Who is Typhoid Mary? A worst case of Healthy carrier of Typhoid Disease

The Facts on Typhoid

Typhoid, also known as typhoid fever or enteric fever, is an infection caused by the bacteria Salmonella typhi.Across the world, millions of people are infected annually by typhoid, and about 200,000 of them die. The number of people infected with typhoid each year is very low in North America and the industrialized world, but typhoid is common in developing countries.
Typhoid is usually curable, but some bacterial strains are becoming increasingly resistant to antibiotics. Most people with typhoid in North America acquire it while travelling to developing areas of the world.
If untreated, about 10% to 16% of people with typhoid will die. This drops to less than 1% when people are treated promptly.Typhoid is usually transmitted by water or food, in much the same way as cholera. People who are infected excrete live bacteria in their feces and urine. They are usually contagious for a few days before any symptoms develop, so they don't know they need to take extra precautions. If they don't wash their hands properly, the typhoid bacillus can be transferred to food or water and from there to another person. Also, it can be spread directly from person to person via contaminated fingers.
About 3% of infected people (treated or not) become asymptomatic carriers of Salmonella typhi. This means that they continue to shed bacteria in their feces for at least a year and often for life but don't have any symptoms of typhoid. There are a small number of typhoid carriers in every country. Even Canada and the United States report dozens of locally transmitted cases of typhoid each year, though most cases in these countries are among travellers or people immigrating who are ill when they arrive.

Symptoms and Complications of Typhoid

Symptoms usually appear 1 or 2 weeks after infection but may take as long as 3 weeks to appear. Typhoid usually causes a high, sustained fever, often as high as 40°C (104°F), and extreme exhaustion.

Other common symptoms include:

• constipation
• cough
• headache
• loss of appetite
• stomach pains
• sore throat

Rarer symptoms include:

• bleeding from the rectum
• delirium
• diarrhea
• temporary pink spots on the chest and abdomen

With antibiotic treatment, symptoms start to subside after 5 to 7 days, but without treatment they continue to get worse for several weeks, and more than 10% of untreated people may die.

A small number of people who recover from typhoid may have a relapse of their symptoms just a few weeks later. The second bout tends to be less severe than the first, and clears up quickly with further treatment.

Many people suffer from mild intestinal bleeding, but it is severe in only a small minority of cases. The main way typhoid kills is by causing perforation of the small intestines, causing bacteria to pour into the abdominal cavity. This condition is called peritonitis, and is often fatal.

Other complications of typhoid occur when a large number of bacteria get into the bloodstream, causing bacteremia. They can travel to the lungs, causing pneumonia, or to the lining of the brain (meningitis), the bones (osteomyelitis), the heart valves (endocarditis), the kidneys (glomerulonephritis), the genital or urinary tract, or the muscles. Hepatitis (inflammation of the liver) can also occur.

Now talking about Typhoid Mary, 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.

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." 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."

MARY'S STRAITS

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. [For more on the quarantine of Mary Mallon, aka "Typhoid Mary," see In Her Own Words.]

She was not permitted to work at a job that had sustained her, but she was not retrained for any comparable work. If Ernst J. Lederle, the New York City Health Commissioner who had released her in 1910, 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.

• By Judith Walzer Leavitt

An old file card detailing results from tests on stool specimens from Mary Mallon gives a capsule history of her capture and quarantine.Enlarge

HARD CHOICES

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. 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 North Brother Island, the East River islet where she was quarantined. But officials had reason to act as they did. And so did Mary Mallon.

Health officials chose not to deal with their first identified healthy carrier in a flexible way.

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, when Mallon was first quarantined on North Brother Island, and positions not solidified, various compromises and possibilities would have been available for education, training, and 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.

PROPER TREATMENT

How can we address the problem that is now, still, again, before us? Shall we insist on locking up the people who are sick or who are at risk of becoming sick because they threaten the health of those around them? Our own situation in large part determines how we think about these questions and informs our various responses to this public health dilemma. We can view people who carry disease as if they consciously bring sickness and death to others—like the demon breaking skulls into the skillet, as a 1909 newspaper illustration depicted Mary Mallon [see image at right above]. We can view such people as inadvertent carriers of disease, as innocent victims of something uncontrollable in their own bodies. We can see disease carriers as instruments of others' evil, as victims of society's or science's perversity.

Wherever we position ourselves, as individuals and as a society, we must come to terms with the fundamental issue that whether we think of them as guilty or innocent, people who seem healthy can indeed carry disease and under some conditions may menace the health of those around them. We can blame, fear, reject, sympathize, and understand: withal, we must decide what to do. Optimally, we search for responses that are humane to the sufferers and at the same time protect those who are still healthy.

The conflict between competing priorities of civil liberties and public health will not disappear, but we can work toward developing public health guidelines that recognize and respect the situation and point of view of individual sufferers. People who can endanger the health of others would be more likely to cooperate with officials trying to stem the spread of disease if their economic security were maintained and if they could be convinced that health policies would treat them fairly. Equitable policies applied with the knowledge of history should produce very few captives to the public's health.

• By Judith Walzer Leavitt