It is fair to say, I think, that what is most jarring to some Americans about both the Cuban example and Mary Mallon’s experience is that individual liberty seems to be irrevocably and maybe too quickly overridden by the perceived larger good of protecting the public’s health. Health officials went immediately to what even their own policies said should be their last resort when they isolated Mary Mallon without trying possible alternatives, and they were supported in their arbitrary actions two years after the fact by the court of law and even later by the court of public opinion. The actions of the officials—establishing indefinite and involuntary permanency to her isolation—were condoned even though they had not initially included due process procedures and rehabilitative measures. By devaluing Mallon with the label of “Typhoid Mary,” society helped to cast her aside to an island where her risk to social order and health could be contained. A health policy that emphasizes a custodial as much as a health-keeping function makes it easier to dismiss individuals from the social polity, but these custodial aspects are also the ones we find so perplexing and problematic as we develop public health policies at the end of the twentieth century.18
If health officials at the time could have more convincingly argued that Mallon was such a unique menace to those around her that there was no choice but to apply the harshest penalty, historical judgment might be kinder. But the hundreds or thousands of other carriers remaining on the streets of New York, both unidentified and registered, belied such a conclusion, especially in light of other carriers who had caused more typhoid fever than Mary Mallon and had shown equal resistance to restraint. There were other ways to keep Mary Mallon from transmitting typhoid fever short of leaving her on an island for twenty-six years. If health officials could have initially approached her without force, if they could have initially—in 1907—retrained her for a job of equal or higher status and pay that did not involve food preparation, she might not have continued to be a risk to others. If she had been provided with a subsidy to help her survive until such time as she could have become economically independent, she might have been of a mind to try to learn prescribed sanitary routines. Clearly, these and other alternatives are easier for us to see now than for New York health officials early in the century. But the fact that some of these alternatives were strongly supported by public health experts such as Charles V. Chapin of Rhode Island and Health Commissioner Ernst Lederle in New York suggests that other possibilities were within reach at the time and could have been applied to Mallon.
This is not to suggest that Mallon herself should remain blameless in historical judgment. While it seems that health officials acted too precipitously and without sufficient tact or understanding of her situation, it also seems that Mallon herself overreacted to their advances. Mallon felt that public health officials discriminated against her, and her perception made her resistance to public health authority all the stronger. Her ire, once raised, could not be contained again, and it contributed to escalating the chain of events and in part to her long-term incarceration. But she was the one who was the most vulnerable, and, in the face of a powerful health authority, she paid the highest price.
If we can use history to explore the various aspects of identification and isolation, even though the analogy with the past is imperfect, perhaps we can avoid some of the mistakes health officials made in Mallon’s case and act more judiciously today We can learn to pay careful attention to the injury that is caused by stigmatizing labels. If public health law were to be applied more equitably, then people might begin to trust it not to discriminate in their particular cases. A more highly trusted public health system could more effectively educate people who carry disease to refrain from activities that put others at risk, making isolation truly a last resort. There might remain a few individuals who would need to be forcibly separated from society in order to stop them from willfully transmitting disease, but with an equitably applied public health policy, we might expect the number to be small.
People who have the potential for putting others at risk need, probably more than anything else, to be made aware of their infectivity and taught how to minimize or prevent it. This argument is made, for example, by Johan Giesecke, an infectious disease specialist in Stockholm who studied and participated in Sweden’s efforts to control AIDS. Giesecke believes that “strong public confidence in a benevolent and non-discriminatory state and health care system” is more valuable than “repressive legislation.”19 This is also the conclusion that emerges from our study of Mary Mallon’s experiences. If she had had confidence in a benevolent system, she would have been more inclined to cooperate with authorities. Instead, she had reason to believe the system would work against her, that who she was—a poor, immigrant, single, middle-aged woman—made her vulnerable to harm by the system rather than protection by it.
Unfortunately, there are numerous examples in twentieth-century U.S. public health history that lead people to conclude, with Mary Mallon, that policies have been discriminatory and have not been fairly applied. In 1900, San Francisco health authorities literally strung a quarantine rope around Chinatown in their efforts to stem an outbreak of the plague, blatantly relying on prejudices and stereotypes to identify the group blamed for putting the population at risk.20 In the 1930s, the U.S. Public Health Service began an experiment in Macon County, Alabama, to trace the natural development of syphilis in African-American males, and in the process denied the participants the benefits of effective therapy.21 The Tuskegee experiment, now notorious, lasted forty years. It is no accident, according to historian Alan Kraut, that immigrants and racial minorities have historically felt the strongest pressure from the discriminatory application of health policies. Nativist beliefs lead society to attach the stigma of disease to such already marginalized individuals, isolating them even further from the mainstream. Immigrants have been consistently despised and feared—and then labeled—as harbingers of disease and death to the native-born.22
Fairness in health policy is not just a matter of uniform and consistent application of the laws. If so, the Cuban example of incarcerating all people who test positive for HIV would be our model for creating a system that could be trusted. Process and method are also crucial to our thinking about equity in health policy. How we as a society decide which of the myriad health issues facing us will receive our priority attention, and how we talk about, identify, and treat those individuals we consider to put others at risk reflect our cultural values and our strength as a nation. What Mary Mallon’s story contributes to our efforts to create a more just health system is exemplary pitfalls to avoid and signposts for flagging important individual issues.
