How did the different epidemiological histories of Europe and North America affect the morbidity and mortality rates of the Great Influenza Epidemic of 1918


The Great Influenza Epidemic (GIE) of 1918 occurred at the end of World War One and had a massive effect on populations and health care policies around the world. It is difficult to separate the mortality rate of the disease and the war, but it is abundantly clear that both exacerbated each other and increased the amount killed. Part of the reason that the disease had such a massive effect on the world was the way in which the infected body reacted to the virus. The strain of influenza that cause the GIE is thought to cause a “cytokine storm” in the body, an extreme immune response that can cause more harm than help. It is not impossible that a new flu strain could mutate in the same way, making it important to study how and why this flu had such a devastating effect on the world. In order to study that, a comparison of the epidemiological histories of America and Europe and the rates of infection and death from the GIE is essential. It would give a new insight into whether the spread of disease was related to an environmental factor, or was indiscriminate in how it spread from person to person.The histories of disease showed what types of diseases populations were less vulnerable too, and whether they could have possibly built a resistance to the GIE based on their resistance to diseases they had previously encountered. Looking at the American and European histories of disease helped to determine that the virus was, in fact, indiscriminate in how it spread. Despite being contrary to initial hypothesis’ about the Great Influenza Epidemic, this information is still valuable to the investigation as a first step in solving why and how this disease became a pandemic.


“Influenza”, otherwise known as the flu, is a common disease that strikes every year from November to March, in a period of time often called “flu season”. Despite the fact that this disease strikes yearly and is thus very familiar to doctors and creators of vaccines, it appears in different strains, or mutated forms, that have mutated and adapted over time to new environmental factors or human preventions.

There are several different types of vaccines, but at their essence, they work by injecting the body with a type virus, alive or dead, and allowing the body time to create T-lymphocytes or cells that will remember how to combat a certain disease. Having these T-lymphocytes allows the body to create B-cells or cells that create antibodies to defend against viruses, much quicker than if it was encountering a virus for the first time. This quick response allows the body to combat the virus much more effectively, making the virus not as devastating as if the body was experiencing this “invasion” for the first time (Vaccines: How They Work)

Of the many types of viruses out there, the flu virus works in a unique way, by mutating itself regularly, in ways that the body cannot always recognize.This renders previous vaccines useless against this new flu because the body has no T-lymphocytes that remember this particular type of flu. This means that new vaccines have to be created yearly for each new strain, which is a danger to at-risk populations and places a burden on the developers of vaccines. It is also important to note that the flu may not always mutate the way researchers were expecting, making that vaccine useless against the present strain of influenza. In order to prevent potentially fatal outbreaks of the flu, researchers have to be knowledgeable about the ways in which the flu may mutate. This is why the study of past mutations of the flu is so important, as they give researchers a basis for new ways in which the flu can possibly mutate.

A strain of H1N1, a type of influenza, manifested itself in 1918 and caused one of the worst pandemics the world has ever seen. The spread and widespread effect of this strain were directly affected by World War One, which had high levels of diffusion between different countries and continents. This spread of people allowed the disease to spread as well, resulting in the pandemic we know today as the Great Influenza Epidemic of 1918. The Great Influenza Epidemic, otherwise known as the “Spanish Flu”, took an estimated 20 to 50 million lives. These statistics make the Great Influenza Epidemic one of the worst epidemics ever recorded, falling only to The Black Plague and the more recent 1990s outbreak of HIV/AIDS.

Because of the global effect of the epidemic, it left a lasting mark on the world as a whole and is important to study for the future of disease prevention. The results of studying the disease could be used to help predict how future diseases could potentially mutate and spread throughout populations. It is important to me personally, because the topic of epidemiology, the study of how diseases spread and how they affect populations, fascinates me. Diseases have been around since the dawn of time, and humans have been studying it for nearly that long. Joining that legacy will allow me to gain a better understanding of the past and future of human diseases.The history of diseases in populations can have a major effect on the new diseases that spread and form in a population. This topic can be applied to the topic of the flu because the flu spreads and mutates every year, making it an important disease of study for epidemiologists because of the widespread effect on the world. This essay will focus on the different infection and death rates of the Great Influenza Epidemic in America and Europe, and how they could have been affected by the history of major disease outbreaks in those regions.


The Great Influenza was a flu pandemic that spread across the world in 1918. Commonly known as the “Spanish Flu”, this strain of flu was a form of the H1N1 virus, a common type of flu that we still see today. The flu comes with symptoms like “chills, fever, and fatigue, [although victims] usually recover after several days.” ( These symptoms come as a result of the body’s fight against foreign invaders which are attempting to use its cells to create more viruses. The process begins when a virus enters the body through some kind of an orifice, like the nose or the mouth, after being passed through the respiratory droplets of an infected victim’s coughs or sneezes. The virus then goes on to invade the cells of the host body and starting the process we know as infection.

