Minnesotans have long considered health to be as central to their identity as the weather; in fact, to recruit settler-colonists, Minnesota's early promoters touted the state's distinctive, supposedly fever-free climate and its potential to foster health. The settler-colonists who responded shaped health in Minnesota in turn, altering the physical environment with their tools and the social environment with their traditions of cooperative self-help.

Thus, a modern public health infrastructure grew side by side with medicine in an expanding state. Innovations in medical care and in models for its delivery developed as responses to local conditions and needs, and became products that could be exported to the nation and the world.

Minnesotans' intimate relationship with the natural environment has been, at times, a double-edged sword: long winters and isolation have strained mental health; agricultural practices have polluted the water and threatened the health of farm communities; sparse population and rural distances have produced disparities in access to medical care. Still, Minnesotans see their state as a healthy place, one in which the production of health and medicine has become big business.

Early Colonization, Early Disease

Explorers' accounts of the Minnesota territory do not describe a health paradise. Father Louis Hennepin's 1683 account of his travels with Native Americans records sickness, fatal rattlesnake bites, and chronic hunger.

By the 1780s, new diseases carried by Europeans, notably smallpox, were causing deadly epidemics in the non-immune Native American population. The disease, starvation, and cultural destruction among Native Americans that resulted from interaction with Europeans arguably quickened the decline of the Upper Mississippi Valley fur trade by reducing the ranks of Native hunters.

European-American settler-colonists also suffered epidemics. Steamboats carried cholera up the Mississippi River to St. Paul in 1854 and 1855. St. Paul's newspapers, city council, and city board of health worked together to suppress information about the epidemic, lest it undermine the area's healthful image. The Sisters of the Order of St. Joseph of Carondelet responded more pragmatically, opening the state's first hospital, St. Joseph's, in St. Paul in 1854.

Published guides to Minnesota appealed to invalids—the medical tourists of the nineteenth century. But even as these guides described Minnesota's "fever-free" landscape and its frosty air as a help for lung problems, consumption (tuberculosis) accounted for almost 15 percent of deaths in the state in 1872. In fact, Minnesota mirrored trends elsewhere in the United States from the late 1800s into the early 1900s. Infectious diseases such as measles and scarlet fever were rampant: hundreds of Dakota women, children, and elders died of disease and malnutrition while kept at Fort Snelling after the US–Dakota War; diphtheria and typhoid epidemics were common until the 1910s; and smallpox outbreaks—preventable through vaccination—continued into the 1930s. Medical treatments for these illnesses were limited, and many people relied on midwives, healers, and home remedies rooted in their ethnic traditions rather than physicians.

Ole Edvart Rølvaag's epic novel Giants in the Earth describes the toll that long winters, isolation, backbreaking work, and the grasshopper plagues of the 1870s took on the mental health of settler-colonists. Urbanization and the recruitment of young immigrant workers for Minnesota's new farms, mines, and lumber camps loosened the family and community ties that had traditionally provided care for the mentally ill, disabled, and elderly.

To support the state's expanding social and medical needs, charitable and religious organizations and state government established new institutions. St. Peter State Hospital for the Insane (later renamed St. Peter State Hospital) opened in 1866; by 1900, the state had five public mental institutions.

Protecting the Public: A State Board of Health

One challenge for Minnesota leaders was keeping the state's new citizens healthy and productive by preventing disease. In 1872, Minnesota followed Massachusetts and California in establishing a state board of health. Responsibility for public health rested with local communities' part-time health officers and boards of health, while the state board set policy and provided support services.

Minnesota was putting public health structures in place as old humoral and miasmatic theories of disease causation were giving way to germ theory, the idea that specific pathogens cause specific diseases. Germ theory offered compelling logic for new public health measures, such as regulation of the cleanliness of food and water supplies. The State Board of Health provided sanitary inspection services and in 1896 established a bacteriological laboratory, replacing the Secretary of the Board of Health's personal lab, which had been used for water analyses since 1873.

Meanwhile, environmental changes caused by humans drove an increased demand for medicine. Steam laundries, knitting mills, grain mills, and mines produced occupational respiratory diseases. Mechanized agriculture, sawmills, railroads, and industry mangled workers' bodies daily and caused occasional catastrophes, such as the 1878 Washburn flour mill explosion in Minneapolis. The artificial limb companies that were started to serve Civil War amputees thrived with the steady demand from victims of industrialization.

