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6natural history September 2017
At the end of May 1918, the Spanish government
was one of the rst to admit that a new disease
had emerged in their country. The newswire
from Reuters reported that King Alfonso XIII,
the prime minister, and other ofcials were all
sick with inuenza. This outbreak was later referred to as
“the rst wave” or “spring/summer wave” of the 1918–
1920 Spanish u pandemic. As a neutral country during
World War I, Spain lacked the incentive to censor the news
the way combatants did. Although it was recognized early
on that the disease did not originate in Spain, the name
nevertheless stuck.
The contemporary mass media as well as subsequent
academic and popular historical accounts emphasized that
not even royals, world political leaders, or members of the
economic or cultural elites escaped. King Alfonso XIII of
Spain was stricken and recovered, but Prince Erik of Swe-
den died at the age of twenty-nine on September 20, 1918,
during the start of the second wave of the pandemic. The
famous Norwegian painter Edvard Munch, who was fty-
ve, became severely ill and barely survived. The literature
published up to the end of the twentieth century perpetu-
ated this “socially neutral” view, claiming that the inu-
enza virus infected and killed all classes equally because
the disease was so highly transmissible.
Scientic studies published after 2000, however, started
to question the idea that the pandemic engulfed its victims
so randomly. For instance, Prince Erik of Sweden, de-
spite having access to high-quality nutrition and the best
available medical care, was demonstrably vulnerable for
two reasons. First, his health appears to have been quite
poor. He suffered from epilepsy and a mild mental dis-
ability, possibly as a result of strong medication taken by
his mother while pregnant. Such neurological disorders
are risk factors for severe outcomes from inuenza. Sec-
ond, the prince, born on April 20, 1889, was only seven to
ten months old when Sweden was hit by the Russian u
pandemic in the winter of 1889–1890. That pandemic has
since been attributed to an inuenza virus known as H3Nx.
(Back then, it should be noted, inuenza was attributed to
a bacillus; it was not shown to be caused by a virus until
the 1930s.) It has been hypothesized that young adults had
an increased risk of dying from the Spanish u (a strain of
H1N1 virus) if they had been infected by the Russian u in
utero or as infants. We don’t know, but Prince Erik may
well have fallen into that category.
It is not necessary, however, to examine each individu-
al’s health history to understand why some people and not
others died of the Spanish u. Statistical studies since 2000
have documented higher mortality rates for the poor, in
comparison with the more prosperous. Relative afuence
and poverty can be measured in various ways—between
countries, as dened by gross national product and per
capita income, or by looking at the quality of people’s resi-
dential districts, degree of homeownership or apartment
size, literacy, occupational class, unemployment rates, and
similar indices. We need more research to disentangle the
biological and social mechanisms that drove inequalities
in mortality. But a person’s overall risk was increased by
such socioeconomic factors as poor nutrition, overcrowd-
ing, living conditions (such as poor heating) conducive to
secondary infection with bacterial pneumonia, pre-exist-
ing infection with other diseases, and low access to health
care—or inadequate understanding of health information
because of low literacy.
For example, in Norway’s capital city of Kristiania (re-
named Oslo in 1924), mortality was 19 percent lower in the
middle class and 25 percent lower in the upper class com-
pared with the working class; it was up to 45 percent lower
among those residing in the largest apartments versus the
smallest, and 50 percent lower in the richest parish versus
the poorest. A good documentation of the direct impact of
prior illness comes from a Swiss tuberculosis sanatorium
in 1919. There, 64 of 103 patients (62.1 percent) and 24 of
33 employees (72.7 percent) contracted inuenza. Among
the infected tuberculosis patients, 7 died and 57 survived;
in other words, 12.3 percent of the cases among those with
a pre-existing disease were fatal. Among the infected em-
ployees, however, none of the cases were fatal.
In times when inuenza was a less familiar disease, popu-
lation groups that lived in more isolated areas or seldom
mixed with the wider society may have been more vul-
nerable than those living in more connected urban areas.
That is because they had little or no exposure to seasonal
inuenza before 1918. Such exposure would have acted in
two ways to strengthen such communities. In part, it would
have culled some of the weaker members of the commu-
nity ahead of time. Beyond that, people who had multiple
exposure to various u strains (including H1-like viruses)
in the past, especially before the Russian u pandemic
of 1889–1890, would have acquired increased immunity
Profiling a Pandemic
Who were the victims of the Spanish flu?
