nurses’ accounts of the 1918–1919 flu published in AJN offer a reminder of the conditions health care providers faced then, and a warning about future pandemics. One nurse from New England, who wrote to AJN during the fall of 1918, when the Spanish flu was nearing its worst, described her experiences and those of her military station’s medical officer. A portion of her letter, which depicts a devastating health emergency, was published in an editorial comment, “The Epidemic of Influenza” (free), in the November 1918 issue: Here’s a brief excerpt:

It would be impossible to relate all the sad and terrible scenes . . . all night long he was witnessing death scenes, seeing weeping relatives and trying to take care of emergencies. . . . Nearly all the nurses living [in the nurses’ pavilion] were taken sick. . . . One by one the help succumbed and for two weeks we depended entirely upon sailors for all the work but the actual nursing. One little nurse passed out with meningitis. Another one’s life has been hanging in the balance for a week. Several boys from the school died, two of the doctors and a carpenter, a civil employee who had been on duty at the hospital for a number of years . . .

I find this description particularly poignant, knowing that my kind grandfather, who lost his mother at such a young age, was one of the “weeping relatives” this nurse describes. He and my grandmother raised four daughters, two of whom became nurses. My grandfather was a man of relatively few words, but even as a child I sensed how he valued their work. He saw the sacrifices they made to care for their patients, and he knew all too well the difference they could make during a health crisis.

For more firsthand accounts and reporting on influenza during the past century, see Influenza Classics from the AJN Archives, a collection of articles that “document the scientific thinking of the time on influenza prevention, transmission, and patient care practices.”