The Spanish flu of 1918, the deadliest pandemic of modern times, remains an enduring medical conundrum: no one knows for certain where it came from, how many it killed and why it ended so swiftly. Its virulence may have had more to do with malnourishment, poor hygiene and wartime troop movements than the nature of the virus. Its scale and spread were masked by official censorship.

And it wasn’t Spanish.

But it was lethal on a scale not seen since the Black Death.

Spanish flu infected roughly 500 million, or about a quarter of the world’s population. Estimates of the death toll usually range between a low of 17 million and a high of 100 million people. The global economy shrank by 5 per cent.

In countries fighting the First World War, including Britain, America, France and Germany, the numbers of infected and dead were suppressed to maintain civilian morale. However, in Spain, a neutral country, journalists were freer to report on the impact (including the lingering illness of the Spanish king), giving the false impression that it was particularly dire on the Iberian peninsula, hence Spanish flu. (Spaniards, offended, immediately blamed the Italians, and referred to the illness as “the Naples Soldier”.)

Healthcare was very different a century ago: hygiene was rudimentary, life expectancy shorter, the understanding of viruses limited and the chances of being carried off by flu through what would now be called “an underlying health condition” far higher. Yet Spanish flu offers important insights into how to cope with a global flu pandemic today; and how not to.

Spanish flu was one of only two pandemics caused by a strain of the H1N1 virus, the second being the swine flu pandemic of 2009. Some historians believe the virus originated in Étaples, a key staging area and hospital camp behind the lines in France. The area was ideal for flu transmission, with overcrowded hospitals and thousands of troops passing through on their way to and from the trenches. There was a large piggery in the camp, and some scientists believe that the disease may have migrated from poultry to swine and thence to humans.

A Chicago-area public-health notice warning theatergoers of the Spanish flu.

However, others have identified the source, variously, as east Asia, Austria, Sierra Leone and Fort Riley, Kansas, where the military cook Albert Gitchell reported sick on March 4, 1918, in what may have been the first case.

The virus was notably less lethal in China, leading to the theory that the Chinese may have experienced an earlier outbreak and acquired immunity. Almost 100,000 Chinese labourers were brought in to work behind the French and British lines, and it is possible they brought the virus with them.

What is certain is that the enormous troop movements of the war distributed the virus across the whole of Europe, then the rest of the world, spreading it to every corner of the globe with bewildering speed. Soldiers were particularly susceptible to infection, their immune systems reduced by malnourishment, mustard gas, the stress of combat and living in cramped dugouts and barracks.

The virus of 1918 showed certain distinct anomalies. Influenza pandemics usually disproportionally affect the elderly and the very young. Spanish flu, however, killed mostly young adults in apparently good health. Some scientists believe that this specific strain of flu induced a cytokine storm, an overreaction of the body’s immune system; paradoxically, the healthier the host body, the more acute was the overreaction. Older people may also have been protected by an earlier pandemic, the Russian flu of 1889-90.

The enormous troop movements of the war distributed the virus across the whole of Europe, then the rest of the world, spreading it to every corner of the globe with bewildering speed.

Every statistic on Spanish flu is the subject of intense dispute. The World Health Organisation has estimated that 2-3 per cent of those infected eventually died as a result, but others put the disease-to-death ratio far higher or lower. Most victims succumbed to secondary infections of bacterial pneumonia.

The high infection rates and the severity of the symptoms were unprecedented. Indigenous peoples, often living in crowded and unhygienic conditions, were frequently the most badly affected. In New Zealand, Maoris died at eight times the rate of Europeans. Entire villages of Alaskan Inuit perished. A quarter of the adult population of Western Samoa did not survive. According to one estimate, as many as 14 million Indians may have died in British-ruled India, while 10 per cent of Irish deaths in 1918 were attributed to the flu.

Further impeding accurate assessment of the spread, Spanish flu was frequently misdiagnosed as some other disease, such as cholera and typhoid.

An estimated 250,000 people died in Britain as the disease swept the country in three distinct waves: mild in spring 1918; catastrophic in late 1918; and moderate in early 1919. A shortage of gravediggers and undertakers meant that funerals took place at night and bodies sometimes lay unburied for days.

