Sept. 20, 2021 -- COVID-19 has now killed at least 675,000 Americans, a death toll that has now surpassed that of the 1918 influenza pandemic, according to data collected by Johns Hopkins University.

Though the raw numbers match, experts point out that 675,000 deaths in 1918 was a much greater proportion of the population. In 1918, the U.S. population was 105 million, less than a third of the 333 million people in America today.

In terms of mortality rate, then, the 1918 flu was probably deadlier, said Graham Mooney, PhD, an associate professor of the History of Medicine at the Johns Hopkins School of Medicine in Baltimore.   

The demographics of those deaths are different, too.  While the very young and very old were impacted by the 1918 flu, it was mainly people between the ages of 20 and 40 who were the hardest hit by that highly virulent strain.

“We still don't totally understand why. Although there are a number of theories, but was that unlike the typical influenza which affected the elderly,” says Jennifer Gunn, PhD, an associate professor and medical historian at the University of Minnesota School of Medicine in Minneapolis.

Still, Mooney says that shouldn’t be a reason to dismiss today’s tragic milestone.

“It’s a big number. It’s not an insignificant number, whichever way you want to cut it.  It’s 675,000 deaths that we otherwise wouldn’t have had from a disease that wasn’t in our midst 18 months ago,” Mooney says.

Though the 1918 epidemic is often called the "Spanish Flu," there is no universal consensus regarding where the virus originated, according to the CDC.

The AIDS pandemic of the 1980s remains the deadliest of the 20th Century, claiming the lives of 700,000 Americans.

Still, the almost incomprehensible loss harkens back to a time when medicine and technology were far less advanced than they are today.

In 1918, the U.S. didn’t have access to a vaccine, or near real time tools to trace the spread and communicate the threat. And they didn't have a test to detect the virus.

“Virology was a young science,” says Gunn. “We didn’t have the ability to identify the virus. That didn’t happen for decades afterward,” she says.

Influenza was diagnosed based on signs and symptoms.  There was no national, uniform system for recording births and deaths, so the 675,000 tally was reconstructed by calculating excess deaths—subtracting the expected number of deaths from influenza and pneumonia over those years from the total number of deaths.

There were other important differences, too.  The 1918 flu killed quickly.

“It seemed to have a pretty rapid trajectory to, you know, to death over several days,” Gunn says.  Typically, COVID turns dire over a span of weeks.

And doctors didn’t have as much to offer patients in the way of supportive care.

“We didn't have the some of the treatments that we have today, like mechanical ventilators,” Gunn says. There was a type of negative pressure ventilator, but Gunn says “it was not anything you would expect to find routinely in a hospital,” she says.

In some ways, reaching 675,000 deaths today means we’ve squandered some of the advances of our age.

“I've actually been pretty appalled,” says Gunn.

At a time in history when we have the ability to coordinate a rapid, national response, Gunn says public policies have siloed states, letting the pandemic fester and resurge.  When we most needed a strong public health system, it faced disinvestment.

Gunn says a uniform, coordinated response is something we should have done much better.

There are many similarities between the two pandemics. In spring 1918, when the first wave of the Spanish flu hit, the U.S. and its allies were nearing victory in Europe in World War I. Just this summer the U.S. has ended its longest war, the conflict in Afghanistan as COVID cases surge.

In both pandemics, hospitals and funeral homes were overrun and make-shift clinics were opened where space was available. Mask mandates were installed, schools, churches and theaters closed, and social distancing was encouraged.

As is the case today, different jurisdictions took different steps to fight the pandemic and some were more successful than others.

According to, in 1918, Philadelphia’s mayor said a popular annual parade could be held. In less than 2 weeks more than 1,000 local residents were dead. But in St. Louis, public gatherings were banned , schools and theaters closed and death toll there was one-eighth of Philadelphia’s.

Just as in 1918, America has continued to fan the flames of the epidemic by relaxing restrictions too quickly and relying on unproven treatments. Poor communication allowed younger people to feel that they wouldn’t necessarily face the worst consequences of the virus, contributing to a false sense of security in the age group that were fueling the spread.

"A lot of the mistakes that we definitely fell into in 1918, we hoped we wouldn't fall into in 2020," Epidemiologist Stephen Kissler, PhD, of the Harvard TH Chan School of Public Health, told CNN.

"We did."

Medscape Medical News


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