Restricting Freedom, from Typhoid Mary to Covid-19

We are seeing a lot of pushback on government restrictions imposed to limit the spread of COVID-19. Many people refuse to wear masks or practice social distancing. Some claim that the disease has been conquered, pointing to improvement in survival rates, and manage to ignore the increasing number of new infections and hospitalizations. Some continue to believe that the disease is nothing more serious than a mild flu. They deplore the disastrous effect of restrictions on the economy. Some even refuse to accept that there is a pandemic at all. Businesses are closing; people who have lost their jobs are applying for unemployment benefits; people who can’t pay their rent are being threatened with eviction. Some even claim that their First Amendment rights are being violated. Conspiracy theories are rampant, including the bizarre idea that Bill Gates introduced the virus with the intention of using a resulting vaccine to implant microchips so he could control everyone. Distrust of scientists and government officials is more and more widespread.

Typhoid Mary

Protests like this are nothing new. They date back to the 1918 flu epidemic and even earlier. Typhoid Mary had far more reason to protest that her rights had been violated. She was not allowed to work as a cook, and she was locked up and kept in isolation for nearly three decades.

You have probably heard of Typhoid Mary. My daughter recognized the name as that of a fictional supervillain in Marvel comics. But Typhoid Mary was very real, and her story is instructive.

Mary Mallon was born on September 23, 1869, in Ireland. She may have been born with typhoid because her mother was infected during pregnancy. She never had symptoms of typhoid infection; she was an asymptomatic carrier of the bacteria. She migrated to the United States at age fifteen. She first worked as a maid and then was employed as a cook. She worked for a series of well-to-do families in the New York area between 1900 and 1907. In one household, seven out of eight family members quickly became ill with typhoid. In a seven-day period after she started to cook for a family in Long Island, six of eleven members of the family were diagnosed with typhoid fever. She changed jobs frequently, and everywhere she went illness and death followed. Mary was identified as the source of the infections after Charles Warren’s only daughter died of typhoid fever. Mary refused to cooperate, refusing to believe she could be responsible, claiming that the outbreaks must have been caused by contaminated food and water. The concept of a healthy carrier was not yet recognized, and she never believed she was a carrier.

After an investigator named George Soper identified Mary Mallon as a carrier of typhoid, she was arrested and quarantined. It took five policemen to get her into the ambulance, and someone had to sit on her to restrain her. She admitted that she almost never washed her hands. She protested loudly, tried to sue the New York Health Department, and suffered a nervous breakdown. Three years after she was quarantined, New York State Commissioner of Health Eugene H. Porter released her after she agreed to stop working as a cook and take precautions to avoid transmitting typhoid to others. After several years of failing to earn a decent living with other occupations, she resumed cooking again using fake names, moving frequently, not giving a forwarding address, and refusing to cooperate. Everywhere she went, there were outbreaks of typhoid. She may have caused as many as fifty fatalities. She tried to evade arrest, but the police eventually found her and quarantined her for a second time in 1915. She remained isolated for the rest of her life. The typhoid bacteria were carried in her gallbladder, but she refused the gallbladder surgery that might have cured her. She was forcibly treated with a series of medications that were ineffective and had side effects. She had a stroke in 1932 that left half of her body paralyzed, and she died of pneumonia in 1938 at age sixty-nine. Only nine people attended her funeral.

Typhoid Mary was the first asymptomatic carrier to be forcibly isolated. Her personal rights and liberty were violated to save lives. By the time of her death, 400 other healthy carriers of typhoid had been identified, but no one else was forcibly confined. There was controversy over her punishment; some doctors thought isolation was too severe and that she should have been taught to manage her condition to avoid infecting others.

The History of Quarantines

Pandemics are a public health emergency. If no action is taken, huge numbers of people will die. The Black Death pandemic killed up to 40 percent of the population in some countries. The 1918 influenza pandemic killed fifty million people around the world. There are many precedents in history where quarantine was imposed to prevent the spread of disease. The Bible describes procedures for priests to isolate patients for skin lesions (probably leprosy). For Muslims, the prophet Muhammad advised quarantine for those with contagious diseases. In Medieval Europe, lepers were isolated from society. During the Black Death, new arrivals were required to live on islands or other restricted places until it could be established that they were not infected. The term quarantine is derived from a Venetian word meaning “forty days.” Venice required a forty-day period of isolation for ships and people to prevent the Black Death from spreading.

