“The first wave hits the poor, the second wave hits the rich”: Lessons from the 1918 pandemic

Black and white interior photograph of workers inside a factory. Men and women are shown, with the women lined up on the right hand side of a long piece of equipment with sloping sides and circular holes in it, perhaps containing sinks, with a man looking over a low wall on the left side of the space. The interior is brick, and there is a mezzanine at the back of the space. There are various pipes, buckets, wooden barrels and crates in the space, with glass plate racking on the right hand side.
Workers waiting to use the ‘inhalatorium’ at the Kodak Australasia Pty Ltd factory in Abbotsford, 1919. The inhalatorium was thought to protect workers from being infected with the influenza during the 1919 Spanish flu epidemic. A zinc sulphate solution was steamed onto the worker’s faces to ‘disinfect’ the workers’ throats and air passages. Staff were given this treatment twice a day for four minutes at a time.
Source: Museums Victoria
Photographer: Unknown
Credit: Courtesy of Kodak Australasia Pty. Ltd.
Terms of use: Public Domain

The poor came down with influenza first and were overall most affected, while the rich with less exposure in the first wave tended to have higher morbidity in the second wave. This finding is concurrent with prior studies documenting that the poor had the highest 1918 pandemic mortality. Although this study could not tease out the mechanisms for the SES crossover in morbidity, results suggest that preparedness plans should consider how (non‐)pharmaceutical interventions can hinder socioeconomic morbidity disparities in future pandemics. Surprisingly however, social inequalities in pandemic outcomes do not form part of the discussion in international preparedness plans for pandemic influenza. This is not conducive to achieving the international goals of eradicating poverty, reducing social inequalities and ensuring good health for all by 2030.


My knowledge about the 1918-1919 influenza pandemic is woeful. I was prompted to learn more by this diagram from the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19), which describes COVID-19 as similarly transmissible to the H1N1 influenza in 1918-1919. I’ve been reading a few articles, keeping an eye out for potential lessons for our looming COVID-19 pandemic.

Source: Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19, p. 11

I’m just beginning to read into the literature. There are some pretty clear lessons—though no thunderclap revelations. These include:

  • Handwashing was effective then and will remain amongst our most effective practices now .
  • There will likely be two or more waves of COVID-19 .
  • In the absence of specific treatments, we’ll have to rely on community mitigation measures to contain the virus, as was the case in 1918 .
  • There is likely to be a social gradient in transmission, i.e. the poor are more likely to get COVID-19, at least at first . This is a concern that some have already flagged in the U.S.
  • If there is a social gradient in the disease, there needs to be a social gradient in our response. The most affected locations and communities should be the focus of the health system’s initial response (we can’t just assume this will be the case). If antiviral therapies are found to be effective, or if a vaccine is eventually developed, consideration should be given to deploying them to poorer areas first .
  • Air pollution may increase the impact of the pandemic (important given the recent bushfires and poor air quality in Australia).
  • We’re much better placed to respond now than health systems were in 1918. Things like intensive care units and protective equipment simply didn’t exist then .
  • The economic impacts of the pandemic will likely have health consequences that dwarf those of the virus itself.

The social impacts of the 1918 pandemic were far-reaching, but also still seem to be poorly understood. “What if” questions abound but are unanswerable. For example, the Indian independence movement was strengthened by the British mishandling of its influenza response in India. Would independence have happened in the same way without the pandemic?

It’s similarly difficult for us to imagine what COVID-19’s far-reaching future social consequences will be.

I’ll keep reading. Your suggestions about good sources are welcome.


Wilson, Nick, Osman D Mansoor, and Michael G Baker. “The First Analytic Evidence for Socio-Economic Gradients in 1918 Pandemic Influenza Mortality Rates for New Zealand.” New Zealand Medical Journal 131, no. 1486 (2018): 5.
Mamelund, Svenn-Erik. “1918 Pandemic Morbidity: The First Wave Hits the Poor, the Second Wave Hits the Rich.” Influenza and Other Respiratory Viruses 12, no. 3 (2018): 307–13. https://doi.org/10.1111/irv.12541.
Jester, Barbara J., Timothy M. Uyeki, Anita Patel, Lisa Koonin, and Daniel B. Jernigan. “100 Years of Medical Countermeasures and Pandemic Influenza Preparedness.” American Journal of Public Health 108, no. 11 (2018): 1469–72. https://doi.org/10.2105/AJPH.2018.304586.
Clay, Karen, Joshua Lewis, and Edson Severnini. “Pollution, Infectious Disease, and Mortality: Evidence from the 1918 Spanish Influenza Pandemic.” The Journal of Economic History 78, no. 4 (December 2018): 1179–1209. https://doi.org/10.1017/S002205071800058X.
Martini, M, V Gazzaniga, N L Bragazzi, and I Barberis. “The Spanish Influenza Pandemic: A Lesson from History 100 Years after 1918.” Journal of Preventive Medicine and Hygiene 60, no. 1 (2019): E64–67. https://doi.org/https://doi.org/10.15167/2421-4248/jpmh2019.60.1.1205.
Jester, Barbara, Timothy M. Uyeki, Daniel B. Jernigan, and Terrence M. Tumpey. “Historical and Clinical Aspects of the 1918 H1N1 Pandemic in the United States.” Virology 527 (January 15, 2019): 32–37. https://doi.org/10.1016/j.virol.2018.10.019.
Cristina, Juan, Raquel Pollero, and Adela Pellegrino. “The 1918 Influenza Pandemic in Montevideo: The Southernmost Capital City in the Americas.” Influenza and Other Respiratory Viruses 13, no. 3 (2019): 219–25. https://doi.org/10.1111/irv.12619.