Recalling Typhoid Mary

Stephen DeAngelis

May 31, 2007

Since the spread of AIDS, the scare of SARS, and looming threat of Avian Flu, people are more aware than ever of the potential for a pandemic. A pandemic is one of the wild cards that most futurists fear could wreak havoc with the global economy. a pandemic would cause the travel industry to suffer like it did following 9/11. Businesses would suffer because sick workers couldn’t report for work or were dead. Money normally spent on consumer goods would flow into healthcare. Crops would sit unharvested in their fields. The list would go on. When we think about how pandemics begin, we conjure up pictures of rats carrying bubonic plague, or “Patient Zero” carrying AIDS or Typhoid Mary from an earlier era, spreading her sickness from house to house. Typhoid Mary did spread typhoid in households where she worked as a cook, but she never actually started a pandemic (records indicate she infected 33 people, 3 of whom died). Nevertheless, because she couldn’t be cured and couldn’t be trusted to seek employment other than as a cook (the only skill she had), Typhoid Mary Mallon was exiled to the Riverside Hospital on North Brother Island in New York for over 35 years.

Yesterday, the big news, as reported by the New York Times and others, was that a new carrier of disease, a man with a particularly rare form of tuberculosis, has been quarantined by the U.S. Government [“Man with Rare TB Detained, Isolated,” by David Brown, 30 May 2007]. Unlike Mary Mallon, who didn’t travel extensively once she arrived in the U.S. from Ireland, this newly identified TB carrier has traveled extensively, even after being warned not to. Brown reports:

“The federal government last week detained and quarantined an Atlanta man who had spent nearly two weeks traveling in the United States, Canada and Europe with ‘extensively drug-resistant’ tuberculosis, a rare and often fatal form of the infection, officials said yesterday. The Centers for Disease Control and Prevention imposed an ‘order of isolation’ on Friday after catching up with the man, who had flown into Montreal the day before and then driven to New York City. He was flown in a government plane on Memorial Day to Atlanta, where he is now undergoing treatment. Although states occasionally use their authority to forcibly detain and treat patients with infections, this was the first time since 1963 the federal government has done so.”

The threat of a tuberculosis outbreak recalls the days when so many people were afflicted by “consumption” that sanitoriums were established for TB patients; but that was nearly a century ago. TB, however, has not gone away. In Africa alone, over 600,000 people die from the disease each year. TB is the leading cause of death among AIDS patients around the world. That is the reason the CDC is so concerned in this case and has taken the extraordinary measure of quarantining the man. According to Brown, the last time the federal government quarantined someone was back in the 1960s in order to isolate a suspected case of smallpox. The chances of this patient causing a TB pandemic are remote according to the CDC, but they are still trying to get in touch with people who had intimate and prolonged contact with him.

“‘We don’t think, from past scientific investigation, that their risk is high. But we want to offer them the chance to be tested,’ CDC Director Julie L. Gerberding said yesterday afternoon in a news briefing. … Brief or long-distance exposure to people with infectious TB rarely results in transmission of the microbe. Health authorities want to trace the people who sat in his row and two rows in front of and behind him on the transatlantic flights. Studies have shown that risk of infection is very unlikely outside that zone of exposure, or even within it for short periods of time.”

This case points out how easy it is for someone with a communicable disease to travel extensively and expose many. In this case, the man traveled even though he knew he could infect people.

“Although many details of the patient’s recent activities were unknown or were not being disclosed yesterday, officials said the man had recently been diagnosed with TB and knew he should not travel when he left the United States on May 12. After testing revealed his tuberculosis was extensively drug-resistant, he was contacted in Europe by health authorities and told not to take a commercial flight home — advice he ignored. Martin Cetron, a physician who directs the CDC’s division of global migration and quarantine, said he spoke to the man by phone Friday and told him to go to a New York hospital. The man went willingly. While the man had broken the ‘covenant of trust’ that is usually sufficient to keep infectious TB patients from willfully exposing others, ‘from our perspective no laws were broken here,’ Gerberding said.”

The man in question claims he was never warned not to travel, but the CDC continues to insist otherwise. Trust is critical in maintaining global order. That is why we are generally shocked when we see egregrious breaches of that trust. We often think about TB as being a third world disease but, as the patient in Atlanta knows, it still lingers in the developed world as well. And the problem is growing.

“TB cases that are resistant to the two first-line classes of drugs and to at least two second-line classes have been detected in 37 countries and are increasing worldwide. It is especially a problem in places such as South Africa and the former Soviet Union where TB treatment is inadequate, or prevalence of HIV infection is high. An outbreak killed 52 of 53 people it infected in a rural hospital in South Africa in 2005 and 2006, according to reports last summer. XDR-TB, as it is known, is rare in the United States, with only 49 cases detected since 1993, of which at least 12 were fatal, according to a CDC report in March. Earlier this month, public health officials in Arizona obtained a court order allowing them to confine and treat a 27-year-old dual Russian-U.S. citizen who had undergone months of TB treatment in Russia, where he had often been homeless. He is undergoing treatment for XDR-TB in a Phoenix hospital. In most people, the body’s immune system controls the TB bacterium on its own, forcing it to become ‘latent,’ or inactive. Drug resistance does not make that less likely, nor does it make the microbe inherently more virulent or contagious. Instead, XDR-TB’s danger stems from the fact that when it does cause active illness, the infection is very hard to cure. That, in turn, increases the risk it will be passed on to someone else and that patients ill from it will die.”

Globalization has far more upsides than it has downsides, but the ability to spread disease easily and broadly is one of the downsides. As a result, disease control will become a national security issue as important as stopping terrorism. We saw that scenario play out during the SARS epidemic and that won’t be the last time disease raises national security fears. The trick will be finding a way to detect potential carriers then rapidly diagnose people who are actually carrying infectious diseases. That’s no small order, but the effort will be worth it. The world cannot suffer a redux of the carnage left in the wake of the 1918 Spanish Flu pandemic that killed between 50 and 100 million people and sickened even more millions.

As we think about development and how best to bring millions of people out of poverty, healthcare needs to be high on our list of priorities. For those people who might not be filled with altruism, they should consider how easily and quickly diseases “over there” can get “over here.” If a sense of moral obligation doesn’t move you, consider fighting disease in the developing world as the first line in a layered defense that is protecting you and your family. In order to raise people out of poverty, they need jobs. In order for them to get jobs, they need to healthy and educated. Typhoid Mary was exiled to a hospital because she lacked the education that would have provided her with an alternative means to make a living. We cannot quarantine the entire undeveloped world, although it often seems like that that is the policy that many U.S. politicians would like to pursue. A healthy global population helps ensure a healthy and resilient local population.