ArticlePDF Available

Lessons Learned from the 1918–1919 Influenza Pandemic in Minneapolis and St. Paul, Minnesota

Authors:

Figures

Public Health Chronicles
P H R / ND 2007 / V 122 803
LESSONS LEARNED FROM
THE 1918–1919 INFLUENZA
PANDEMIC IN MINNEAPOLIS
AND ST. PAUL, MINNESOTA
M O, AB
SF. S, MPH
R N. D, PD, MPH
R L, MD
Those who cannot remember the past are condemned
to repeat it.
George Santayana
Spanish Inuenza of 1918–1919 killed more than 50
million people worldwide over the course of two years.
1
The true origin of the 1918 inuenza pandemic is
unknown. During World War I, propaganda in war-
engaged countries only permitted encouraging news, so
as a neutral party, Spain was the rst country to publicly
report on the health crisis.
1
Thus, Spanish Inuenza
became a popular term. However, historical research
has shown that Spain was an unlikely candidate as the
initial source and some suggest that it originated in
Kansas in the spring of 1918.
Inuenza pandemics have occurred regularly every
30 to 40 years since the 16th century. Today, inuenza
experts consider the possibility of another inuenza
pandemic, not in terms of if but when. Due to the
high likelihood of an inuenza pandemic, planning is
underway in many U.S. states and other countries. We
reviewed the responses of two neighboring Minnesota
cities during the 1918–1919 pandemic to gain insight
that might inform planning efforts today.
Many of the components of current pandemic
inuenza plans were utilized to some degree in Min-
neapolis and St. Paul during 1918–1919. Coordination
between different levels and branches of government,
improved communications regarding the spread of
inuenza, hospital surge capacity, mass dispensing of
vaccines, guidelines for infection control, containment
measures including case isolation and closures of pub-
lic places, and disease surveillance were all employed
with varying degrees of success. We focus on medical
resources, community disease containment measures,
public response to community containment, infection
control and vaccination, and communications.
PANDEMIC BEGINNINGS IN MINNESOTA
Minnesota’s rst Spanish Inuenza cases were identi-
ed in the last week of September 1918. As in the rest
of the country, Minnesota’s rst cases “were directly
traceable to soldiers, sailors, or [their] friends.”
2
Every
military base and military hospital in the Minneapolis-
St. Paul area was severely affected. Case isolation was
slowly implemented at both Fort Snelling and the
Dunwoody Naval Detachment (military installations
in Minneapolis). On September 30, the rst day of
isolation, cases numbered in the hundreds.
3
Inuenza cases were not limited to enlisted men
for long. In Minneapolis, the number of civilian cases
outstripped the number of military cases for the rst
time on October 9, less than two weeks after the rst
case was identied in the state (700 civilian cases; 675
cases at Fort Snelling).
4
Inuenza had become a report-
able condition in Minnesota on October 8 in response
to the growing epidemic.
5
MEDICAL RESOURCES
Two major issues contributed to the gravity of the pan-
demic: the war effort and limited scientic knowledge.
World War I was not only costly, it required much of the
medical community to be stationed overseas. In 1918,
little was known about inuenza. While this lack of
knowledge did not negatively impact infection control
actions, effective treatment and prevention methods
were not fully utilized.
When inuenza rst appeared in Minnesota on
September 27, the state was ill equipped for a health
crisis.
2
Although World War I was coming to an end,
more than four million Americans were mobilized and
the nation’s resources were directed to supporting the
war effort. An editorial in the Minneapolis Tribune daily
newspaper described the lack of physicians and nurses:
“The medical fraternity is severely taxed already. So
many physicians and surgeons have gone to Europe or
to training that those at home have more than they can
attend to comfortably and to good advantage.”
6
The number of inuenza patients that needed the
attention of physicians and nurses overwhelmed St.
Paul and Minneapolis clinicians. The war’s consider-
able drain on the medical profession was compounded
by other factors that hindered nurse and physician
mobilization. Methods to keep them healthy while
caring for inuenza patients were ineffective. Many
804 P H C
P H R / ND 2007 / V 122
health-care providers fell ill, and some died. At one
point, Minneapoliss City Hospital reported that “nearly
half of the nursing staff has been ill with inuenza in
the last three weeks.”
7
This bleak situation discouraged
some clinicians from providing their services. Dr. H.M.
Bracken, Secretary of the Minnesota State Board of
Health, reported to Dr. Rupert Blue, U.S. Surgeon
General, on his campaign to recruit physicians for the
inuenza effort: “A number who we have called for
have made excuses and have not come at all.”
8
Other
physicians who were recruited by Dr. Bracken simply
did not show up.
9
Dr. Bracken attempted to secure senior medical
students for inuenza work. Dr. Bracken worked not
only with the U.S. Surgeon General but also with the
Surgeon General of the Army, the Committee on
Education and Special Training, and the Dean of the
University of Minnesota Medical School for three weeks
and still was unable to obtain senior medical students
for assistance, because each party insisted that someone
else had to authorize it. In the end, Bracken failed to
receive any medical students.
10
Not surprisingly, Minneapolis and St. Paul hospitals
proved to be inadequate to handle the large num-
ber of patients. Minneapolis’s City Hospital and St.
Paul’s St. John’s Hospital were solely devoted to treat-
ing inuenza patients. Non-inuenza patients were
transferred to other area hospitals. This inadequacy
was not entirely due to the lack of beds and supplies;
there simply were not enough healthy nurses. At City
Hospital, Superintendent Dr. Harry Britton reported
that the “hospital was caring for about 150 cases, and
had about 70 on the waiting list. It had beds available
for that waiting number, but not nurses.”
11
In St. Paul, a system was set up between St. John’s
Hospital and other hospitals to insure an adequate
number of nurses to care for inuenza patients, but
unfortunately this system failed. Dr. F.C. Plondke, St.