The official British response was patchy and muted. Some local authorities urged people who felt unwell to remain at home, keep handkerchiefs away from children, clean their teeth thoroughly and eat plenty of porridge. “Give up shaking hands for the present and give up kissing for all time,” one pamphlet urged. Many elementary schools were closed, but secondary schools remained open, as did cinemas and churches. Among the cures suggested were whisky, cigarettes and raw onions. Quacks offered such remedies as Dr Williams’ Pink Pills for Pale People.

A “pneumonia porch” at a U.S. Army hospital in Aix-les-Bains, France. While World War I hastened the spread of the flu, the disease might have tipped the outcome to the Allies.

There was no concerted strategy for tackling the flu and it was not even deemed “notifiable” to medical authorities until 1919, by which time it was on the wane. The Royal College of Physicians declared Spanish flu to be no more dangerous than its “Russian” predecessor.

The Times suggested that the illness was mostly in the mind, the result of “the general weakness of nerve power known as war-weariness”, with the implication that becoming ill was unpatriotic. “Women are not going to wear ugly masks,” declared The Manchester Guardian. Punch suggested that anyone who insisted on getting the flu did so “at their own risk”.

Most official energies were put into playing down the true scale of the problem to maintain civilian morale, and thanks to wartime censorship the precise figures for infection and mortality may never be known.

The pandemic reached a peak with the second wave in October 1918, exacerbated by the peculiar circumstances of trench warfare. In “normal” flu epidemics, the very ill stay at home (and a proportion die there), while those only mildly infected may carry on with their lives in the wider community; in war, the most ill soldiers were immediately transported away from the lines, spreading the deadliest form of disease elsewhere, whereas those only lightly infected stayed put and fought on.

The Times suggested that the illness was the result of “the general weakness of nerve power known as war-weariness,” with the implication that becoming ill was unpatriotic.

Copenhagen experienced a notably low death rate from infections (just 0.29 per cent), in part because Denmark had experienced the milder first wave of infection on a wide scale, leaving a level of immunity and making its population better prepared to withstand the far deadlier second wave.

The pandemic ravaged entire communities and left a lasting legacy, including higher levels of disability and lower educational attainment among children born to mothers infected by the virus. The mortality rate was notably higher in Germany and Austria, possibly helping to tilt the outcome of war in favour of the Allies.

Doctors in 1918 understood the existence of viruses, but had never been able to see them (the electron microscope would not be invented until 1933), let alone test antiviral drugs and swiftly manufacture vaccines. The disease spread too fast for any concerted policy of self-isolation or quarantine. For most people, death from flu was not a matter of science and medicine, but an act of God or fate.

Spanish flu declined as mysteriously and suddenly as it had appeared. Doctors and nurses may have simply got better at treating the pneumonia that so often resulted. Or else the virus rapidly mutated to a less lethal strain after the hosts carrying the most virulent form had died — a feature of some pandemics.

Self-quarantining, circa 1918.

In part because press coverage had been limited, memory of the scourge faded swiftly, leading some to label this the “forgotten pandemic”. With the war over, people also sought to obliterate memories of the human carnage at home that had accompanied its last chapter. Amid the economic, social and psychological chaos left by a world war, people needed an armistice from illness.

In 2005 US scientists successfully recreated the genetic sequence of the 1918 flu using tissue samples from a female victim preserved in the Alaskan permafrost. Three years later, in a bid to better understand modern bird flu, the body of the British diplomat and MP Sir Mark Sykes was exhumed from the lead coffin in which he had been buried in 1919 after succumbing to Spanish flu.

As Bill Gates once remarked, “The worst pandemic in modern history was the Spanish flu of 1918, which killed tens of millions of people. Today, with how interconnected the world is, it would spread faster.” That prediction is being tested as countries, communities and individuals rush to disconnect as fast as possible in the face of a new contagion.

The First World War is engraved on our national memory, carved into stone war memorials in every town and village. Spanish flu, spread by war and obscured by it, killed many more people than the bombs and bullets on the battlefields. For the millions who died of Spanish flu there are no memorials comparable to those who have died of aids (35 million), or ebola (12,000). Instead it slipped swiftly from the world’s collective memory.

The plague of 1918 was supposed to be the flu to end all flus, except that, like the war to end all wars, it wasn’t.