Reconsidering COVID-19 and the Spanish Flu: a follow up post

Six months ago, I posted this article in which I pushed back against the media-hype comparing the novel Coronavirus to the Spanish Flu. While I believe parts of my argument still stand, the last few months have been far worse than many people--myself included--feared. In this article, I cover what I got right, what I got wrong, and where we go from here.

Death Rate

In my previous post, I discussed how the death rate of the Spanish Flu appeared to be significantly higher than that of COVID-19. The reality, as it turns out, is a bit more complicated.

The death rate of both viruses does depend heavily on the risk profile of the patient. For the Spanish Flu, the highest risk group was young adults in their 20s. For COVID-19, it is elderly individuals with pre-existing conditions. For both of these groups, the death rate is over 10%. But when you look at the global population, the total death rate for both viruses appears to be closer to 1-2%.

It has remained true since January that COVID-19 does not primarily affect the young, which was a primary driver of the Spanish Flu’s devastation. But children’s role in spreading the disease is still very much an open question, and while few young people seem to get sick with the common viral symptoms, a very rare but terrifying number of Kawasaki disease-like multi-system inflammatory syndrome cases have been observed.

COVID-19 has killed over 600,000 individuals, and cases are still rising in multiple countries. The Spanish Flu killed an estimated 20 to 40 million. Those numbers alone show we are not dealing with the same death rate. But COVID-19 has been devastating, and global failure to prevent more deaths has fueled public outrage. Most importantly, both of these viruses demonstrate that some segments of the population are always more at risk, and it is a public health necessity to anticipate those segments and provide the requisite reinforced support in order to better protect vulnerable populations.


For a brief period of time (which encompassed when I published my last article) the theory that COVID-19 has derived from snakes was gaining popularity. This theory has since fallen out of favor, and most scientists now believe that the coronavirus jumped from bats to humans. This is more consistent with COVID-19’s close relationship to MERS and SARS, which also jumped to humans from bats.

This is still a different species from which the Spanish Flu jumped, which was birds. Birds and bats are both sold at large wild game markets in China, which is believed to be where the virus originated. China has since outlawed the trade and consumption of wild meat, a public health measure that will hopefully decrease the risk of future zoonotic transmission.

Zoonotic viruses continue to be a major public health risk. Regardless of COVID-19’s source, it’s novelty to the human immune system was part of what enabled it to spread so rapidly and have such a devastating effect; just like the Spanish Flu. Acknowledging and working to anticipate the risk of zoonotic infections may be a critical aspect to protecting against future epidemics: an H1N1 virus recently found in pigs, for example, shows high risk of jumping to humans. Scientists should begin designing a vaccine now, and public health officials preparing response plans, should the virus ever enter human populations.


In regards to spread, my previous article was woefully incorrect and embarrassingly optimistic. COVID-19 has since spread around the globe despite unprecedented travel restrictions in the majority of countries. In this sense, the new coronavirus was much more similar to the Spanish Flu than was originally anticipated. This perhaps should not have been a surprise, given the ease of international travel.

This photo is adapted from

My similarly optimistic hope that the early identification of the virus would allow countries to prepare adequately before the inevitable global spread was also misled. No country is a better example of that failure than the U.S. and the abject failure of the government to competently manage the virus.

The good news is that a number of countries, particularly China and Northern Europe, have successfully contained the virus and have begun reopening public spaces and returning to normal. This is evidence that the virus can be managed, even if not eradicated.

Ability to respond

Thankfully, one area in which I was correct has been our ability to respond rapidly with both vaccine and therapeutic development. More than 100 vaccines are in clinical trials, with four in Phase III clinical trials; and therapeutics are not far behind. While a lot remains to be seen on the efficacy of these vaccines, the sheer number suggests that a successful candidate cannot be more than a year or two away. This rapid pace of development was impossible in the early 1900s, when the Spanish Flu simply burned itself out.

This photo is adapted from the New York Times.

Similar to the Spanish Flu, however, is that the most effective prevention mechanisms are social practices. Wearing masks and practicing social distancing, as well as closing public spaces, have been the most successful method of slowing the spread of the virus. Similarly, individuals in 1918 were obligated to wear face coverings, and public spaces were closed. Retroactive studies have demonstrated that these efforts successfully slowed the outbreak of the Flu, just as they have for COVID-19.

Photo adapted from, by way of Fox Photos/Getty Images. This photo also appears in the cover image of this article.

Social Cost

Another area in which I wish I had been more wrong was the social costs of this virus. In my last post, I talked about the psychological fear and emotional scarring that can occur from epidemics. We have unfortunately seen these realities play out in real time. Children who have been ripped away from reliable routines of school and community groups have begun acting out after weeks at home, unable to fully comprehend the changes and tension around them. Healthcare workers and epidemiologists, after months of little sleep and poor social responses to the pandemic, are on the verge of collapse. Similarly to the trauma literature and art that came out of the Spanish Flu, creators are already responding in various mediums to the trauma shared within our communities. 

On top of the emotional burden has been the economic. Unemployment in the U.S. is down to 11% from its peak of 14% in March. Small business owners particularly have struggled to keep doors open in the face of social distancing. Some universities, faced with the threat of a remote semester or year, have blocked students from deferring their admission or taking a leave of absence for fear of losing revenue. Companies that rely on crowded spaces as a model--such as movie theaters and clubs--have little hope of reopening soon, and the long term impact is grim. 

There is optimism that the economy will bounce back quickly once cases stall; after all, unlike 2008, this was recession was not caused by the economy itself failing. But if a second wave occurs, or if the U.S. is unable to slow case growth, the long term economic impact could be devastating.

Future concerns

As I mentioned in my previous post, the most alarming observation of the Spanish Flu is that the second wave was significantly more deadly. If COVID-19 follows a similar pattern, this coming autumn could see a resurgence of the virus. It is unlikely that a vaccine would be readily available that quickly, leaving a heavy question as to what the realities of a deadlier strain could look like.

Perhaps even more sobering has been COVID-19’s painful demonstration of how poorly we have learned from history. The global lack of preparedness for a pandemic--despite epidemiological scholars warning for years about the inevitable--has never been more apparent. The coronavirus has brought the world to its knees, but it will not be the last epidemic in the history of mankind. Will we learn this time?

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Sonja K. Eliason

July 20, 2020