John’s Hospital’s Medical Director, complained that
the other hospitals were abandoning their promises
to assign help from their nursing staff. “The other
hospitals had refused to furnish a single nurse to aid
the fteen who are caring for ninety patients at St.
John’s from their individual nursing staffs.”
12
In 1918, medical science maintained that inuenza
was bacterial in origin. Physicians at Fort Snelling
claimed that the “bacillus inuenza of Pfeiffer,” which
is today known as Haemophilus inuenzae, was the cause
of Spanish Inuenza.
1,13
Nevertheless, despite this lack
of understanding about viruses, advice to curb infection
was relatively accurate. The Minnesota State Board of
Health recommended the use of handkerchiefs to cover
sneezes and coughs, plenty of fresh air, avoidance of the
sick and of crowds, and to contact a physician if ill.
14
CommunItY dIsease ContaInment
As inuenza was beginning to take hold in the civil-
ian population, there was disagreement between the
Minneapolis and St. Paul health commissioners, Dr.
Guilford and Dr. Simon, respectively. Their approaches
varied; Dr. Guilford tended to be broadly proactive
to prevent cases, whereas Dr. Simon tended toward
initiating activities in response to individual cases. Dr.
Guilford believed that closing public places was the
best course of action and that isolation of individual
cases was useless.15 Dr. Simon asserted that isolation of
inuenza cases would be more effective in preventing
the spread of disease.14
The St. Paul Health Department and the Minnesota
State Board of Health met Dr. Guilford’s strong advo-
cacy with opposition. Dr. Bracken, siding with St. Paul,
questioned, “If you begin to close, where are you going
to stop? When are you going to reopen, and what do
you accomplish by opening”?
11
Debate between the two cities on the merits of clos-
ing schools caused further strain. Dr. Simon held that
St. Paul’s school nurses were the best defense against
the spread of the disease, and that closing schools
would allow cases to go undetected as the children
would not be under any medical supervision. Dr.
Guilford disagreed, pointing out that 30 school nurses
would not be able to adequately care for the 50,000
pupils in the Minneapolis public school system during
a pandemic.
16
Minneapolis closed the schools on two
separate occasions (October 12 to November 17, and
December 10 to December 29, 1918).
Despite Dr. Simon’s conviction that the closing of
public places would be ineffective, on November 6 St.
Paul government ofcials overruled him and enacted
a closing order for the whole city, including schools,
theaters, churches, and dance halls. The St. Paul Citi-
zens’ Committee—consisting of 15 physicians, church
leaders, and community members who were appointed
by Dr. Simon—which was concerned by the record of
218 new cases on November 5, as well as 36 deaths
between November 4 and November 5, 1918, recom-
mended this policy change (Figure 1).
17
The number
of new cases began to decline 10 days later, with only
24 new cases, and the next day, Dr. Simon reopened
St. Paul businesses and churches.
Minneapolis and St. Paul both attempted to combat
inuenza by limiting crowding in places with restricted
access to fresh air. Both cities enacted streetcar regula-
tions aimed to keep the air in the streetcars fresh by
mandating open windows and limiting the number
of passengers to 84 (streetcars had a seating capacity
of 46).
5,17,18
Because the measure limiting the number
of car passengers, implemented on October 26 in St.
P H C 805
P H R / ND 2007 / V 122
Paul, was deemed successful, Minneapolis enacted a
similar regulation on October 30.
17
As an experiment,
Dr. Bracken also proposed that St. Paul regulate the
business hours of stores and theaters to keep streetcar
congestion to a minimum. Once again, Minneapolis
followed St. Paul’s example on October 16, 1918, by
regulating the hours of retail stores, ofce buildings,
and wholesale stores.
19
There were several complaints that the mandate in
Minneapolis to keep three streetcar windows open at
all times caused people to get sick due to winter colds.
A compromise was reached by Dr. Guilford allowing
streetcars with heating and ventilation systems to close
their windows once the temperature dropped to 32
degrees Fahrenheit.
20
St. Paul also targeted elevators as places where
inuenza could easily be transmitted due to the tight
quarters and limited fresh air. Buildings with fewer
than six stories were no longer permitted to use their
elevators.
21
Public response to community disease containment
The measures used to contain inuenza greatly affected
the day-to-day lives of citizens. While some accepted
the changes imposed on them, others protested regula-
tions that they considered unfair. Some called for more
stringent methods, while others blatantly broke the new
rules that were intended to protect them.
The closing of public places in Minneapolis was
announced in advance, so people rushed to complete
those activities that would soon be banned, resulting
in the very same crowded conditions the ban sought
to prevent. “Downtown theaters were packed last night
with patrons who took advantage of their last chance
to see a performance until the ban is lifted.”
22
While
some St. Paul citizens were relieved that Dr. Simon
initially pledged to keep public places open, others
felt this was wrong. “Fear of inuenza contagion in
crowded places has reduced the patronage of St. Paul
motion picture theaters by nearly half, according to
reports to Dr. H.M. Bracken.”
23
Many sporting organizations responded negatively
to closing orders. For example, in November 1918, the
bowlers of St. Paul drew up a petition that requested
permission to begin bowling again.
24
Minneapolis
football teams chose to ignore the ban and attempted
to play against each other in front of large crowds.
Police were called in to disperse the crowds and halt
Figure 1. Influenza cases in St. Paul as recorded by the St. Paul Health Department
in the St. Paul Daily News, 1918–1919
a
a
Cases were not uniformly reported on Sundays, so Monday’s data may be inflated.
806 P H C
P H R / ND 2007 / V 122
the games.
25
Minneapolis teams found a way to play
despite the closing order. Because Minneapolis high
school football games were banned, practice games
were scheduled with St. Paul teams.
26
Several estab-
lishments serving alcohol and food deliberately broke
the closing order to continue their regular business.
“One saloon was discovered with the back door route
open.”
