CONCLUSION
Several factors impede direct comparisons of the two cities' approaches. The cities border each other and residents travel back and forth. Although the containment philosophies differed greatly, in reality St. Paul government officials 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 specifically determined, other lessons can be learned from what happened in 1918. Many steps could have been taken to prevent illness and save lives. Prior planning, clear orders, as well as consistent and transparent advice and information to the public may have made a significant difference in the number of cases and deaths due to influenza in 1918.
There was a paucity of planning for a health emergency when influenza first appeared. While the actions that the two city health departments took to stem the spread of influenza align closely with current pandemic plans, health officials 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 sanitation 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 influenza pandemic, it is imperative that the safety of health-care workers is insured. The number of nurses and physicians who fell ill and even died as a result of assisting in the fight 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 different public officials 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 members 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 officials were generally lacking at the federal and state levels. It was almost as if the fear of using their authority 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 officials, “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 defined 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 define their own rules while attempting to decipher conflicting messages from the state and federal level.
Because clear orders were not being given to public health officials, 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 influenza a life-threatening condition, or was panic the most dangerous element of the influenza 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 communicated 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 interventions were implemented early in the pandemic fared better.45 Of primary importance is developing a plan ahead of time that incorporates all levels of government 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 benefit of isolation should be weighed against the possibility that some people would be discouraged from seeking care. Clear explanations of the reason for isolation, 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 scientific data whenever possible, and include input from ethicists. Unlike in 1918, a pandemic influenza 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 messages that are scientifically 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.
Basically Concart,.....you can talk shit all you want,....means absolutely NOTHING. 
