Originally published 2021-09-22.
By 20 September 2021, COVID-19 had killed about 675,000 people in the United States, according to the Johns Hopkins University count. That matched the usual estimate for American deaths in the 1918–19 influenza pandemic, the so-called Spanish flu, making COVID-19 the deadliest disease outbreak in modern US history by raw numbers.
The comparison needs care, though. In 1918 the US had roughly a third of today's population, so the flu killed a far larger share of Americans. And the 1918 figure is itself a rough estimate built from patchy records. This article explains what the milestone did and did not mean, how the two pandemics differed, and how the COVID-19 toll grew after that point.
Two death tolls, two very different countries
The US population in 1918 was around 105 million. Today it is well over 330 million. A death toll of 675,000 therefore meant something very different in each era: roughly one American in 155 died of the flu, compared with about one in 490 by the time COVID-19 reached the same number.
The global picture was similar. The 1918–19 flu is usually estimated to have killed about 50 million people worldwide, at a time when the world had about a quarter of its present population. Published estimates range from around 17 million to as many as 100 million, which shows how uncertain the historical record is. When COVID-19 matched the US flu toll, its official global death count had passed 4.6 million.
So the milestone did not mean COVID-19 was a worse disease than the 1918 flu. It meant that, even with modern medicine, a new virus had killed as many Americans in about 19 months as the deadliest pandemic of the last century.
Why the 1918 numbers are uncertain
Doctors in 1918 had no test for influenza; the virus itself was not identified until the 1930s. Deaths were often recorded as pneumonia or other causes, many places kept poor statistics, and the First World War disrupted record keeping. The 675,000 figure comes from later analyses of excess deaths and has been described by researchers as an educated estimate. Some studies put US flu deaths anywhere between about 500,000 and 850,000.
The name "Spanish flu" is also misleading. Wartime censorship kept newspapers in the fighting nations quiet about the outbreak, while neutral Spain reported it openly. That made it look as though the disease had started there. It did not; its true origin is still debated.
How the two pandemics differed
The 1918 virus was an H1N1 influenza strain. It came in waves, with the deadliest one in the autumn of 1918, and it was unusually lethal for healthy young adults, not just the very old and very young. There were no flu vaccines, no antibiotics to treat the bacterial pneumonia that killed many patients, and no intensive care units. Cities relied on closures of schools, churches and theatres, masks and quarantine, with mixed enforcement.
COVID-19, caused by the SARS-CoV-2 coronavirus, hit older people hardest. Modern hospitals could provide oxygen, ventilators and, over time, effective drugs. Above all, vaccines arrived within a year: the first US doses were given on 14 December 2020.
That last point is why many public health experts found the 2021 milestone so frustrating. Howard Markel, a medical historian at the University of Michigan, told the Associated Press: "Big pockets of American society — and, worse, their leaders — have thrown this away."
The situation in September 2021
The milestone came during a surge driven by the highly contagious Delta variant. US deaths were averaging more than 1,900 a day, the highest level since early March 2021, although the wave appeared to be peaking.
Just under 64% of Americans had received at least one vaccine dose. Coverage varied widely, from about 77% in Vermont and Massachusetts to under 50% in states such as Idaho, Wyoming, West Virginia and Mississippi. Polls throughout 2021 found that vaccine hesitancy tracked political identity closely, with distrust of authorities and online misinformation playing a large part. Most deaths in that period were among unvaccinated people.
Forecasters at the University of Washington projected about 100,000 more US deaths by 1 January 2022, which would bring the total to around 776,000. Experts warned that colder weather, indoor gatherings and new variants could drive further waves.
What happened next
The forecasts proved, if anything, cautious. The Omicron variant swept the world in the winter of 2021–22, and the United States passed one million recorded COVID-19 deaths in May 2022. The cumulative US count has since passed 1.2 million.
Official counts also understate the true toll worldwide, because many deaths were never tested or registered as COVID-19. In May 2022 the World Health Organization estimated that the pandemic was associated with about 14.9 million excess deaths in 2020 and 2021 alone, with a range of 13.3 to 16.6 million. That was nearly three times the official count for the same period, and most of those deaths occurred in middle-income countries.
By that measure COVID-19 ranks among the deadliest pandemics on record, although the 1918 flu still killed a much larger share of the world's population.
Common misunderstandings about the comparison
- "COVID-19 was deadlier than the Spanish flu." In absolute US deaths it eventually was. As a share of the population, the 1918 flu was roughly three times as deadly in America, and far deadlier worldwide.
- "Most COVID deaths were really something else." Death certificates list contributing conditions, but excess-death studies, which simply compare total deaths with normal years, show a large rise that cannot be explained by other causes.
- "Herd immunity would end it without vaccines." As retired epidemiologist Ann Marie Kimball put it to the AP: "The trouble is, you have to survive infection to acquire the immunity."
- "COVID-19 is now just like a cold." For most vaccinated or previously infected people, illness is milder than in 2020, but the virus still causes serious disease and deaths, especially among older people and those with weak immune systems.
Lessons for the next pandemic
Both pandemics showed the same pattern: early, clear public action saves lives, while confusion and mistrust cost them. In 1918, cities that closed public gatherings early and kept the measures in place tended to see lower peaks than those that waited. In 2021, the gap between the most and least vaccinated states became one of the starkest public health divides in the country.
For individuals, the practical lessons are modest but real: keep up with recommended vaccinations, stay home when sick, and seek medical advice early if you are in a high-risk group. If you have questions about which vaccines are right for you, talk to a doctor.
Sources: Original report: Associated Press, 20 September 2021 (as republished by WTTW); World Health Organization: 14.9 million excess deaths, 2020–2021; Wikipedia: Spanish flu; Wikipedia: COVID-19 pandemic in the United States.
COMMENTS