27
The elevator regulations in St. Paul were particularly
unpopular. “Some of the downtown hotels objected to
stopping their elevators, saying that they would lose
guests. This caused a change in the ruling to permit
hotel elevators and those in apartment houses to oper-
ate.”
28
Many insisted it was unhealthy for the sick to
be forced to climb stairs in their impaired state, while
others felt concerned that people would be shut off
from fresh air if they were not allowed to use their
elevators. Consequently, the city compromised and
all elevators were back in use starting November 9,
1918, although only one person per 5 square feet was
permitted.
29
The Hennepin County School Board (where Min-
neapolis is located) was exceptionally deant to the
closing order. The school board was concerned for the
health of the students as well as the “12,000 dollars a
day” that the closing orders cost because teachers con-
tinued to be paid, and extra school days would have
to be added to the school year.
30
Against the explicit
orders of Dr. Guilford, and the pleading of several
Parent-Teacher Association ofcers, the school board
reopened schools on October 21, only to be shut down
on the same day under threat of police action.
31
In St. Paul, all inuenza cases were supposed to
be reported to a physician, who in turn was required
to isolate the case in his or her own home and notify
the health department. Several problems sprung up
with these requirements that hampered surveillance,
the care of patients, and protecting people from get-
ting sick. For one, both physicians and patients were
often hesitant to bring attention to cases. “Physicians
are not reporting their cases to prevent homes from
being quarantined.”
21
(Note: At the time of the 1918
inuenza pandemic, the separation of the ill from the
general population, what is now referred to as isola-
tion, was termed “quarantine.”) The ill also sought to
evade isolation in their homes by not seeking medical
attention, or only seeking medical attention when they
became gravely ill. “Hundreds of persons in the city do
not call for medical assistance until the second, third,
or fourth day and in many cases pneumonia already
has developed when medical attention is rst given.”
29
Stafng shortages made isolation even less desirable.
Because there were a limited number of inspectors to
release houses from isolation, houses were not released
promptly from isolation.
32
Starting on November 15, St. Paul telephone opera-
tors went on strike. According to the Pioneer Press daily
newspaper, “Less than one third the new cases [are]
being reported to the health department,” as a result
of the telephone strike.
33
This strike not only affected
the reporting of cases, but also isolation, as well as their
release from such a measure.
After all of the difculties involved in establishing
isolation for each case, some agrantly disobeyed
the isolation orders altogether. “Disregard of the city
quarantine yesterday caused the arrest of one man who
insisted on taking his child from the city hospital before
the patient was ready to be discharged. The mother
and father and the child later were found mingling
with other persons in the neighborhood.”
29
InfeCtIon ControL and VaCCInatIon
In addition to closing public places and isolating
cases in their homes, both Minneapolis and St. Paul
health departments took other steps to keep people
from getting infected. The use of gauze masks, more
stringent sanitation laws, and vaccination campaigns
were deployed in this effort.
Directions for wearing the masks were issued to the
public. “The outside of a face mask is marked with a
black thread woven into it. Always wear this side away
from the face. Wear the mask to cover the nose and
the mouth, tying two tapes around the head above the
ears. Tie the other tapes rather tightly around the neck.
Never wear the mask of another person. When the mask
is removed . . . it should be carefully folded with the
inside folded in, immediately boiled and disinfected.
When the mask is removed by one seeking to protect
himself from the inuenza it should be folded with
the inside folded out and boiled ten minutes. Persons
considerably exposed to the disease should boil their
masks at least once a day.”
21
However, there was incon-
sistent advice on the use of gauze masks. Dr. Bracken,
of the State Board of Health, advocated the wearing
of masks, though he did not wear one himself, saying,
“I personally prefer to take my chances.”
34
Medical students working in clinics in each district
of St. Paul distributed gauze masks.
12
But the Citizens’
Committee rejected an ordinance requiring the wear-
ing of masks at all times, even though, “All physicians
were united in the opinion that the gauze covering
should be worn in hospitals or in the presence of
doubtful cases.”
35
Despite the lack of ofcial orders
requiring the wearing of masks and Dr. Bracken’s
unclear message, many people sought out masks for
P H C 807
P H R / ND 2007 / V 122
themselves. The Northern Division of the American
Red Cross manufactured tens of thousands of masks.
Minneapolis ordered 15,000 masks from the Red Cross
on October 1, 1918.
36
These masks were used by nurses
in schools and hospitals, doctors, hospital visitors, and
those suspected of being infected with inuenza.
37
As the number of cases increased in St. Paul,
employers sought ways to keep their workers healthy
and productive. Several companies requested masks
to distribute to their workers. Despite the thousands
of masks provided by the Red Cross, still more were
needed to fulll the demand. The Citizens’ Committee
suggested that companies ask their female employees
to fabricate masks for all their employees.
21
St. Paul
introduced new sanitation laws that called for the
sterilization of dishes and cups in restaurants and bars,
and the banning of roller towels and common drinking
cups in public restrooms.
38
At least two different vaccines were administered
in Minneapolis-St. Paul, neither of them effective as
neither actually contained inuenza virus. One made
by bacteriologists at the University of Minnesota was
purported to prevent pneumonia.
39
The Mayo Clinic in
Rochester, Minnesota, made another vaccine that was
intended to prevent both pneumonia and inuenza.
40
This latter vaccination was composed of Streptococcus
pneumoniae types I, II, and III, S. pneumoniae group
IV, hemolytic streptococci, Staphylococcus aureus, and
“inuenza bacillus.”
41
Military personnel as well as civilians were inoculated
beginning as early as October 4, 1918.
37
Both city health
departments purchased vaccine and distributed it to
physicians at no charge to encourage widespread use.
In Minneapolis, people desiring the vaccine “thronged”
the ofces of doctors hoping to be vaccinated, and
in St. Paul it was reported that “thousands of persons
have been inoculated.