Hospitals, Clinics, and Medical Education

Unlike eastern states, which had hospitals and medical schools dating back to the eighteenth century but were just creating public health departments in the 1880s, Minnesota developed its medical system in tandem with its modern public health infrastructure, in response to the specific needs of the growing state. In 1883, the state legislature passed a law regulating who could practice medicine, and by the end of the 1880s, there were five hospitals in the Twin Cities and several medical colleges.

New medical graduates William and Charles Mayo joined their father's medical practice in Rochester in this period. In an era before residency training, the Mayos became surgical specialists by practicing on a large number of cases and by observing and reading about other surgeons' work. But it was the combination of the Mayos' medical craft, the modern facilities and nursing care provided by the Sisters of St. Francis at St. Mary's Hospital, and an expanding railway network that made Rochester a medical destination. Patients were attracted to the specialized, but integrated, expertise at the Mayo Clinic, which pioneered the efficient management of patients and information within group practice.

Licensing doctors was not enough by itself to elevate the quality of medical practice in Minnesota; in 1888, Minnesota medical leaders sought to improve care by standardizing medical education under the umbrella of the University of Minnesota, the state's land-grant university. By 1909, all the state's small, proprietary medical colleges had merged into the University's College of Medicine. As Minnesota's only medical school, the College of Medicine offered medical students basic science and laboratory experience, and clinical education in its hospital, which also provided care for the state's poor. These attributes earned the college rare praise in the Carnegie Foundation's 1909 survey of American medical schools. Two years later, Minnesota became the first medical school in the nation to require a year of hospital experience (internship) for the MD degree.

Additional Public Health Initiatives

While Rochester and the Twin Cities were becoming regional medical centers focused on individual health, the state health department was taking on population health threats. This was sometimes contentious: on the grounds of individual rights or potential negative commercial impacts, individuals and business interests opposed measures such as mandatory smallpox vaccination and restrictions on travel and public gatherings during the influenza epidemic of 1918. Minneapolis could not agree on milk pasteurization until 1948. The Minnesota Sanatorium for Consumptives at Ah-Gwah-Ching opened in 1907, the first of a network of state and county hospitals where people with active tuberculosis were preventatively isolated and treated. However, many tuberculosis sufferers resisted being sent to these hospitals.

By the 1910s, the state's attention shifted from attracting new settler-colonists and controlling infectious disease to breeding healthy citizens and preventing chronic disease. Federal funds encouraged the state health department to establish a Division of Child Hygiene in 1922. The division targeted high infant mortality, employing public health nurses to provide prenatal and well-baby care in rural areas and poor urban neighborhoods, and on Native reservations. The focus on cultivating a healthy future population took a coercive form, however, in the state's 1925 eugenics law. In the decades that followed the law's passing, more than 2,200 so-called defective residents at the School for the Feeble-Minded in Faribault, Minnesota, were surgically sterilized.

Across the twentieth century, support for public health in Minnesota has been paradoxical: the state has benefited from an activist Board of Health and progressive social welfare programs, both public and private, but going back to the 1920s, its per capita spending on public health has lagged behind some of the poorest states in the country.

Still, by most measures, health status for white Minnesotans has consistently ranked among the best in the nation since at least 1945. Higher incomes and educational levels probably have played a role, as have the state's prosperity and commitment to the common good. All of these factors have contributed to a higher proportion of citizens with health insurance at the turn of the twenty-first century than the national average.

Medical Enterprises: Big Business for the State

As Minnesota emerged from the Depression and World War II, its economy was increasingly shaped by its medical enterprises. These enterprises also influenced medical science and practice throughout the world, as they exported medical knowledge, technology, and skilled practitioners. Mayo Clinic chemist Edward Kendall isolated the hormone that led to the development of cortisone, for which he shared the 1950 Nobel Prize in Physiology or Medicine. Australian nurse Sister Elizabeth Kenny received a rare positive reception among the faculty at the University of Minnesota Medical School in 1940 for her physical therapeutic approach to polio. The Sister Kenny Institute in Minneapolis brought polio patients, physicians, and research money to Minnesota; by the mid-1940s, Kenny's method had overtaken traditional immobilizing therapies for polio.

The University of Minnesota nurtured innovation and research in this period. Physiologist Ancel Keys's work on nutrition became common knowledge—he invented the "K-ration" for soldiers in World War II as well as the "Mediterranean diet," based on his Seven-Country Study of diet and cardiovascular health, which continues to inform contemporary medicine. Owen Wangensteen established the University's surgery department as an international center for research and training; pioneer transplant surgeons Norman Shumway and Christiaan Barnard earned PhDs there.

