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A lesson from history: the human cost of the 1918 flu pandemic

An exhibition on the devastating Spanish flu of a century ago is a timely reminder of the value of the flu jab today

An exhibition on the devastating Spanish flu of a century ago is a timely reminder of the value of the flu jab today

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An emergency hospital at a former US Army camp in Kansas during the flu pandemic
of 1918. Picture: Courtesy of the US National Museum of Health and Medicine

One of the most striking items in the Florence Nightingale Museum’s exhibition on the 1918 Spanish flu pandemic is a small bottle containing a prototype vaccine.

Produced in 1919 by the Royal Army Medical College using lung scrapings infected with Spanish flu, the vaccine demonstrates the desperate efforts to protect people from the deadly disease. It is also a reminder of how far we have come in the past century.

A rare vial of influenza vaccine created by the Royal Army Medical College in 1919
A vial of flu vaccine made in 1919 
by the Royal Army Medical College.

‘It’s a rare vial of an early attempt at an influenza vaccine,’ explains the London museum’s collections officer Holly Carter-Chappell, who curated the exhibition. ‘It wasn’t very effective. They knew the basis of inoculation but didn’t have the same level of knowledge that we have now.’

Lessons for today

As the UK enters the 2018 flu season, GP practices and other healthcare organisations are getting into the stride of this year’s vaccination programme. By looking back at how things were during the pandemic of 100 years ago, the exhibition prompts visitors to consider what lessons it holds for today.

In particular, public health nursing leaders hope it will encourage people, including nurses, to take up the opportunity to be vaccinated – and to appreciate the important new roles that nurses are playing in tackling flu.

The Spanish flu pandemic took hold towards the end of the first world war, and its spread was exacerbated by the large numbers of troops moving as hostilities ceased. Some half a billion people were infected worldwide and up to 100 million died, including 250,000 in the UK. Unlike in most seasonal flu outbreaks, young and healthy adults were particularly at risk.

‘Many nurses contracted the virus from patients – it was a bigger killer of military nurses than the war’

Holly Carter-Chappell, exhibition curator

Spanish flu: the facts

  • Around one third of the world’s population was infected 
  • Although its exact origins are unknown, it was named Spanish flu because the first newspaper reports of the virus came from Spain, which was neutral in the first world war so its media was not subject to wartime censorship
  • In the UK a quarter of a million people died from Spanish flu. By comparison, 17 million died in India
  • People tried all sorts of remedies, including injecting themselves with strychnine and eating sugar lumps soaked with kerosene
  • Notable survivors of Spanish flu include Mahatma Gandhi, Greta Garbo, Walt Disney and Edvard Munch, the painter best known for The Scream
  • Key political figures of the era, including British prime minister David Lloyd George, US president Woodrow Wilson and German Kaiser Wilhelm II, were also infected and survived

Source: Florence Nightingale Museum

The terrible symptoms included severe nosebleeds, delirium and heliotrope cyanosis, a condition in which a dark blue or purple flush spreads across the patient’s body. 

With no antibiotics available to combat secondary infections such as pneumonia, many patients effectively died from drowning as their lungs filling with fluid.

‘Nursing was key to treating flu 100 years ago, as it is today,’ says Ms Carter-Chappell.

‘In 1919 there were no vaccines, antivirals or antibiotics. All that could be done was to practise good hygiene and keep the patient comfortable, giving them fluid and nutrition. Nursing played a crucial role.

 ‘Of course, many nurses contracted the virus from patients – it was a bigger killer of military nurses than the war.

‘Nurses across the country could see their friends and colleagues going down like nine pins, but they kept going.’

Nursing during the pandemic drew on the work of Florence Nightingale in the Crimean War, she says, work that remains relevant today.

Hygiene and infection control

‘She introduced hygiene and infection control, which was vital to preventing disease. That hasn’t changed.

‘Without Florence Nightingale we wouldn’t have nursing as we know it.’