39,42
Some physicians took advan-
tage of their access to vaccine and the public’s fear of
inuenza. According to St. Paul’s CitizensCommittee,
it was discovered that “a few physicians were charg-
ing a fat fee for inoculations.”
29
This was particularly
disturbing as the vaccinations were supplied to the
physicians for free.
CommunICatIons
Postal workers, Boy Scouts, and teachers were enlisted
to provide educational materials to the public and to
teach health precautions. Mail carriers distributed
educational materials on their routes. Boy Scouts
distributed posters to stores, ofces, and factories in
downtown Minneapolis.
22
Minneapolis teachers who
were put out of work by the closing of schools were
asked to volunteer for a health education campaign.
The main goals of the campaign were to get rid of
shared drinking cups, which were the precursor of the
water fountain, as well as the roller towels, which were
used to dry hands after washing.
43
St. Paul teachers were
sent “to ascertain the plight of families worst affected
by the epidemic.”
28
This was accomplished through a
canvas of homes where the teachers learned if anyone
was sick, needed to see a physician, or needed food.
27
St. Paul set up a public kitchen, a children’s home,
and an emergency hospital for these cases.
21
Limitations
Although the two cities chose different methods of
disease containment, determining which method was
more successful is challenging. Information on cases
in both cities depended on ill individuals seeking the
attention of physicians, who were in short supply. The
physicians were then required to report the number
of new cases each day to their city health department.
The city then reported the total number of cases to
the newspapers, which published the number of new
cases and deaths each day. This chain of information
left much room for error and possible falsication.
Because St. Paul chose to utilize isolation and Min-
neapolis did not, case reporting varied greatly between
the two cities. Individuals with inuenza who had their
status reported in St. Paul had to endure isolation
until they were released with a physician’s approval.
This may have discouraged people from seeking the
attention of physicians, and thus being reported—an
undesired consequence of enforced isolation (Table).
Because those with inuenza were not isolated in Min-
neapolis, more people might have felt comfortable
seeking medical attention. This could explain why St.
Paul had such a high case fatality rate compared with
Minneapolis (Table, Figures 2 and 3).
ConCLusIon
Several factors impede direct comparisons of the two
cities’ approaches. The cities border each other and
Table. Minneapolis and St. Paul influenza cases and
deaths, September 30, 1918, to January 6, 1919
Minneapolis St. Paul
Total deaths 747 645
Total cases 14,411 4,399
Death rate (per 100,000) 264 300
Incidence rate (per 100,000) 4,781 2,049
Case fatality rate (percent) 5.2 14.7
808 P H C
P H R / ND 2007 / V 122
residents travel back and forth. Although the contain-
ment philosophies differed greatly, in reality St. Paul
government ofcials overruled public health, and
schools and public gathering places were closed in
both cities for varying lengths of time. Although the
effects of isolation vs. closure of public places cannot
be specically determined, other lessons can be learned
from what happened in 1918. Many steps could have
been taken to prevent illness and save lives. Prior plan-
ning, clear orders, as well as consistent and transparent
advice and information to the public may have made
a signicant difference in the number of cases and
deaths due to inuenza in 1918.
There was a paucity of planning for a health emer-
gency when inuenza rst appeared. While the actions
that the two city health departments took to stem the
spread of inuenza align closely with current pandemic
plans, health ofcials had the disadvantage of trying
to conceive and realize plans during a health crisis.
Many current recommendations were implemented,
including the use of masks, the use of vaccines (albeit
ineffective ones), increasing the stringency of sanita-
tion measures, limiting crowding in public places,
and trying to coordinate hospitals, nurses, physicians,
and medical students to maximize resources. As part
of maximizing human resources during an inuenza
pandemic, it is imperative that the safety of health-care
workers is insured. The number of nurses and physi-
cians who fell ill and even died as a result of assisting
in the ght against the pandemic scared other nurses
and physicians away.
Had these ideas been generated prior to such a
large emergency, several problems could have been
averted. The debates and disagreements between dif-
ferent public ofcials and health agencies, as with the
Hennepin County School Board and the Minneapolis
Health Department or between the Minneapolis Health
Department and the St. Paul Health Department, could
have been discussed in advance. Supplies could have
been stockpiled, business leaders and community mem-
bers could have provided input on controversial disease
containment policies, and medical students could have
been put to work in hospitals and communities that
lacked physicians. Unfortunately, these disputes arose
and continued throughout the pandemic.
Clear authority and management by public health
Figure 2. Influenza case rates per 100,000, Minneapolis and St. Paul, 1918–1919
a
a
Cases were not uniformly reported on Sundays, so Monday’s data may be inflated.
P H C 809
P H R / ND 2007 / V 122
ofcials were generally lacking at the federal and state
levels. It was almost as if the fear of using their author-
ity led Surgeon General Blue and Dr. Bracken to fail
to take decisive action. Surgeon General Blue suggested
to Dr. Bracken, and all other state health ofcials, “the
advisability [of] discontinuing all public meetings,
closing all schools and places of public amusement…
on appearance of local outbreaks.”
44
Because this was
merely a suggestion, and local outbreaks were not
dened objectively, Blue’s urgent telegram had no
effect.
On the state level, Dr. Bracken acknowledged that
the St. Paul Health Department “followed his advice” to
not close public places, and went on to say that St. Paul,
“has the power to do the opposite any time it wants
to.”
11
This statement forced local health departments
to dene their own rules while attempting to decipher
conicting messages from the state and federal level.
Because clear orders were not being given to public
health ofcials, the public in turn was not receiving
transparent and consistent advice and information.
Should the public wear masks? Why was it allowable
to be next to someone in a streetcar and not in an
elevator? Why were church services closed while Red
Cross workers gathered in crowded conditions in those
very same churches? Was inuenza a life-threatening
condition, or was panic the most dangerous element of
the inuenza pandemic? In Minneapolis and St. Paul.
there was no single message on any of these issues.
