Our results indicate that there was a considerable extra burden on the public medic system during the initial wave of the epidemic in 1918, with a significant loss of lives reported by both the public medic system and the 12 large public hospitals. In comparison, only a substantial number of excess hospitalizations in the public hospitals was reported in 1920, indicating that the population was relatively unprepared for the first wave in 1918 and did not fully utilize the public hospital system.