Early experience with HIV infection indicates that American public health has not yet moved very far away from some of the social insensitivities evident in Mallon’s day. In the early 1980s, the infection’s initial association with gay men and Haitian refugees allowed the marginalization of homosexuality and race to shape an emerging disease-associated stigma and exacerbate what seemed to many an unfair distribution of blame. The response from gay men was rapid. Believing the governmental response flawed and inadequate, gay activists, predominantly white, middle-class men accustomed to working within the system despite the homophobia they felt daily, organized to combat the disease within their own communities. The combination of local organization and public efforts proved beneficial, and in cities like San Francisco, where AIDS initially hit hardest, incidence rates began to fall.23 But other groups affected by HIV—“gay/bisexual black and Hispanic men . . . many black and Hispanic i.v. drug users; black and Hispanic women and black and Hispanic babies born to these women”—could not offer effective, organized responses, and they continued to suffer greater social stigma and higher rates of disease.24 The initial thinking and early actions to combat AIDS provide a powerful example of how public health policy still falls short of equitable judgment and treatment for all.
The United States can legally decide, as the Cuban government did, tha
t protection of the public health is a higher national priority than are individual rights and the liberty of the stricken. Or it can instead choose to continue to consider civil liberty an equally dominant national priority and work to establish a policy of fair nondiscriminatory health reform that will earn the confidence of all American citizens and provide them genuine, cooperative, long-term protection. Such changes would move the country in a direction that will foster the public’s health and at the same time show maximum respect for individual rights. As I write, millions of uninsured Americans continue to feel that they are outsiders to the health system. Perhaps Mary Mallon’s story of the confusion, anger, and final bitter denial of an outsider should be in the minds of those who will determine our future public health strategies.
Blame and Responsibility
Public support plummeted and opinion turned against Mary Mallon in 1915 because of her conscious return to cooking when people believed she should have learned her lesson. “The chance was given to her five years ago to live in freedom,” editorialized the New York Tribune, and “she deliberately elected to throw it away.”25 Historians have since that time been no more lenient in their assessment of Mallon’s informed return to cooking. In 1994, Robert J. T. Joy put it directly: “Consider that Mallon disappeared for five years, and used several aliases and went straight back to cooking! . . . Now, as far as I am concerned, this verges on assault with the possibility of second degree murder. Mallon knows she carries typhoid, knows she should not cook—and does so.”26
To be sure, Mary Mallon was not entirely blameless when she knowingly returned to cooking in 1915, but the blame must be more broadly shared. Much of what Mallon did can be explained by events greater than herself and beyond her control. It is only in the full context of her life and the actions of the health officials and the media that we can understand the personal position of Mary Mallon and people like her—people whom society accuses of endangering the health of others—and can hope to formulate policies that will address their individual needs while still permitting governments to do what they are obligated to do, act to protect the public’s health.
Mallon was not a free agent in 1914, when she returned to cooking. Consider her circumstances. She had been abruptly, even violently, wrenched from her life, a life in which she found various satisfactions and from which she earned a decent living. She was physically separated from all that was familiar to her and isolated on an island. She was labeled a monster and a freak. She was not permitted to work at a job that had sustained her, but she was not retrained for any comparable work. If Lederle helped her find a job in a laundry, it did not provide the wages or job satisfaction to which she had previously become accustomed. Nor did it provide the social amenities, as limited as they were, of domestic work in the homes of New York’s upper class. The health department, for all of Lederle’s words of obligation to help her in 1910, did not provide her with long-term gainful employment. Neither did health officials, who precipitously locked Mallon up, succeed in convincing Mallon that her danger to the health of people for whom she cooked was real and lifelong. The medical arguments that carried weight among the elite at the time and have become more broadly convincing since did not resonate with her. There was no welfare system to support her. There was no viable “safety net,” practical or intellectual, for an unemployed middle-aged Irish immigrant single woman.
So she did what many other healthy carriers since have done: returned to work to support herself. And the health department responded by doing what it felt it had to do when faced with a now very public uncooperative typhoid carrier: returned her to isolation. As we have seen, New York health officials did not isolate all the recalcitrant carriers it identified; many who had disobeyed health department guidelines were out in the streets during the years Mallon remained on the island. But officials had reason to act as they did. And so did Mary Mallon.