In many cases, the public had to decide for itself. In
which case, the effect of the messages that were com-
municated only served to contradict each other.
In reviewing this history, some lessons stand out.
Recent analyses of nonpharmaceutical interventions
during 1918 indicate cities in which multiple interven-
tions were implemented early in the pandemic fared
better.
45
Of primary importance is developing a plan
ahead of time that incorporates all levels of govern-
ment health infrastructure and describes clear lines
of responsibilities and roles. Plans for surge capacity
and community containment must be discussed with
stakeholders and consensus must be achieved.
Further, general approaches should be put forth
for public comment and approval. The public health
benet of isolation should be weighed against the pos-
sibility that some people would be discouraged from
Figure 3. Daily death rates per 100,000, Minneapolis and St. Paul, 1918–1919
a
a
Cases were not uniformly reported on Sundays, so Monday’s data may be inflated.
810 P H C
P H R / ND 2007 / V 122
seeking care. Clear explanations of the reason for isola-
tion, generous employer support, and providing food,
medicine, and social service to those in isolation may
mitigate fears and increase cooperation. The public
must also be educated about the reasoning behind
other health measures (i.e., closures), should those
methods be implemented.
Approaches and plans should be based on scien-
tic data whenever possible, and include input from
ethicists. Unlike in 1918, a pandemic inuenza vaccine
will likely be available today, albeit four to six months
after the pandemic starts. But similar to 1918, the
challenge will be designing an orderly and ethical
distribution of a scarce commodity. Further, experts in
risk communication should assist in developing mes-
sages that are scientically accurate, understandable,
clear, and useful. Finally, we need to take careful note
of local and national lessons from the past so we do
not repeat them.
Miles Ott is a Public Health Graduate Student Worker, Shelly F.
Shaw is an Epidemiologist, Richard N. Danila is a Deputy State
Epidemiologist, and Ruth Lyneld is a Medical Director and State
Epidemiologist. All are with the Minnesota Department of Health
Infectious Disease Epidemiology, Prevention and Control Division,
in St. Paul, Minnesota.
Address correspondence to: Richard N. Danila, PhD, MPH,
Minnesota Department of Health Infectious Disease Epidemiol-
ogy, Prevention and Control Division, Acute Disease Investigation
and Control Section, 625 Robert St. N, P.O. Box 64975, St. Paul,
MN 55164-0975; tel. 651-201-5414; fax 651-201-5743; e-mail
<richard.danila@health.state.mn.us>.
referenCes
1. Barry JM. The great inuenza: the epic story of the deadliest plague
in history. New York: Penguin; 2004.
2. State Board of Health and Vital Statistics of Minnesota. Eighth
biennial report 1918–1919. Minneapolis: State Board of Health
and Vital Statistics of the State of Minnesota; 1920.
3. Spanish Inuenza gains headway here. Minneapolis Tribune 1918
Oct 1; 8.
4. Inuenza gains slowly in city. Minneapolis Tribune 1918 Oct 10;
1,8.
5. Inuenza gains among civilians. Minneapolis Tribune 1918 Oct 9;
1,7.
6. Editorial. Minneapolis Tribune 1918 Oct 3; 16.
7. Sailors may attend inuenza patients. Minneapolis Tribune 1918
Nov 3; 4.
8. Henry Bracken to Rupert Blue, 1918 Nov 13, Minnesota Department
of Health Correspondence and Miscellaneous Records, 1895–1954,
Minnesota Historical Society.
9. Henry Bracken to Rupert Blue, 1918 Nov 2, Minnesota Department
of Health Correspondence and Miscellaneous Records, 1895–1954,
Minnesota Historical Society.
10. Henry Bracken to Dr. Merritte W. Ireland, 1918 Nov 16, Minnesota
Department of Health Correspondence and Miscellaneous Records,
1895–1954, Minnesota Historical Society.
11. Business hours may be changed to curb epidemic. Minneapolis
Tribune 1918 Oct 15; 1,10.
12. Lid on tomorrow includes schools. St. Paul Pioneer Press 1918 Nov
5; 6.
13. 150 cases of inuenza in Minneapolis. Minneapolis Tribune 1918
Sep 30; 1.
14. Mill City closed. St. Paul Pioneer Press 1918 Oct 12; 1,6.
15. Doctors propose drastic lid be clamped on city. Minneapolis Tribune
1918 Oct 11; 1,2.
16. Clash over school order due Monday. Minneapolis Tribune 1918
Oct 20; 1.
17. Push grip ght. St. Paul Pioneer Press 1918 Oct 30; 1.
18. Epidemic controlled in city’s army camps car crowds, 558 pupils
stricken. Minneapolis Tribune 1918 Oct 29; 10.
19. Trade hours set to stem Spanish Inuenza here.
Minneapolis Tri-
bune 1918 Oct 16; 1,2.
20. Ban on until deaths decrease to 7 a day. Minneapolis Tribune 1918
Nov 10; 14.
21. Sweeping order against inuenza in effect here today. St. Paul
Pioneer Press 1918 Nov 6; 1,7.
22. Inuenza lid clamped tight all over city. Minneapolis Tribune 1918
Oct 13; 1,10.
23. See less inuenza. St. Paul Pioneer Press 1918 Oct 15; 8.
24. Pins will fall. St. Paul Pioneer Press 1918 Nov 17; 7.
25. “Flu” order stops park grid games. Minneapolis Tribune 1918 Oct
14; 18,12.
26. High school games neither on nor off. Minneapolis Tribune 1918
Oct 15; 18,12.
27. Fail to report grip. St. Paul Pioneer Press 1918 Nov 8; 10.
28. Plan survey of inuenza cases. St. Paul Pioneer Press 1918 Nov 7;
1.
