Syndemic
The worst of the 20th century influenza pandemics was the 1918 pandemic, where between 20-40 percent of the world’s population became ill between 40-100 million people died. More people died of the so-called Spanish flu (caused by the H1N1 viral strain) pandemic in the single year of 1918 than during all four-years of the Black Death. The pandemic had devastating effects as disease spread along trade and shipping routes and other corridors of human movement until it had circled the globe. InIndia, the mortality rate reached 50 per 1,000 population. Arriving during the closing phase of the World War I, the pandemic impacted mobilized national armies. Half of U.S. soldiers who died in the "Great War," for example, were victims of influenza. It is estimated that almost ¾ of a million Americans died during the pandemic. In part, the death toll during the pandemic was caused by viral pneumonia characterized by extensive bleeding in the lungs resulting in suffocation. Many victims died within 48 hours of the appearance of the first symptom. It was not uncommon for people who appeared to be quite healthy in the morning to have died by sunset. Among those who survived the first several days, however, many died of secondary bacterial pneumonia. It has been argued that countless numbers of those who expired quickly from the disease were co-infected with tuberculosis, which would explain the notable plummet in TB cases after 1918.
Modern history
Much of the fighting in World War I took place along the Western Front, within a system of opposing manned trenches and fortifications (separated by a "No man's land") running from the North Sea to the border of Switzerland. On the Eastern Front, the vast eastern plains and limited rail network prevented a trench warfare stalemate from developing, although the scale of the conflict was just as large. Hostilities also occurred on and under the sea and—for the first time—from the air. More than 9 million soldiers died on the various battlefields, and nearly that many more in the participating countries' home fronts on account of food shortages and genocide committed under the cover of various civil wars and internal conflicts. Notably, more people died of the worldwide influenza outbreak at the end of the war and shortly after than died in the hostilities. The unsanitary conditions engendered by the war, severe overcrowding in barracks, wartime propaganda interfering with public health warnings, and migration of so many soldiers around the world helped the outbreak become a pandemic.