The simple, disposable bubble oxygenator that helped transform heart surgery was developed by Richard DeWall and C. Walton Lillehei at the University. They used it for their frequent operations on newborns with blue-baby syndrome—cyanotic heart defects caused by nitrates from fertilizers leaching into wells and groundwater, linked to Minnesota's agricultural environment.

Engineer Earl Bakken and Medtronic, the small company he founded in his garage in 1949, supported University surgeons' technical needs and, in the process, launched Minnesota's medical device industry. More than sixty years later, the state's biobusiness technology sector encompasses hundreds of firms employing more than 34,000 people, with revenues of more than $11 billion in 2007.

Minnesota's dominant food and agricultural industries have had sometimes contradictory consequences for global and state health. Nutritional-deficiency diseases like pellagra were made worse in the late nineteenth century by Minnesota companies' adoption of new degerming and milling technologies; but in the 1940s, nutrition science and food industry processes added nutrients back into the flour and baked goods Minnesota supplied the world. University of Minnesota agronomist Norman Borlaug won the 1970 Peace Prize for his contributions to the Green Revolution—engineering high-yield crops to feed the world's expanding population. However, the chemically intensive farming methods of the Green Revolution era created new health problems in the form of water pollution and increased rates of cancer for agricultural workers and rural residents.

Health Care Disparities

Minnesota remained a mostly rural state three decades longer than the nation as a whole. Until 1950, half of the state's population lived in rural areas or in towns of 2,500 or less. However, changes in the countryside, the rise of hospitals and medical technology, and reliance on medical insurance to pay for care favored the health of city-dwellers. Poorer access to medical care in rural areas was more evident than ever by the end of the 1930s, and federal and state efforts to improve it helped only a little. The federal Emergency Maternity and Infant Care Act for low-ranking soldiers' families in World War II increased the percentage of Minnesota babies born in hospitals, and the 1946 Hill-Burton Hospital Construction Act helped fund new hospitals in 29 Minnesota communities in its first four years alone.

Medicine has been a profitable state industry, but Minnesotans' geographic and financial access to care has been an increasing issue since World War II. Racial disparities in disease incidence, mortality, and life expectancy also have revealed an unhealthy underside to the state's reputation for social equality. To address the problem of access, Community Health Associates in Two Harbors (1944) and Group Health Plan in the Twin Cities (1957) built on the state's historic tradition of cooperatives to offer prepaid direct medical service plans to members. Innovative models for the organization and delivery of care—group practice; cooperative health plans; the 1973 law requiring that health maintenance organizations (HMOs) be nonprofit; public health insurance for children; and the 1992 MinnesotaCare insurance plan for low-income citizens—have reflected a distinctly Minnesota approach and have provided leadership for the nation.

Regulating Environmental Hazards

By the 1970s, pride in Minnesota's natural environment was tinged with concerns about health risks, such as Lyme disease and mercury-contaminated fish. Human actions had altered the state's landscape, and environmental hazards could no longer be easily hidden.

Legislative and judicial initiatives sought to address existing hazards, just as the State Board of Health had policed hygienic perils seven decades earlier. Citizens' organizations and state and federal governments sued Reserve Mining Company for dumping taconite tailings with asbestos-like fibers into Lake Superior and polluting municipal water supplies along the North Shore. But the damage has been long-lasting: today, Northern Minnesota residents and miners exhibit excess rates of mesothelioma, a rare lung cancer caused by asbestos exposure.

In 1975, Minnesotans tackled chronic disease by becoming the first state to prohibit smoking in restaurants and other public places. The state also was among the first to sue the tobacco industry successfully, arguing that cigarettes caused multiple health problems in the population, thus raising the costs of public health and medical health care for thousands of patients in state-funded insurance programs.

Changing Context for the State's Future Health

Minnesota has a critical stake in national debates about universal health coverage, the education and distribution of the medical workforce, climate change and environmental policies, and the responsibility of government for the health and well-being of its citizens. Following national trends, health care and medicine will likely remain cornerstones of the state's economy, but new people, new needs, and new attitudes will shape Minnesota's health status in the context of the twenty-first century.

Jennifer Gunn is an associate professor and Director of the Program in the History of Medicine at the University of Minnesota. She is the author of Plains Practice: A History of Rural Health and Medicine in the Upper Midwest, 1900-1950.