29. All lifts to run. St. Paul Pioneer Press 1918 Nov 9; 1,7.
30. School chiefs face arrest or injunction, city ofcials to use law as
directors defy inuenza ban. Minneapolis Tribune 1918 Oct 21;
1,2.
31. Guilford wins ght to keep schools shut. Minneapolis Tribune 1918
Oct 22; 1.
32. Shows open today. St. Paul Pioneer Press 1918 Nov 15; 1.
33. Inuenza relief work disrupted as a result of telephone strike. St.
Paul Pioneer Press 1918 Nov 16; 1.
34. Inuenza lid to go on city today. St. Paul Pioneer Press 1918 Nov
4; 1,3.
35. Speed grip ght. St. Paul Pioneer Press 1918 Nov 2; 1.
36. Inuenza spread held slight here. Minneapolis Tribune 1918 Oct
2; 1,4.
37. Inuenza halts “U” opening to all but S.A.T.C. Minneapolis Tribune
1918 Oct 5; 1,22.
38. Cafes and bars hit by grip ban. St. Paul Pioneer Press 1918 Dec 14;
1.
39. Serum to be issued. St. Paul Pioneer Press 1918 Oct 19; 6.
40. Epidemic statistics show decline in city. Minneapolis Tribune 1918
Oct 25; 15.
41. Rosenow EC. Prophylactic inoculation against respiratory infections
during the present pandemic of inuenza. Preliminary report.
JAMA 1919;72:31-4.
42. Epidemic brings mercy problems. St. Paul Pioneer Press 1918 Nov
17; 1.
43. Teachers released for school closing period. Minneapolis Tribune
1918 Oct 15; 11.
44. Telegram from Rupert Blue to Dr. Henry Bracken, 1918 Oct 6,
6:49 pm, Minnesota Department of Health Correspondence and
Miscellaneous Records, 1895–1954, Minnesota Historical Society.
45. Hatchett RJ, Mercher CE, Lipsitch M. Public health interventions
and epidemic intensity during the 1918 inuenza pandemic. Proc
Natl Acad Sci 2007;104:7582-7.
... In this difficult time, these figures can make a great contribution. In the light of these considerations, in the study proposed by Lee (5): (I) starting from the critical issues highlighted in the current pandemics (6) and the previous pandemic experiences (7,8); (II) in consideration of the changes already requested by some key figures of the health system in relation to technologies (9,10) due to new intervention models (11)(12)(13) consolidated during the current epidemic (11); (III) some consensus studies on digital rehabilitation were analysed in particular focused around the new figure of the digital physiotherapist (14)(15)(16)(17)(18)(19) without forgetting the ethical and curricular aspects (20). The author offers very precious indications for advancing digital practice and telemedicine in the physiotherapist profession due to the COVID-19 pandemic and to interact therefore with the above cited devices. ...
... From a general point of view our study is complementary to Lee's study (5). Adam Lee has analyzed current literature (6)(7)(8)(9)(10)(11)(12)(13) and studies on consensus around the figure of the digital physiotherapist (14)(15)(16)(17)(18)(19)(20). In particular he highlighted: (I) activities of important international working groups, in particular the World Confederation for Physical Therapy (WCPT) and the International Network of Physiotherapy Regulatory Authorities (INPTRA) which together they developed recommendations that gave rise, among other things, to the conclusion of important initiatives in this direction during the first wave of the pandemic; (II) the clear identification of the significant role and tasks that the digital physiotherapist must have in society, without forgetting any action limits; (III) the ethical and curricular impact. ...
... Throughout history, pandemics, including cholera, the Black Death, the Spanish flu, and now, Covid-19 have threatened millions of lives worldwide. Public officials have historically worked to prevent the spread of diseases by giving public messages such as wearing masks, social distancing, or self-quarantining (Ott et al., 2007), especially when vaccination is not possible due to various reasons such as unavailability or allergies. Similarly, during the COVID-19 pandemic, health experts have believed that any measures to prevent the transmission of the disease and avoid these worstcase scenarios are of great importance, and individual behavior is crucial to control the spread (Anderson et al., 2020). ...
... Similarly, during the COVID-19 pandemic, health experts have believed that any measures to prevent the transmission of the disease and avoid these worstcase scenarios are of great importance, and individual behavior is crucial to control the spread (Anderson et al., 2020). In line with this, recent models and evidence from successful lockdowns during the Spanish Influenza (1918)(1919) show that behavioral changes can reduce the spread of COVID-19 if most people comply (Ott et al., 2007;Alwan et al., 2020). ...
... Guidance and preparedness planning has substantial historical precedence in previous pandemics, especially the 1918-19 influenza (Ott et al., 2007). Relatedly, a study compared historical guidance (1921) with 2007 guidance and showed close similarities (Morens et al., 2009). ...
Article
Full-text available
COVID-19 is the most recent respiratory pandemic to necessitate better knowledge about city planning and design. The complex connections between cities and pandemics, however challenge traditional approaches to reviewing literature. In this article we adopted a rapid review methodology. We review the historical literature on respiratory pandemics and their documented connections to urban planning and design (both broadly defined as being concerned with cities as complex systems). Our systematic search across multidisciplinary databases returned a total of 1323 sources, with 92 articles included in the final review. Findings showed that the literature represents the multi-scalar nature of cities and pandemics – pandemics are global phenomena spread through an interconnected world, but require regional, city, local and individual responses. We characterise the literature under ten themes: scale (global to local); built environment; governance; modelling; non-pharmaceutical interventions; socioeconomic factors; system preparedness; system responses; underserved and vulnerable populations; and future-proofing urban planning and design. We conclude that the historical literature captures how city planning and design intersects with a public health response to respiratory pandemics. Our thematic framework provides parameters for future research and policy responses to the varied connections between cities and respiratory pandemics.
... Modern minimal design with terraces, balconies and flat roofs to capture sunlight and air [38,39] and reject dust, pollution and diseases [40]. Spanish Flu 20th century Social distancing and gauze masks [41,42]. ...