By Svenn-erik MaMelund
06-08, 10 NH Mamelund 917.indd 6 8/1/17 6:32 PM
7
September 2017 natural history
against the 1918 u. If a large proportion of a community is
essentially immune to an infection, this also reduces trans-
mission to those with little or no immunity. That protective
effect is known as “herd immunity.”
For example, in urban areas and nations with good com-
munication networks, fewer than one in a hundred inhabit-
ants died. Mortality was three to eight times higher among
indigenous people than among white majority populations
The NaTioNal MuseuM of arT, archiTecTure aNd desigN, oslo
Self-portrait with the Spanish Flu by Edvard Munch,
oil on canvas, 59 × 51.5 inches, 1919
06-08, 10 NH Mamelund 917.indd 7 8/1/17 6:32 PM
8natural history September 2017
in the United States, Canada, Pacic Islands, Australia,
New Zealand, and Scandinavia. In extremely isolated ar-
eas in Alaska and Labrador, nine out of ten inhabitants
died. The global death toll, estimated to have been between
50 million and 100 million, represented a mortality rate
of between 2.8 and 5.7 percent of the world population.
However, during the disastrous second wave of inuenza,
loss of life was so overwhelming in some isolated areas that
the demand for burial services, grave digging, and cofns
could not be met. Many of the victims were buried without
cofns and in mass graves. This was the case in Brevig Mis-
sion, Alaska, where 90 percent of the Iñupiat inhabitants
died—including all the adults. Only a handful of children
aged ve to fourteen years survived. In the Moravian Inuit
mission of Okak, Labrador, 80 percent died; afterward the
settlement was abandoned.
In addition to poor immunity against inuenza, a high con-
current disease load from other pathogens (such as tubercu-
losis), crowding, and low genetic variability may also have
played a role in the extremely high mortality of the isolated
indigenous groups. And reports from Alaska and Labrador
indicate that sick individuals, who might otherwise have
survived, froze or starved to death because there was nobody
around to stoke the re, prepare food, and fetch water.
While mortality could reach 80 to 90 percent among cer-
tain communities of Iñupiat on Seward Peninsula in Alaska
and Inuits living at Moravian Missions in northern Lab-
rador, similar groups in nearby or distant inland villages
could be unaffected by the pandemic. Up to 20 percent of
settlements in Alaska and Labrador had no reports of ill-
ness or death. Why this was so remains a mystery. The nor-
mal seasonal freezing of navigable rivers combined with the
high morbidity and mortality may have effectively stalled
all travel and thus the spread of the disease from the coast
to the inland. Strict quarantine imposed in several inland
areas of Alaska (but not in Labrador) may also have had an
effect. So while experiencing the world’s highest recorded
mortality rate from the pandemic, Alaska and Labrador
also provided refuges where people escaped the disease.
Many Spanish u survivors of different ages displayed
a variety of psychiatric symptoms, such as insomnia,
that made it hard for them to cope with work and
everyday life for months or even years afterward. Some
fell into a temporary or long-term coma and were assigned
a psychiatric diagnosis of encephalitis lethargica. This
disease, often called “sleeping sickness,” was widespread
in the period 1918–1928 and caused more than 500,000
deaths globally. How or whether infection by the Span-
ish u precipitated or shaped this disease remains a mat-
ter of debate. Many patients who initially recovered from
the sleeping sickness subsequently developed a profound,
chronic Parkinsonism that prevented them from moving
on their own. In his 1973 book Awakenings, Oliver Sacks
described his partial success, decades later, in reviving
some of the latter patients with the drug L-DOPA.
The emotional stresses during historical inuenza epi-
demics are impossible to measure in statistical terms, but
the suffering of bereavement from the sudden loss of loved
ones cannot be ignored. The mortality toll of the 1918–
1920 pandemic was not only high but also involved an
unusually large proportion of victims between twenty and
forty years of age. One consequence was a markedly high
number of young widows and widowers and the orphaning
of small children.
A signicant rise in suicides was reported from several
countries across the globe. In the U.S., an increase of one
unit in excess u mortality (one more death per year per
1,000 population) increased the rate of suicide by 10 percent.
That statistic takes into account the possible confounding
At Kanakuk Hospital in Dillingham, Alaska, Dr. Linus French surveys Iñupiat children orphaned by the Spanish flu in 1919.
Although many communities in the region were devastated, some were bypassed by the pandemic.