Once the virus has entered the cells of the host body, it injects its own RNA, type of nucleic acid which carries genetic code, into the nuclei of the host body’s cells. The genetic code, which holds the basic instruction of how and when an organism should develop, works in the cell by forcing the DNA of the original cell to stop producing the proteins it needs for its own development, and to start using the virus’ RNA. The host cell then begins to replicate copies of the original virus until the pressure within the cell compromises the cell membrane, and cell lysis or the bursting of the cell membrane occurs. The viruses that the cell produced are then released into the host body, free to infect new cells with their RNA and repeat the virus reproduction cycle all over again.

The body, however, does not take this invasion lying down. Fevers are caused by the body raising its own temperature in order to make itself an inhospitable host for the virus. Thicker mucus is caused by an influx of white blood cells (parts of the blood that are meant to fight off infection) to the nose and throat. The symptoms typically exhibited by an infected host are not because of the virus, but because of the body’s response and attempt to fight off a foreign agent that has entered the body.

The body’s response to infection is believed to be the reason that the Great Influenza Epidemic of 1918 was so deadly. It is thought, based on experiments with samples of the disease, to have elicited an extreme and severe immune response in the body called a cytokine storm. These “storms” as they are called, are caused by the immune response that goes unregulated and is not able to stop itself, causing a victim to succumb to the response of their own body. In the case of this strain of influenza, the virus rapidly multiplies in the body, causing the body to react acutely, creating symptoms like inflammation, or the lungs filling up with fluid and white blood cells. An afflicted patient could possibly die of suffocation if the inflammation and fluid buildup go untreated. Younger, better developed immune systems are more susceptible to cytokine storms because their immune systems work faster and harder, making their cytokine storms more intense. This is thought to be one of the main reasons why more young and healthy people died of the flu when typically, “[the] conventional flu usually claims mostly the very young and very old.” (NBCNews). The very young have yet to build up a strong immune system that can fight away harmful viruses like influenza, and the very old do not have a strong immune system anymore that can put up a fight against influenza, neither strong enough to produce a cytokine storm.

The Great Influenza was able to gain contact with more young people due to the state of the world at the time of the pandemic. The last year of World War One was 1918, the same year as the outbreak of this disease. Young men and women, as soldiers and nurses, were in constant movement between America and Europe to “serve at the frontline[s].” (American Experience) [American Nurses in World War 1] This wartime movement of people caused the disease to spread at an increased rate, as shown by the first wave of influenza coming from a military camp in America, which eventually spread to Europe when the soldiers shipped out. The soldiers who were moving back and forth were none other than those who were most susceptible to complications from the flu: the young and healthy. The Great Influenza hit hard and fast, all across the world, including America and Europe where the epidemiological histories of each area could have had an effect on the virus’s morbidity and mortality rate.


An epidemic is classified as a number of cases of a disease in an area that is higher than the expected amount for that time period. The United States of America, while being much younger than many countries in Europe, has a lengthy history of epidemics and disease outbreaks, due to its history of immigration and colonization. These disease outbreaks can be studied in regards to how they affected the population of America and then applied to if they would have affected the infection rate of the Great Influenza Epidemic of 1918.

In 1793, there was an outbreak of yellow fever in Philadelphia, which eventually reached epidemic proportions. When a group of immigrants arrived from the Caribbean, they brought with them pestilence that caused the city to slowly erupt into chaos as more and more people fell ill with the yellow fever. The virus itself is “mosquito-borne…fever.” (Yellow Fever- prevention in travelers) spreading where mosquitos bite and feed on an infected person and then spread it to another person by biting them. Yellow fever comes with typical flu symptoms like fever, body aches, and nausea, and then once a victim goes into the toxic phase, they experience symptoms like jaundice, seizures, or bleeding from various orifices in the face such as the eyes, nose, or mouth. The virus killed over 3,000 people despite efforts by volunteers, specifically the black community in Philadelphia. The most widespread treatment at the time, popularized by Dr. Benjamin Rush, was bloodletting, in an effort to rid the body of toxins in the blood. Many people were treated this way by Rush and other doctors who believed in its healing properties. It was not until nearly 100 years later that bloodletting fell out of practice when people realized that it was germs and not toxins in the blood that were causing people to be sick.

