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.
German casualties in World War II
Civilian deaths, due to the flight and expulsion of Germans and the forced labor of Germans in the Soviet Union, are sometimes included with World War II casualties. During the Cold War, the West German government estimated the death toll at 2.225 million in the wartime evacuations, forced labor in the Soviet Union as well as the post war expulsions. This figure was to remain unchallenged until the 1990s when some German historians put the actual death toll in the expulsions at 500,000 confirmed deaths listed in a 1965 German Red Cross study. The German Historical Museum puts the figure at 600,000 dead; they maintain the figure of 2 million expulsion deaths cannot be supported. However, the position of the German government, the German Federal Agency for Civic Education and the German Red Cross is that the death toll in the expulsions is between 2.0 and 2.5 million civilians. The German historian Rüdiger Overmans maintains that there are more arguments for a lower figure of 500,000 rather than the higher figures of over 2.0 million. He believes that the previous studies by the German government should be subject to critical revision and new research is needed to establish the actual number of expulsion deaths.