105 Bull. Hist. Med., 2002, 76: 105–115
Updating the Accounts:
Global Mortality of the 1918–1920
“Spanish” Influenza Pandemic
NIALL P. A. S. JOHNSON AND JUERGEN MUELLER
summary: The influenza pandemic of 1918–20 is recognized as having generally
taken place in three waves, starting in the northern spring and summer of 1918.
This pattern of three waves, however, was not universal: in some locations
influenza seems to have persisted into or returned in 1920. The recorded
statistics of influenza morbidity and mortality are likely to be a significant
understatement. Limitations of these data can include nonregistration, missing
records, misdiagnosis, and nonmedical certification, and may also vary greatly
between locations. Further research has seen the consistent upward revision of
the estimated global mortality of the pandemic, which a 1920s calculation put
in the vicinity of 21.5 million. A 1991 paper revised the mortality as being in
the range 24.7–39.3 million. This paper suggests that it was of the order of
50 million. However, it must be acknowledged that even this vast figure may be
substantially lower than the real toll, perhaps as much as 100 percent understated.
keywords: influenza, pandemic, mortality, 1918
The epidemiology, morbidity, and mortality of the most deadly influenza
pandemic in history have been described at the local, regional, and
national level in many studies. Few authors have attempted to present the
global situation, and the last major effort was made in 1991.
1
An interna-
tional conference on the history, virology, demography, and geography
of the pandemic was held at the University of Cape Town in September
NOTES AND COMMENTS
We would like to acknowledge all our colleagues whose work on the pandemic, along
with our own, made this paper possible. We would also like to thank the three anonymous
reviewers for their useful feedback.
1. K. David Patterson and Gerald F. Pyle, “The Geography and Mortality of the 1918
Influenza Pandemic,” Bull. Hist. Med., 1991, 65: 4–21.

106 niall p. a. s. johnson and juergen mueller
1998;
2
the new approaches and new regional studies presented there, in
addition to some comparative studies, have helped redress our patchy
knowledge. This paper does not attempt to summarize the entire confer-
ence; rather, its purpose is limited to updating the tally of mortality
caused by this single massive pandemic.
3
One of the most striking aspects of the influenza pandemic of 1918–
1920 was the heavy toll on the young adult population. Some regions
reported mortality rates for the entire population as high as 5–10 per-
cent.
4
On the other hand, there are areas where very low morbidity and
mortality were reported.
5
Svenn-Erik Mamelund has suggested that coastal
locations, urban centers, and areas with higher levels of connection via
communication and transport networks endured higher mortality rates
than remote, rural, and isolated areas.
6
It has been suggested that a fresh
look at the epidemiology may help to explain examples of regional
mortality variations. This, however, is outside the scope of this paper.
Indeed, it could be argued that such local variations are rendered trivial
2. “The Spanish ’Flu 1918–1998: Reflections on the Influenza Pandemic of 1918 after 80
Years,” meeting held at University of Cape Town, 12–15 September 1998.
3. A collection of the papers from the Cape Town conference is due to be published as
Howard Phillips and David Killingray, eds., The Spanish Flu Pandemic of 1918–19: New
Perspectives (London: Routledge, 2002).
4. See, for example, Colin Brown, “The Influenza Pandemic of 1918 in Indonesia,” in
Death and Disease in Southeast Asia: Explorations in Social, Medical and Demographic History, ed.
Norman G. Owen (Oxford: Oxford University Press, 1987), pp. 235–56; Beatriz Echeverri
Dávila, La gripe española: La pandemia de 1918–1919 (Madrid: Centro de Investigaciones
Sociológicas, 1993); Ian D. Mills, “The 1918–1919 Influenza Pandemic—The Indian Expe-
rience,” Indian Econ. & Soc. Hist. Rev., 1986, 23: 1–40; Juergen Mueller, “Patterns of
Reaction to a Demographic Crisis: The Spanish Influenza Pandemic (1918–1919) in Sub-
Saharan Africa. A Research Proposal and Preliminary Regional and Comparative Find-
ings,” Staff Seminar Paper no. 6 (Nairobi: University of Nairobi, Department of History,
1995); Karl David Patterson, “The Influenza Epidemic of 1918–19 in the Gold Coast,” J. Afr.
Hist., 1983, 24: 485–502; Howard Phillips, “Black October”: The Impact of the Spanish Influenza
Epidemic of 1918 on South Africa, Archives Year Book for South African History (Pretoria:
Government Printer, 1990); Geoffrey W. Rice (with assistance from Linda Bryder), Black
November: The 1918 Influenza Pandemic in New Zealand (Wellington: Allen & Unwin, 1988);
Sandra M. Tomkins, “The Influenza Epidemic of 1918–19 in Western Samoa,” J. Pacific
Hist., 1992, 27: 181–97; idem, “Colonial Administration in British Africa during the Influ-
enza Epidemic of 1918–19,” Can. J. Afr. Stud., 1994, 28: 60–83.
5. See, for example, Mueller, “Patterns of Reaction” (n. 4); Phillips, “Black October”
(n. 4).
6. Svenn-Erik Mamelund, “Spanskeskyen i Norge 1918–1920: Diffusjon og demografiske
konsekvenser” (master’s degree thesis, University of Oslo, 1998). Phillips reached similar
conclusions in explaining the variations in South Africa, especially for Natal: Phillips, “Black
October” (n. 4).