Rules already in place by the beginning of the twentieth century forbade any person sick with typhoid fever, or any infectious disease, to handle food. Although rarely enforced, no doubt because of the enormous size of the problem of tracing the activities of the sick who were not hospitalized, this policy provided the precedent upon which regulation of healthy carriers rested. The department determined in 1913 that typhoid fever convalescents who worked in food establishments would not be allowed to return to work until they had been examined for typhoid bacilli and proven to be free of them.42 A small number of carriers were identified through the execution of this rule. In 1915, for example, the year when Mary Mallon was found cooking at Sloane Maternity Hospital and returned to North Brother Island, 159 food handlers recovered from typhoid fever and were closely examined. The laboratory identified four persistent chronic carriers and refused them permission to return to work.43
In 1915 and 1916, the health department instituted new rules clearly related to the reappearance and demonstrated continuing danger of Mary Mallon. These regulations, aimed specifically at more effective control of typhoid fever carriers, were again modified in 1919, 1921, and 1922. First was a more precise definition of when convalescents could be terminated and declared free of carrying bacilli: when both feces and urine could be shown in the laboratory to be free of bacilli if taken at least ten days after the patient’s temperature returned to normal. Most significant was the provision that typhoid fever cases (specific coverage of carriers came with the 1921 revisions) should be forcibly removed to the hospital unless the department found “home conditions . . . satisfactory.” Health officers would be satisfied that strict quarantine rules could be applied at home if the household provided for the disinfection of all stools and urine of the affected sufferers, agreed to immunize all susceptibles, and insured that those attendant on the sick would have nothing to do with the cooking or care of children for the rest of the family. The sick had to have separate toilet facilities, a stipulation that limited the stay-at-home to the more privileged classes. Health authorities further limited who could remain at home with the stipulation: “The family must be intelligent and willing to carry out rules of the Department of Health.”44
The names of the unfortunate few who after a bout of typhoid fever continued to test positive for bacilli were entered on a health department list of typhoid carriers. The department kept an individual card for each carrier, on which was entered the specific data available for that carrier. Health officers tried to keep in close contact with these carriers, required them to submit to laboratory analysis on a regular basis, and insisted that they not handle any food. In 1916, New York officials sent their carrier list of twenty-four individuals to the United States Public Health Service.45 The list grew rapidly, and, by 1918, the health officers wrote: “The problem of supervising typhoid carriers requires constant watchfulness and study. At present we have a record of 70 chronic carriers, three of whom are detained forcibly in Department hospitals [one of these was Mary Mallon], the others being permitted to stay at home under constant supervision.”46
Despite the obvious difficulty of finding and monitoring healthy carriers, New York City Health Department annual reports optimistically continued to carry the motto “Public health is purchasable.”47 Health officials maintained optimism in part because of frequent carrier cooperation. In New York State, health officer F. M. Meader answered the question “What can be done with these carriers?” with the statement “Inform them that they are carriers. Most persons so informed will care for themselves in such a way that they will not be a menace to the public.”48 In his study of 1,004 New York City carriers, Stephen Friedman similarly concluded:
Most carriers lived with the restriction imposed on them. . . . These restrictions required the carrier to practice good hygiene in his toilet habits, and to keep the Health Department informed as to his address and place of employment. Carriers were forbidden to work as food handlers, nurses or teachers. Thus being declared a carrier sometimes meant economic hardship for that individual.49
High-level cooperation might have been predicted by the demographics of the carriers themselves. Most carriers identified were women, and the search for carriers yielded housewives more than any other occupation category. But housewives did not cause most of the typhoid outbreaks. Despite the small number of public food handling carriers identified (only 8.5 percent of the entire city sample), including butchers, bakers, cooks, and waiters, the food handlers accounted for more associated cases of typhoid fever than any other group. Friedman concluded, “The mean number of cases caused by food handlers was therefore about five times the number caused by housewives.”50
Even with high levels of carrier cooperation, the difficulties of maintaining the program remained enormous. In 1919, one health official estimated that New York City harbored 25,000 typhoid carriers.51 In that year, the health department restrained two typhoid fever carriers in city hospitals (one of them Mary Mallon), three others had absconded from department purview, and the other sixty-two identified chronic carriers lived under conditions that “in all cases were excellent. They had been carefully instructed how to protect others, and they carefully observe[d] these instructions.”52 Although the majority of healthy carriers under department supervision followed the rules, still a substantial number did not. As the official list of chronic carriers continued to grow—in New York City, in the state, and in the country—so too did the list of those lost to the regulations.