Throughout the nineteenth century, most Western countries imposed strict rules to control the spread of contagious diseases during epidemics of yellow fever, cholera, smallpox, and plague. The Ottoman Empire enlisted the army to control borders and monitor disease. During the 1918 influenza epidemic, governments instituted isolation and surveillance and closed schools, churches, theaters, and public events. International conventions developed guidelines that countries could agree on.

In 2007, Andrew Speaker was involuntarily isolated because he was thought to carry multi-drug-resistant tuberculosis and had been traveling extensively. Several state governors responded to the Ebola outbreak by imposing mandatory three-week quarantines for patients who had been in contact with Ebola patients. When Kaci Hickox returned to the United States after treating Ebola patients in Africa, she was quarantined in a medical tent; she filed suit, claiming she had been treated inhumanely. Soldiers returning from Operation United Assistance in Liberia in 2014 were ordered into quarantine by the U.S. Army Chief of Staff. Public fears led to overreactions. Some schools were closed, and a principal in Mississippi was forced to take personal vacation time because he had traveled to an African country that had no Ebola cases. Some schools denied admission to students from Africa, and universities canceled speaking engagements for people who had traveled to Africa.

COVID-19 Restrictions

Countries have responded to COVID-19 in different ways. Those that quickly implemented masks, social distancing, frequent hand washing, testing, and contact tracing were most successful in limiting the spread of the disease. Those methods work. Their efficacy is no longer open to question by rational people who acknowledge the evidence. But some rational people still question whether it was necessary to devastate the economy to save lives. Was the cure worse than the disease? It appears that it probably wasn’t. An economic analysis estimated that public health measures would save between 900,000 and 2.7 million lives in the United States by the end of 2020, whereas the effects of the economic downturn could contribute to between 50,400 and 323,000 deaths. The numbers are staggering, but consider the individual. If you lose your source of income and are unable to visit your dying mother in the hospital, you will feel a direct impact; if your life is one of the ones saved, you may never know.

Objections to Masks

We wear masks mainly to protect other people. Masks will help reduce the risk that infected but asymptomatic people may infect others. They also reduce the risk to the wearer, but to a lesser degree. They are not meant to offer complete protection. Dr. Steven Novella’s advice is excellent: wear masks in public but learn to wear them properly, and act as if the mask does not work. Some people claim they can’t breathe with a mask on. That’s nonsense, considering operating room personnel wear masks all day every day, and they breathe just fine with no ill effects.

Some falsely claim that masks are killing people and compare public health measures to the Nazi’s treatment of the Jews. Some refuse to follow public health guidelines because they are young, healthy, and think they are safe. Some are just contrarians who don’t want any authority to tell them what to do. Some claim that their First Amendment rights are being violated, but that’s not true. They are not prevented from practicing their religion; the restrictions only make it safer to do so. Their right of peaceable assembly is not infringed upon as long as they maintain social distancing. Their right to vote is not infringed upon; most states have vote-by-mail options, and there’s no reason it couldn’t be offered in all states. The government is obligated to promote the common welfare. That’s the purpose of quarantine. There is nothing in the Constitution that gives citizens the right to ignore public health measures. Citizens have rights, but they also have responsibilities. One of them is not knowingly spreading contagious diseases.

In short, governments can issue recommendations or can impose quarantines using regulations or physical coercion. They must weigh the impact on the common welfare of controlling contagious diseases against the impact on the common welfare of the economic consequences. This is not an easy decision. Science can inform us about facts and evidence, but it can’t tell us what we should do. Society as a whole has to make choices, and so do individuals. Individuals have to consider fear, altruism, and their tolerance of inconvenience. When I see someone not wearing a mask in public, it suggests to me that they don’t value science or care about others and are guided by emotion rather than by reason. They want to make an emotion-based political statement. When I see someone wearing a mask, I think, “Thank you for protecting me.”

Helpful Definitions

Shelter in place: seek safety in the building you already occupy rather than evacuating.

Social distancing: keep a safe distance between yourself and others, usually around six feet.

Isolation: separating sick people from people who are not sick.

Quarantine: restricting the movement of people who may have been exposed to a disease while waiting to see if they will become sick.

This article was originally published in Skeptical Inquirer as a Reality Is the Best Medicine column.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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