Cholera was another epidemic that occurred in America. Cholera is an intestinal infection that is caused by the bacteria Vibrio cholera, which is found in infected drinking water or food products. Its main symptom is severe diarrhea, which can cause dehydration and even death. This particular outbreak took place in New York, where people lived crowded on top of one another in unsanitary conditions. Cholera exits the body through fecal matter; so when the infected fecal matter is not disposed of properly, it can get close enough to contimunate a water or food source. People injest these contaminated substances and are then infected with the cholera bacterium. Once the outbreak was established, the proper health officials were able to determine that the water had gotten contaminated, and there was a concentrated effort to decontaminate the water and to prevent another cholera outbreak by making concentrated efforts to prevent contamination of food and water sources.

Another epidemic that occurred in America before the 1918 Influenza Epidemic was the outbreak of Scarlet Fever that occurred in waves over the course of the 19th century. It develops from Streptococcus pyogenes, which is the bacteria that causes strep throat. In addition to a sore throat, swollen lymph nodes, and fever that come with regular strep throat, scarlet fever also has other symptoms like a red or “scarlet” rash that makes the skin rough and scaly. Scarlet fever infected and killed those below ten years of age during the height of its spread, due to that age groups susceptibility. It was spread through a healthy person coming into contact with infected respiratory droplets. The end of the outbreak of this bacteria is still mysterious to scientists, due to the fact that it was only later that it was discovered that scarlet fever could be treated with antibiotics.

The final epidemic that occurred in America before the Great Influenza was the outbreak of typhoid fever in New York in the early 20th century. Typhoid is caused by the Salmonella typhi bacteria and spreads by an infected person infecting food or water with the bacteria, and others ingesting the infected water or food. It starts out similar to other fevers or cases of flu, with a fever and body aches, but as the bacteria develops further, diarrhea and a rash can occur. The term “Typhoid Mary” came into being around this time when it was found that a woman by the name of Mary Mallon was an asymptomatic carrier of typhoid and had passed it to at least 7 households. Her unhygienic practices as a cook led to at least one death and the spread of typhoid to many others. These cases and others in the United States were able to be treated with antibiotics, which have since been developed to come with fewer side effects and to be more effective.

These American epidemics all took place before the Great Influenza Epidemic of 1918, but in studying them, it has become clear they are not similar enough for the population to have built up any kind of innate resistance to this influenza based on their exposure to these other diseases. Besides the human prevention attempts, like the new cleanliness standards put into place because of the effect of cholera, and the creation of vaccines in an attempt to eradicate the flu, humans were not at all prepared for a flu such as the strain that presented itself in 1918. The American populace, already weak from the most devastating war in its memory, was not prepared for a flu that hit its youth hardest. Out of a total population of 103.2 million people, “if the whole nation as a whole suffered an equal proportion of flu cases, then… 25 million+ had [the] flu in 1918-1919.” (Epidemic and Peace, 1918) This makes the morbidity rate of this strain of influenza 24%, nearly a quarter of the population.


The history of Europe is marked by many more epidemics than America, due to its longer past. This history is immortalized in writings, as well as works of art, and is thus much more well known than the diseases past in America. The different diseases in that history may determine if there was ever a disease that could have prepared the European population for a disease like the Great Influenza.

The Black Death, or the bubonic plague, occurred during the Dark Ages in Europe. It was not the first instance of this disease, however, it was the first epidemic of this scale to pass through Europe. The disease was passed from the bites of infected rats and fleas, which were prevalent due to the lack of a cleanliness standard in medieval Europe. The Yersinia pestis bacteria that causes the plague was rarely communicable from person to person, and the high infection rate of this time was simply due to the lack of hygiene common at this time. The people who became ill with the disease experienced flu-like symptoms, swollen lymph nodes, and often black spots on the skin. No cure was found at this time, but new standards for cleanliness were put into place when it was realized that unhygienic living was the major cause of the spread of the disease. Quarantining was another tactic to prevent the spread of disease, and stayed relevant even into World War 1, to prevent “returning troops [from carrying] disease home.”(The Great Influenza)

Smallpox is the second of the major epidemics in Europe. Smallpox is caused by the variola virus, and results in flu-like symptoms, along with sores in the nose and mouth and red blisters on the skin that fill with pus. These blisters scab before forming severe scars, the cause for the name of the virus. It is a very communicable disease and spreads from direct contact with the infected, as well as through indirect contact with things the infected may have touched. Variolation, a way to treat smallpox, did not become popular until the early 1800s when an English doctor realized that injecting pus from a person infected with cowpox- a disease very similar to smallpox- into a person who had never been exposed gave them effective immunity from smallpox. This was the first successfully recorded vaccine in the world.

Typhoid fever was another epidemic in Europe, which was also struck America. It was rampant throughout the 19th century, and it was not until an English doctor realized that it was being transmitted through the fecal matter of the infected, that efforts were taken to prevent contamination of drinking water and foods. The late 1800s then saw the creation of a typhoid vaccine and the decline of typhoid fever across Europe and the world.