The health department did not have a lot of success in following those people who, although registered, did not show up for the required specimen examination or who did not provide their addresses to the authorities. In 1922, for example, New Jersey officials found Tony Labella, an absconded New York City carrier, a man who had reportedly caused an outbreak of eighty-seven cases (considerably more than Mallon) and two deaths, and blamed him for yet another outbreak that had resulted in thirty-five cases and three deaths.53 During the year 1922, indeed, six chronic carriers “absconded” from the city list—literally disappeared from the view and control of officials. Four more “refused absolutely to give stool specimens when requested, making it necessary for us to resort to the exercise of police power to procure compliance with the requirements.”54
During the 1920s, it is clear, many registered carriers refused to cooperate with health department regulations, and some continued to cook after being forbidden by the health department. A few of these found themselves isolated, usually briefly, at Riverside or Kingston Avenue hospitals.55 None, as far as I can determine, was isolated for life, as Mary Mallon was. We may never understand all the reasons that made health officials put her on North Brother Island, especially in 1907, or even in 1915, but it is instructive to know how they handled similar cases.
In 1924, Alphonse Cotils, a bakery and restaurant owner whose name was on the city list of healthy carriers and who had been forbidden to prepare food in his own business, appeared in court after he had violated the terms of his agreement with the health department. He defied health department rules, his physician said, because officials were “ ‘annoying’ him about working in his own bakery.” Cotils knew he was a typhoid carrier, and he knew he was not allowed to prepare food for other people. Like Mary Mallon before him, he refused to cooperate with the regulation and continued his work. But unlike the Mallon case, the judge, while finding him guilty, suspended his sentence “after Cotils had promised to remain away from his restaurant and keep out of kitchens. He intends to conduct his business by telephone, he said.” The judge was quoted in the newspaper: “I am thoroughly impressed with the extreme danger from these typhoid carriers, particularly when they are handling food. I could not legally sentence this man to jail on account of his health . . .”56
At the very moment the judge said he could not legally imprison Alphonse Cotils because he was not sick, a healthy Mary Mallon was held on North Brother Island. Both had violated a previously imposed quarantine
; only one was detained for it. Was this because she was the first carrier to be traced in New York City? Were her fighting and swearing during her initial arrest enough to explain her unique treatment?
The policies governing healthy carriers answer some of the questions about the particular detention of Mary Mallon. The somewhat ambiguous 1916 guidelines—written after her second incarceration—stated that carriers “need not be retained in hospitals or institutions if not desired. They will be sent home if home conditions are satisfactory.” The vagueness of how “satisfactory” was to be determined left room for significant maneuvering and permitted health officials to make decisions about healthy carriers that incorporated a range of considerations. They could, for example, differentiate between Mary Mallon, whom health officials did not trust to behave in the public’s interest, possibly because of her blatantly resistant behavior, and other healthy carriers, like Alphonse Cotils, whose resistance was quieter and whose home conditions and personal attributes seemed to predict closer compliance with the health codes.
Although two healthy carriers might have borne equally dangerous pathogenic bacteria as identified in the laboratory, they were not necessarily treated equally in practice. According to the equivocal health department protocols, the carriers’ social condition and even their psychological responses could be applied alongside the laboratory reports to evaluate the dangers they presented and to determine ways to protect the public from the dangers they posed. Health officers judged the home conditions, sanitary facilities, and the individual’s tractability as they determined the proper regulation of healthy typhoid bacilli carriers.
Once people had been entered on the official list of carriers, officials usually released them to their homes with the hope that they would follow the agreement and not prepare food in the public sphere. But it was not possible for officials to watch all the carriers daily to determine if they actually followed the guidelines. The most officials could accomplish was to require continuing laboratory analysis, usually once every three to six months, and the reporting of address changes, monitored monthly beginning in 1929. If people did not appear for the laboratory tests or if they moved and did not report a forwarding address, there was little the health department could do except wait for the ensuing typhoid outbreaks.