The NaTioNal MuseuM of arT, archiTecTure aNd desigN, oslo
06-08, 10 NH Mamelund 917.indd 8 8/1/17 6:38 PM
10 natural history September 2017
role on the suicide rate of World War
I casualties (which proved not to be
signicant) and the decline in alcohol
consumption between 1910 and 1920
(which acted to lower the incidence of
suicide). Many suicides can be related
to mental disturbances resulting from
the fear of contracting the disease (a
stricken person could be dead in three
days) or stress of infection with the u
itself. However, the unbearable loss of
a spouse, children, or close relatives
also contributed, as did a fall in social
integration due to school closures, cur-
tailment of public events, and so on.
Economic stress was also high. In
that era, very few countries had pub-
lic social security schemes or widows’
pensions. Young widows with many
children to care for were especially vulnerable nancially.
In Sweden the pandemic led to a signicant rise in poor-
house rates in the 1920s. South Africa’s introduction, in
1921, of pensions for the white minority to support widows
and their children was likely in response to the Spanish
inuenza.
There was a fertility bust in 1919, followed by a fertility
boom in 1920, well documented for the U.S. along with
several European and Asian countries. It has been de-
bated whether the bust was driven by biological factors, in
the form of fetal deaths, or by social factors. Recent studies
of that era for Japan and Taiwan (then under Japanese co-
lonial rule) show that a fertility bust there followed the 1918
pandemic peak with a lag of nine months. That indicates a
decline in conceptions in 1918 that can largely be attributed
to social causes, both bereavement and people abstaining
from sex due to fear of infection or illness. To a lesser de-
gree, the studies also point to a rise in early miscarriages.
The 1920 baby boom was due to a catch-up of postponed
conceptions in addition to re-marriages and replacement
of dead children. That baby boom has received less atten-
tion than the one that followed World War II, and was for
a long time thought to be similar, a simple resumption of
the marriages and births that the war had prevented. Yet
the 1920 baby boom occurred with similar
intensity in neutral countries, where the
pandemic was the main factor.
A woman infected with inuenza was
at higher risk of death when pregnant, or
of having a miscarriage. She was also at a
higher risk of giving birth to a child with
congenital deformations or mental impair-
ment. In the U.S., individuals who were in
utero during the peak months of the pan-
demic, in the autumn of 1918, gener-
ally fared less well as adults compared
with those who were in utero some
months before and after the height
of the pandemic. They experienced
signicantly lower education and in-
come, with a greater high school drop-
out rate and more unemployment.
They were the recipients of more wel-
fare and physical disability payments,
and were more likely to suffer and die
from a variety of diseases.
The Spanish u was unusual in tar-
geting so many young parents and prime members of the
working population. The poor, isolated indigenous groups,
and pregnant women were other victims. In international
and national pandemic preparedness plans, most of these
are identied as “at-risk groups” that should be rst in line
for pandemic vaccines. But not the poor: although reducing
social inequality in health is central to all international pub-
lic health work today, it does not gure in any international
or national contingency plans against pandemic inuenza.
This is striking, since mortality from pandemic inuenza
seems to hit the socioeconomically disadvantaged the hard-
est. This was true not only in 1918 but also in 2009, when we
had a second, though milder, H1N1 pandemic.
Three of the United Nations’ seventeen Sustainable De-
velopment Goals for 2030 are to eradicate poverty, reduce
social inequality, and ensure good health and well-being for
all. Part of that effort should be giving priority for scarce
pandemic vaccines to low-income countries and socio-
economically disadvantaged groups within all countries.
Currently in line are categories dened from a biomedical
perspective—high-risk age groups, the previously sick, the
pregnant, and indigenous groups. In the case of a pandemic,
taking account of poverty as well will save more lives and re-
duce the total social and nancial costs. It will also stem the
perpetuation of health inequalities and the cycle of poverty.
Svenn-Erik Mamelund, who holds a doctorate in demogra-
phy, is a research professor in the Center for Welfare and
Labor Research, Work Research Institute, at the Oslo and
Akershus University College of Applied Sciences. He has
more than twenty years’ experience studying the demogra-
phy of epidemic diseases, with a particular focus on the 1918
inuenza pandemic. At the Work Research Institute, Mame-
lund has also studied health consequences of workplace re-
organization and conicts and tracked the effects of various
policies implemented by Norway’s Ministry of Labor.
Designed and carved by Tene Waitere, a
cenotaph was erected in New Zealand at
the Te K¯oura marae, or meeting place, in
memory of Maori who died in the 1918
pandemic.
New ZealaNd MiNistry for Culture aNd Heritage /albert PerCy godber
06-08, 10 NH Mamelund 917.indd 10 8/1/17 6:33 PM
