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.
Aftermath of World War I
Through the period from the armistice on 11 November 1918 until the signing of the peace treaty with Germany on 28 June 1919, the Allies maintained the naval blockade of Germany that had begun during the war. As Germany was dependent on imports, it is estimated that 523,000 civilians had lost their lives. N. P. Howard, of the University of Sheffield, claims that a further quarter of a million more died from disease or starvation in the eight-month period following the conclusion of the conflict. The continuation of the blockade after the fighting ended, as author Robert Leckie wrote in "Delivered From Evil", did much to "torment the Germans ... driving them with the fury of despair into the arms of the devil." The terms of the Armistice did allow food to be shipped into Germany, but the Allies required that Germany provide the means (the shipping) to do so. The German government was required to use its gold reserves, being unable to secure a loan from the United States.