In other words, there were choices for both the health officials and Mary Mallon, and judgment, when we make it, should take this full context into account. Events could have evolved in a different pattern. If tempers had not been raised to fever pitch in 1907, and positions not solidified, various compromises and possibilities would have been available for education, training, employment, all of which might have led to decreasing the potential of Mallon’s typhoid transmission. Health officials, who certainly held the reins of power most tightly, chose not to deal with their first identified healthy carrier in a flexible way. They chose to make an object lesson of her case. But it was a choice. If they had shown some personal respect for how difficult it was for Mary Mallon to cope with what happened to her, it is conceivable that she would have responded in kind, and come to respect their position. As it happened, neither side considered the other, and communication was stopped short.
Warren Boroson, who studied Mary Mallon’s case, and Barry Blackwell, a psychiatric authority on noncompliant patients, have also concluded that her story could have been different, and happier, if “health authorities had been [immediately] more understanding and had given her [in Blackwell’s words] ‘a well paying job that would have fulfilled her need to care for others, that would have made her feel competent and appreciated, clean and healthy[.]’ ” These observers believe that health authorities held the power to create an atmosphere in which Mary Mallon could have become compliant, regardless of whether she accepted the theory of healthy carriers.27
But factors determining patient compliance have only recently been studied seriously, and health officials in the first decades of this century understandably focused their concerns elsewhere. Lederle, seemingly alone among New York health officials (although he had company elsewhere in the country), did see a public obligation to help Mary Mallon find satisfying work once they took away her regular employment, but his observation came too late in her history and came with too little force to solve the dilemma. From the vantage point of today, it seems clear that the blame heaped on Mary Mallon in 1915 when she returned to cooking, and by observers since, is more fairly a shared blame.
Not every case of carrier or patient noncompliance can be avoided. The evidence points to potential alternative endings for Mary Mallon’s story which were not realized, but there are instances in which the maximum penalty of law, long-term or even lifetime denial of liberty, have been and will continue to be necessary. Mary Mallon’s resistance came in part because she did not understand how she, a healthy woman, could be a threat to health. But some people who resist public health policy do so with full understanding of the medical theory of disease transmission and choose consciously to transmit disease anyway. It may not always be possible to prevent the involuntary restraint and isolation of individuals who want to use their illnesses to harm others. But our public policy should aim toward protecting individuals as well as society. It is important that we educate ourselves in alternatives, that we stress the human side of public health dilemmas, in order to prevent as much as possible the denial of personal liberty even as we work diligently to protect the health of the people.
In 1922, A. J. Chesley, who was then the executive officer of the Minnesota State Board of Health, clearly expressed the conflicting nature of the dilemma then confronting public health authorities in the control of typhoid fever. His insights can help us today. Chesley saw two parts to the effort to reduce the health threat of typhoid. First, the public had to be convinced that it was “good business” to support the use of public funds for health work. Second, hearkening to the language of President Theodore Roosevelt’s progressive reforms, he urged his colleagues, “the typhoid carrier must be given a square deal.” Chesley explained, “This means compensation for his losses incurred as the inevitable result of strict and logical enforcement of the measures necessary to prevent the swallowing by other people of his infectious bowel and bladder discharges.”28
Chesley heeded the personal stories of typhoid carriers that bespoke the hardships and personal loss of the carrier condition. There was “Mrs. M.
S.,” a fifty-year-old widow, who supported her eight-year-old foster child and herself by doing housework and cooking until she was identified as a typhoid carrier and “forbidden to engage in the only kind of employment which have [sic] enabled her to keep soul and body together.” Chesley concluded, “No safe employment has been provided for her. Is this a square deal for the carrier?”29 There was “A. D. W.” and his family, who rented a farm and produced milk for their livelihood, “compelled to sell his cows at a sacrifice and to give up the dairying business permanently. This is a very serious financial loss to him and his family.” There was “Mr. A. S.,” a fifty-two-year-old cook for a railway construction crew, who was barred from cooking when identified as a carrier. “However, he was unable to make a living at other work, so in June, 1920, against the orders of the State Board of Health, he opened a restaurant.” When the health department found him again and “caused him to close his restaurant,” he promised once again not to engage in the occupation that put others at risk. But “after trying to get work he became discouraged and purchased a resort on a small lake and was about to act as guide and cook for fishermen at this resort” when health officials again banned him from the work. Chesley realized, “Mr. A. S. has become discouraged. His age and physical condition make it impossible for him to find work other than of the type which he is forbidden to do. This man is broken in spirit.”30
How, Chesley asked, is the carrier to be treated more fairly, to get a “square deal”? “Unquestionably, the public must demand protection against the typhoid carrier menace,” he realized. But he also understood, “When an individual suffers for the benefit of the community as a whole as in war service no one questions the justice of his claim against the community.” Thus, “social conscience” demanded that the state similarly compensate “persons whose means of earning are interfered with for the public good.” Only by fulfilling both sides of the equation, both encouraging public officials to do their job by identifying carriers and at the same time understanding the carriers’ difficulties and providing them realistic alternatives to cooking, could typhoid be eliminated.31
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