Article
Full-text available
Since the COVID-19 outbreak, buildings have been viewed as a facilitator of disease spread, where the three main transmission routes (contact, droplets, aerosols) are more likely to happen. However, with proper policies and measures, buildings can be better prepared for re-occupancy and beyond. This study reviews the strategies developed by several Sustainability Rating Systems (SRS, namely WELL, Fitwel and LEED) to respond to any infectious disease and ensure that building occupants protect and maintain their health. The best practices, that are similar between each SRS, highlight that the overall sustainability of the spaces increases if they are resilient. Results indicate that SRS promote a weak sustainability approach since they accept that economic development can reduce natural capitals. SRS are also characterized by an aggregated level of assessment of different criteria that does not allow to map different choices. However, the decomposition of the concept of sustainability in its three bottom lines (i.e., environmental, social and economic) shows that preventive strategies are likely to be systematically adopted as the state-of-the-art. Finally, even if the latest research points out the airborne transmission as the major infection route, the SRS lack analytical measures to address issues such as social distancing.
... Despite widespread fear and uncertainty, history may provide us with valuable lessons about medical education during pandemics. During the Spanish influenza emergence of 1918, medical students in Spain, Minnesota, and Philadelphia were actively recruited to replace physicians lost to infection, and in the 1952 polio epidemic in Denmark students were tasked with manually ventilating patients [22][23][24][25]. More recently, the severe acute respiratory syndrome (SARS) outbreak of 2003 disrupted medical education (cessation of clinical clerkships and electives, delays in exams) in many countries including China and Canada, but substantial roles were attributed to students in order to provide their valuable help [26][27][28]. ...
Article
Full-text available
During the novel coronavirus pandemic outbreak, medical education has been inevitably disrupted, while the clinical exposure of many medical students has been hindered. The current article investigates the student role in this large-scale health crisis, in terms of providing for the continuity of medical training and addressing the growing needs of healthcare systems. By presenting different medical education policies implemented worldwide, new perspectives on student involvement are being illuminated. Even during pandemics, students should be motivated to actively serve. The formation of a clear framework for students’ roles enhances the preparedness of the medical education community for related future challenges.
... While the pandemic substantially decreased manufacturing employment and output, cities that intervened earlier and more aggressively not only ended up with lower mortality but also faster economic recovery. Areas more inflicted remained more depressed through 1923 (Ott et al. 2007;Chen 2020;Correia, Luck, and Verner 2020;Velde 2020). ...
Article
Full-text available
The Coronavirus Disease 2019 (COVID-19) pandemic is bringing about once-in-a-century changes to human society. Three key properties escalate the COVID-19 pandemic into a syndemic. To address this triple crisis, we discuss the importance of integrating early, targeted and coordinated public health measures with more equitable social policy and with a health-care policy that realigns incentives of the major players in the health-care market. Drawing on evidence from past and present epidemics as well as comparing variations in response to the current health emergency between China, the US and beyond, we navigate long-awaited health policy transformation in areas that help us better prepare for the next pandemic.
... The outbreak of the Spanish flu in 1918 has infected over 500 million people and killed more than 50 million worldwide, which was caused by H1N1 influenza. In order to control the spread of the virus, a public gathering was restricted, schools, offices, playgrounds, churches, etc., were shut down (Ott et al., 2007). In 2003, commercial air travel was considered the main cause of the SARS outbreak (Baker, 2015). ...
Article
Background COVID-19 outbreak unfolds as the biggest challenge of this century by far. Virulence of the disease has compelled densely populated countries like India to impose severest measures, which include full or partial lockdown to contain the virus spread. The contagious virus has put the lives of many in urban cities on hold and forced them to abandon or restrict regular activities, which includes a basic human need to travel to satisfy one’s daily needs. The eventual impact of the pandemic on individual mobility and the urban city’s sustainability depends upon the resilience of medium and long-term policies during such disruptive events. Objective In order to gauge the impact of this unprecedented disease on travel behavior and mobility patterns of individuals, a web survey is conducted in urban agglomerations of India. The idea is to record travel mode choices before, during and after situations. The study also attempts to elicit responses towards a safer and disaster-resilient public transport, which can also cater to the needs of private vehicle-owning individuals. Further, the study presents and evaluates a set of medium to long-term policy prescriptions to negate the repercussions of this crisis and seize the opportunity it has created so that the long-held dream of sustainable and resilient cities in the context of urban mobility is realized in the best way possible. Key findings The study findings indicate an increase in the car-dependency pan-India level post the COVID-19 crisis. Strikingly the captive users of public transport and non-motorized transport mode (walk) are also willing to make a shift towards private motorized vehicles (car, motorized two-wheeler). The eventual mobility shift will depend upon- (a) the recovery period of mass transportation systems to normalcy (b) investments and promotion of active travel modes (non-motorized transport, i.e., walk, bicycle). The findings also reveal that demand and the willingness to pay extra for a safer, faster, cleaner, comfortable, and most importantly, resilient public transport exists. Further, policy evaluations for sustainable and resilient recovery reveal - (a) the provision of bicycle superhighway will push the bicycle share from 31% to approximately 44% (b) travel demand moderation efforts such as (i) staggering of working days demonstrates the reduction in the congestion externalities. (ii) flexible arrangements for educational activities (two shifts in a day) facilitates overall gain in the system welfare, and (c) incentive such as reducing public transport fare has a positive impact on its share due to the mobility-shift from the private motorized vehicle. Interpretation and Implications of Results Investment and encouragement of active travel mode should be prioritized for personal well-being and disaster-resilient cities. Resilience planning should be an integral part of public transportation systems to handle the future shock of pandemics and other emergencies. Additionally, self-sustainable neighborhoods should be encouraged to reduce the trip lengths substantially or the need for private motorized transport for various secondary activities.