In a California study tracing healthy carriers over a long period of time, investigators reported that about 12 percent of carriers disappeared and a full 25 percent did not cooperate with officials. They noted that males were “lost to the registry more often than females,” even though there was a significantly larger number of female carriers.57 The proportion of the group of carriers labeled uncooperative changed over time. In the years 1910 to 1919 when California’s healthy carrier regulation program had just started, 50 percent of the registered carriers did not cooperate with the program. The following decade proved even worse, reaching over 58 percent of carriers who refused to cooperate with the restrictions. But from 1930 to 1939, despite the deepening economic crisis, only 40 percent refused to cooperate. The figure decreased to 20 percent during the 1940s and 12 percent during the 1950s.58
There were various reasons why healthy men and women did not cooperate with the healthy carrier restrictions, and it is instructive to compare some of them with Mary Mallon’s situation. The most significant reason given in the California study for uncooperative carriers was the need for employment. For those people who prepared food for others as their paid jobs (in contrast to those who prepared food within the home or for occasions like church suppers), being labeled a typhoid carrier meant giving up their means of support and the necessity of learning new skills and seeking alternative employment. Some could make such a transition smoothly; many could not. Some could not find comparable employment outside the food industry. A small percentage of carriers, like Mary Mallon, would not or could not be convinced that they were dangerous to others. Feeling healthy themselves, they did not accept a laboratory finding that they made others ill. Attitudes and employment possibilities could change over time, and occasionally those who had cooperated during the periods they could find work reversed themselves when they could not. As bacteriological understanding spread by the middle of the twentieth century, however, more and more carriers came to accept the fact that they could be transmitting the disease to others even though they felt healthy themselves.59
Some jurisdictions, realizing that carriers might lose their jobs and need financial help, instituted a system of temporary stipends for carrier breadwinners who had trouble finding employment. The state of New York, through its local county poor officers, provided some monthly allowances to “supplement the earnings of the patient who can not engage in work which will endanger the food supply.”60 Begun in 1918, the subsidy program never fully maintained those carriers and their families who were inconvenienced by the policies restricting their activity, but between 1918 and 1932, for example, it helped fifty-two carriers with allowances running between $10 and $50 per month.61
There is other evidence that health officials provided added services to breadwinners or otherwise treated them with greater lenience than they did those presumed to be without family responsibilities. Health officials helped Tony Labella, who had caused typhoid outbreaks in both New York and New Jersey, to find work outside the food industry They returned Alphonse Cotils to his family and business. Yet health officers did not offer Mary Mallon similar aid and understanding. In a national study of laws and regulations controlling infectious diseases, researchers noted that “exceptions in favor of breadwinners . . . may be made by local health authorities.”62 Perhaps Mary Mallon did not fit the official definition of a breadwinner because she was a woman or because she had no family.63
New York state and city officials, as we have seen, did not isolate most healthy carriers they had located. In this, they followed national public health authorities, notably Milton Rosenau and Charles Chapin, who believed that it was usually not necessary, or desirable, to isolate healthy carriers. In his popular public health textbook, Milton Rosenau offered suggestions for carriers that were significantly less stringent than his proposals for the acutely ill. The textbook first appeared in 1913 and enjoyed seven editions by 1951, becoming the standard for the field and influencing generations of public health workers. The 1935 edition, the last one Rosenau himself wrote, provided this advice:
We cannot lightly imprison persons in good health, especially in the case of breadwinners, even though they be a menace to others. In some infections there are so many carriers that it would require military rule to carry out such a plan. Fortunately in most cases absolute quarantine is not necessary. Sanitary isolation is sufficient. Thus the danger from a typhoid carrier may be neutralized if the person exercises scrupulous and intelligent cleanliness, and is not allowed to handle food intended for others. Such a person might well engage as carpenter, banker, seamstress, etc., without endangering his fellowmen. . . . The price of liberty is “good behavior.”64
Rosenau’s analysis identified the various factors he thought should protect healthy carriers from hospitalization or incarceration: their health; their economic value in the family; their sheer numbers in the population; and their behavior (habits and jobs), which usually could be effectively controlled outside the hospital. Despite obtaining identical laboratory reports for both sick and healthy persons infected with typhoid bacilli, bacteriologically oriented public health officials did not recommend the same regulations for both groups. The sick should be temporarily isolated in homes or hospitals; the healthy carriers could be allowed to walk about on the city streets. The laboratory alone, for these practically oriented public health workers, could not define the full scope of the public health approach.
Rosenau’s formula reveals the other factors that entered into determining public health policy about healthy carriers. If carriers had significant financial responsibilities, health officers felt they should not deny them their livelihood. A person’s social and economic position a
s head of a household provided some immunity against the state’s authority to intervene. The suspended sentence Alphonse Cotils received when found guilty of violating the health codes reflected this viewpoint. The judge let him go not only because he was healthy but because he was an established businessman.65 Furthermore, the very numbers of carriers involved precluded their institutionalization. While it might have been physically possible to isolate the growing numbers of healthy carriers, the political and economic restrictions of city health departments already operating on limited budgets made a full-scale isolation policy unrealistic.
Rosenau’s precepts for healthy carrier control reflected the common faith of early twentieth-century bacteriologists in the potential for altering human behavior. He assumed that both scrupulous personal cleanliness and cooperating in changing jobs offered workable solutions to public health problems. His optimism was echoed in New York City health officers’ statements about the level of cooperation they actually received from most carriers and in the writings of other public health authorities. In his 1910 text, The Sources and Modes of Infection, Charles Chapin similarly found the suggestion to isolate healthy carriers impossible, unjust, and ineffectual.66 Chapin, like Rosenau, advocated retraining carriers to allow them to find jobs outside the food handling occupations instead of indefinite isolation.
Typhoid Mary Page 7