Tuberculosis was the next major epidemic in Europe, caused by the Mycobacterium tuberculosis bacteria. It affects the lungs, for the most part, and causes symptoms like coughing up blood, fever, chills and weight loss. Tuberculosis was often called “consumption” due to the way it seemed to consume its victims. Tuberculosis, as a respiratory virus, was spread through the healthy coming into contact with respiratory droplets from the infected’s coughs or sneezes. This disease inspired caution of avoiding spreading infected respiratory droplets and began the trend of covering their mouths when they coughed.

Cholera was another epidemic in Europe, which spread due to the growth of cities and the lack of sanitation systems. It was also an epidemic in America, but it was in Europe where John Snow, the father of modern epidemiology, traced the source of the cholera epidemic in London and helped to figure out the cause of the outbreak. It turned out to be a contaminated well, where the water became infected because of the fecal matter located very close to it. This finding helped Europeans to realize that they needed to separate their drinking water from their excrement.

Diphtheria was another epidemic to hit Europe before the 1918 influenza. It is characterized by a sore throat, swollen glands, and fever, all started due to a bacteria called Corynebacterium diphtheria, which affects the mucous membrane of the nose and throat. Today, it is stopped with a vaccination, but at the height of its transmission throughout Europe, diphtheria was a highly communicable disease that spread to many people through respiratory droplets from coughing and sneezing.

Measles was the final epidemic that took place in Europe before the 1918 influenza epidemic. Measles is another disease that today is prevented with a vaccination. It is caused by the rubeola virus and its symptoms can include a fever, sore throat, rash, and spots inside the mouth. While the vaccine was not yet invented by the time of the 1918 influenza, efforts to start recording the effects of measles had long been in place. Measles had a great effect on European populations, and an even harsher one on Pacific Islanders and Native Americans, neither of whom had been exposed to a disease like it until the Europeans arrived. European scientists researched islands where there had only been an outbreak of measles a few times and discovered that people who had had measles once in the past did not contract the disease again. This finding helped lay the foundation for the measles vaccine that would come in the future.

None of these epidemics, from the plague to measles, were similar enough to the flu to cause a resistance to it in the European population. Measles was the only other virus to become an epidemic in Europe, and despite the similar symptoms of several of the diseases, they were not of a similar structure to cause a biological change in the population that would affect the flu. These diseases did not influence “the estimated total mortality in Europe [of] 2.64 million deaths…1.1% of the entire population estimated at 250 million [in] 1918.” (Mortality Burden of the 1918–1919 Influenza Pandemic in Europe) The only real influence that these diseases had on the spread of influenza was the health practices that stemmed from them. The advancements in medicine helped for epidemiologists to better understand the flu, and to help advance medicine, so that “…there are fewer infectious disease outbreaks,” (The Most Dangerous Epidemics in U.S. History) however no disease itself made an impact of the spread of flu.


Contrary to initial beliefs, the history of disease outbreaks in European and American populations did not affect the mortality of the Great Influenza of 1918. Any biological effects on the populations of Europe and America were not able to make the human body resistant to the flu. The health practices resultant of those diseases did have an effect on how the flu spread but had no real bearing on what happened to an infected person once they had already gotten the disease.

This conclusion is also supported by the fact that the rates of infection and death as a result of the influenza were not different in Europe and in America. This can be calculated by looking at the population of those who were infected, those who died, and simply the total population, and then creating a proportion in Europe and in America. The total population of Europe was 205 million people, and of those, 69 million were infected. Of those that were infected, 4.7 million died. Using these numbers, we can say that in Europe the morbidity rate, or the number of infected over the total population, was around 34% and that the mortality rate, or the number of those who died over the number of infected, was around 7%. In America, the total population was 103.2 million, and of those 29 million were infected, and 2 million died. It can now be calculated that the morbidity rate of America was 28% and the mortality rate was 7%.These numbers are not statistically significant, in some cases even the same, which illustrates the conclusion that the different histories of disease could not really play a part in the toll the disease took.

The limitations of the research conducted here must also be considered when coming to conclusion. Both areas have epidemiological histories that include many of the same diseases, likely as a result of the constant trade and contact between Europe and America. This could possibly be a reason for the lack of a difference in the morbidity and mortality rates of these areas. Both histories do not have diseases that would give either population a biological edge over the other. They were both just as susceptible to the flu because they had never experienced a disease that most affected the immune systems of the young and healthy, especially when the young and healthy were the people who normally escaped the damages of the flu. In future investigations, it could be researched specific places that were hit the hardest by the flu and what made those locations different from others so that they provided the most opportune breeding ground for influenza.

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