... Information transmission was long and tedious as postal workers, teachers and boy scouts were required to provide educational materials and teach health precautions to the public. Likewise, physicians reported their number of cases daily to the city health department which in turn reported their statistics to the newspapers [2]. This chain of information gave rise to misinformation and falsification. ...
Article
Full-text available
Since the first reported case of the coronavirus disease 2019 (COVID-19) in Wuhan China, the virus has spread to every continent, including sub-Saharan Africa. There exist no cure or vaccine for COVID-19. Classic public health approaches such as hygiene and sanitation, and social distancing are the recommended measures to contain the spread of the causative virus. While it is possible to combine strict lockdown measures in some western countries, this is not practical in almost every country in sub-Saharan Africa. In Cameroon, those without symptoms are encouraged to respect measures of hygiene and sanitation, physical distancing, and to wear a mask in public places. Those who develop symptoms are isolated in accredited COVID-19 management centres until they recover. However, the latter strategy is ineffective in containing the local spread of the virus because testing is not robust. Intuitively, the control of the virus in Cameroon depends largely on how engaged the public is in fighting against the virus. Social media can complement the use of community health workers for community or public engagement. In this viewpoint, we discuss how to optimize public engagement, to combat misinformation and to develop a culture for preparedness amidst the COVID-19 pandemic when time and resources are of the essence.
Article
The present research aims to identify the social consequences of Coronavirus (Covid-19), the role of clinical social worker in addressing this issue, the obstacles that impede him/her and the mechanisms as well as suggestions that improve this role. The author adopted the descriptive analytical approach and designed a questionnaire to collect data. The results showed that the consequence of “concern about losing relatives and friends because of Coronavirus” was ranked the first. However, the consequence of “self-harm that may induce suicide due to the social restrictions imposed by home quarantine” was ranked the last. In addition, the most prominent role of the clinical social worker in addressing this crisis was educating community members about its risks and the relevant social behaviors. Moreover, the most prominent obstacle was lack of training social workers to address this issue. To improve his/her roles, the research recommends presenting courses and workshops to raise the competence of clinical social workers dealing with crises, in general, and Coronavirus, in particular.
In attempting to lessen the incidence and to reduce the severity of infections of the respiratory tract by vaccination, it is essential to consider the wide range of bacterial flora, the relative prevalence of each species, as well as the fluctuations in incidence and severity of these infections with changes in season. The well-defined tendency of bacteria of the same species to localize differently in different epidemics indicates peculiar infecting and antigenic powers. The short duration of immunity to infections following attacks adds greatly to the difficulty. However, owing to the high incidence and high mortality rate from infections of the respiratory tract during the present epidemic, a painstaking effort to raise the resistance of individuals by inoculation with appropriate vaccines appeared to be strongly indicated.In considering prophylactic inoculations in this epidemic of influenza, we put aside the debated question as to the cause of the initial symptoms and
Article
Nonpharmaceutical interventions (NPIs) intended to reduce infectious contacts between persons form an integral part of plans to mitigate the impact of the next influenza pandemic. Although the potential benefits of NPIs are supported by mathematical models, the historical evidence for the impact of such interventions in past pandemics has not been systematically examined. We obtained data on the timing of 19 classes of NPI in 17 U.S. cities during the 1918 pandemic and tested the hypothesis that early implementation of multiple interventions was associated with reduced disease transmission. Consistent with this hypothesis, cities in which multiple interventions were implemented at an early phase of the epidemic had peak death rates ≈50% lower than those that did not and had less-steep epidemic curves. Cities in which multiple interventions were implemented at an early phase of the epidemic also showed a trend toward lower cumulative excess mortality, but the difference was smaller (≈20%) and less statistically significant than that for peak death rates. This finding was not unexpected, given that few cities maintained NPIs longer than 6 weeks in 1918. Early implementation of certain interventions, including closure of schools, churches, and theaters, was associated with lower peak death rates, but no single intervention showed an association with improved aggregate outcomes for the 1918 phase of the pandemic. These findings support the hypothesis that rapid implementation of multiple NPIs can significantly reduce influenza transmission, but that viral spread will be renewed upon relaxation of such measures. • mitigation • nonpharmaceutical interventions • closures
Minnesota Department of Health Correspondence and Miscellaneous Records
  • Henry Bracken
  • Rupert Blue
Henry Bracken to Rupert Blue, 1918 Nov 2, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895-1954, Minnesota Historical Society.
2; 1. 36. Influenza spread held slight here. Minneapolis Tribune
  • Speed
  • St
Speed grip fight. St. Paul Pioneer Press 1918 Nov 2; 1. 36. Influenza spread held slight here. Minneapolis Tribune 1918 Oct 2; 1,4.
Flu" order stops park grid games
  • See
  • St
See less influenza. St. Paul Pioneer Press 1918 Oct 15; 8. 24. Pins will fall. St. Paul Pioneer Press 1918 Nov 17; 7. 25. "Flu" order stops park grid games. Minneapolis Tribune 1918 Oct 14; 18,12.
Influenza relief work disrupted as a result of telephone strike
  • Shows Open Today
  • St
Shows open today. St. Paul Pioneer Press 1918 Nov 15; 1. 33. Influenza relief work disrupted as a result of telephone strike. St. Paul Pioneer Press 1918 Nov 16; 1.
2; 1. 36. Influenza spread held slight here
  • Speed
  • St
Speed grip fight. St. Paul Pioneer Press 1918 Nov 2; 1. 36. Influenza spread held slight here. Minneapolis Tribune 1918 Oct 2; 1,4.
Minnesota Department of Health Correspondence and Miscellaneous Records
  • Henry Bracken To Dr
  • W Merritte
  • Ireland
Henry Bracken to Dr. Merritte W. Ireland, 1918 Nov 16, Minnesota Department of Health Correspondence and Miscellaneous Records, 1895-1954, Minnesota Historical Society.