‘Another pandemic is inevitable. Every time there is a pandemic there are lessons to be learned’

Joanne Bosanquet, Public Health England deputy chief nurse

Public Health England deputy chief nurse Joanne Bosanquet says the exhibition is a timely reminder that flu is still a serious threat.

‘Another pandemic is inevitable,’ she says simply. ‘There was one in the 1960s, a smaller one in 2009. Every time there is a pandemic there are lessons to be learned.’

In many ways we are in a better place than we were 100 years ago, she says. For example, the growth in worldwide travel has been matched by development of worldwide surveillance, including the World Health Organization’s global pandemic plan.

‘We have much more sophisticated surveillance than we had even in 2009,’ says Ms Bosanquet. ‘It enables real-time communication, and social media has been phenomenal in this too.

Public health roles

‘We also have nurses and midwives in public health roles, technical roles, such as nurse epidemiologists. Florence Nightingale was an early health statistician, but now this is a much more normal role for nurses and midwives. It’s been a huge change.’

Improvements in immunology, allowing strains of flu to be tested early on and suitable vaccines to be developed, have been crucial, as has the use of antibiotics and antivirals, Ms Bosanquet says. But she stresses that wider understanding of how the virus spreads has also been hugely important.

‘A hundred years ago they didn’t understand how flu was transmitted and they didn’t understand the need for protection.’ Today, each country in the UK has its pandemic flu plan, and they are tested regularly. ‘We’re as ready as we can be,’ she says.


This lamp was used to produce fumes that could be inhaled. Picture: Thomas Gilder

But she also stresses the importance of protecting against seasonal flu, including taking up the opportunity of vaccination. That goes for nurses too. ‘My view is that as responsible healthcare professionals we should be protecting ourselves and protecting the people we care for,’ she says.

Protecting patients and ourselves

Guy’s and St Thomas’ NHS Foundation Trust deputy head of nursing infection prevention and control Shona Perkins agrees. ‘I’m an infection control nurse so I’m biased – I believe staff should be vaccinated,’ she says.

‘But flu vaccination is not compulsory, so we have to do what we can to persuade people. That includes people having the right education so that we take responsibility for protecting ourselves, and encouraging people to do the right thing.’

Eight out of ten staff at Guy’s and St Thomas’ were vaccinated last year as a result of co-ordinated action led by occupational health teams and backed by enthusiastic peer vaccinators. They hope to do even better this year, Ms Perkins says, with similar efforts taking place in NHS organisations across the country.

‘Flu vaccination is not compulsory, so we have to do what we can to persuade people’

Shona Perkins, deputy head of nursing infection prevention and control at Guy’s and St Thomas’ NHS Foundation Trust

Ms Perkins believes it is vital that people take flu seriously – after all, even with modern healthcare, infection can be fatal. But it is also important to get across the message on how to minimise the impact of the virus.

Her favourite part of the exhibition is a visual ‘aerosol’ effect that demonstrates how flu spreads from person to person via coughing and sneezing. ‘It’s all kinds of gross,’ she says. ‘But it’s a good visual reminder of how we transmit flu.

The human inpact

‘There are really important messages from the exhibition, such as the whole hygiene thing – of using a tissue when we cough or sneeze to “catch it, bin it, and kill it”, and washing our hands.’

Ms Carter-Chappell points to a particularly poignant exhibit. ‘It’s a mourning card for four children from one family in Nottinghamshire who died from flu. Four children – can you imagine what that must have been like? It shows the human impact of a flu pandemic, and that is just as relevant today.’

Spanish Flu: Nursing during history’s deadliest pandemic, runs at the Florence Nightingale Museum in London until 16 June 2019. For visitor information, including admission times and prices, click here

Exhibition goes on tour

Can’t make it to London? Visit a pop-up version of the exhibition, including core and digital content, at:

  • Nottinghamshire libraries and archives: 7 November 2018-January 2019
  • George Marshall Medical Museum, Worcester: January-December 2019
  • Aberdeen City and Aberdeenshire Archives: March-May 2019
  • Derbyshire archives: Summer 2019
  • Liverpool Medical Institution Library: September-October 2019

Jennifer Trueland is a health journalist

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