Public Health Then and Now

Temporarily Detained: Tuberculous Alcoholics in Seattle, 1949 through 1960

Barroni H. Lemer, MD, M Introduction Officials intended to use the locked ward only for the occasional "bad actor."'4 The recent resurgence of tuberculo- Yet by 1960, Firland had detained roughly sis has generated great concern about 1000 patients, and the locked ward had patients who do not complete their pre- become a routine part of the sanatorium scribed therapy. Not only do such individu- care of one group of patients: those als remain reservoirs of infection, but alcoholics who frequented a run-down their erratic compliance has fostered the portion of Seattle called Skid Road. As development of multidrug-resistant strains modern officials reinstitute similar poli- of .' To ensure that noncom- cies, it is well worth revisiting Seattle's use pliant patients complete their drug treat- of compulsory measures to control the ment, health departments have begun to spread of tuberculosis. employ a series of strategies ranging from incentives to involuntary detention. Offi- Earlier Examples ofQuarantine cials designing such policies have carefully approached the difficult issue of balancing Although references to the isolation the public's health with the civil liberties of lepers can be found in the Bible, the of patients.2 term quarantine did not appear until the The use of coercion to prevent the Middle Ages. In that period, quarantine which officials spread of infectious diseases is nothing referred to the practice by the landing of ships suspected of new. For hundreds of years, health offi- delayed carrying victims of the plague or other cials have used various forms of quaran- contagious diseases. Quarantine has since infectious Al- tine to segregate persons. come to mean "the making of a boundary been though such policies have designed to separate the contaminating from the as public health measures, their actual uncontaminated."5 implementation has been influenced by Municipal officials aggressively used who is being isolated and who is carrying quarantine to combat diseases such as out the isolation. As a result, quarantine cholera well before the discovery of the has represented a mechanism for society germ theory of disease in the late 1800s.6 to control not only infection, but also Yet it was the knowledge that infectious those who are infected. diseases were caused by specific microor- Once tuberculosis was definitively ganisms transmitted between persons that shown to be communicable in the late gave new impetus to the practice of nincteenth centurv, health departments quarantine. Indeed, the scientific imprima- startcd to forcibly isolate tuberculous tur of the germ theory enabled health persons that they believed were a danger to the public s health. One of the most ambitious of these programs began in The author is with the Department of Medi- cine. Columbia University, New York. NY. 1948 at Firland, a public sanatorium in Requests for reprints should be sent to Seattle, Washington. Not only did city Barron H. Lerner, MD, MA, Department of officials inaugurate a policy of quarantin- Medicine, Columbia University, Black Building- ing so-called "recalcitrant" patients at 101, 650 W 168th St. New York, NY 10032. Note. The views expressed here are the Firland, but they also established a locked author's and do not necessarily reflect those of ward within the sanatorium for the pur- the Arnold P. Gold Foundation or the Robert pose of involuntarv detention.3 Wood Johnson Foundation.

American Journal of Public Health 257 Public Health Then and Now officials to solidify their authority to hereditary predisposition and environmen- Another important development oc- determine the appropriate boundaries tal exposures.13 The use of quarantine curred in 1946 when Firland became one between the well and the "diseased."7 became logical, however, once it became of the earliest sanatoria to use streptomy- During the early twentieth century, state clear that tuberculosis was spread when cin, the first effective for tuber- laws routinely granted health depart- someone inhaled bacilli from an infected culosis. Before this time, the primary ments the power to quarantine individuals person's sputum. therapies for the disease were bed rest with infectious diseases such as diphtheria The most aggressive early attempt to and fresh air, supplemented by surgical or typhoid fever.8 isolate infectious tuberculosis patients collapse of the lung.20 By 1952, two Although intended for the purpose occurred in 1903 when New York opened additional drugs, para-aminosalicylic acid of preventing the spread of infection, a detention facility at Riverside Hospital. and isoniazid, were also available. These quarantine has traditionally been im- The driving force behind this effort was drugs enabled doctors to shorten the posed on "the bodies of those who were Hermann Biggs, a local health officer and average hospital stay from 2 years in the least able to protest."9 On the one hand, a pioneer in tuberculosis control. Al- early 1940s to 6 months by 1960.21 this policy made sense, because infectious though designed for public health pur- Nevertheless, Firland staff believed that diseases preferentially affected the poor. poses, Riverside also served as a reposi- the combination of , bed rest, The use of quarantine and other compul- tory for "fractious and intractable" and surgery-in a supervised setting- sory public health measures, however, has patients, many of whom made the rounds provided the best chance to cure tubercu- also reflected society's tendency to stigma- of city hospitals, leaving against medical losis and thus recommended at least 6 tize and punish those groups that become advice before approved discharge.14 Biggs's months of hospitalization. Patients com- associated with given diseases. own language bespoke how his policy of pleted drug therapy as outpatients. There are numerous historical ex- forcible detention reflected not only the The major obstacle to this strategy, amples of this process. For example, patients' disease but also the fact that they not surprisingly, were discharges against health officials incarcerated over 30 000 were usually poor immigrants, vagrants, medical advice.22 Like other sanatoria, prostitutes in federally funded institutions or alcoholics. "Homeless, friendless, de- Firland had long experienced this prob- during World War I to prevent the spread pendent, dissipated and vicious consump- lem. Nevertheless, given the new ability to Allan Brandt has of venereal disease. tives," he wrote, "are likely to be most cure patients, the staff grew increasingly this event "the most concerted termed dangerous to the community."'5 frustrated with the idea that partially liberties in the name of attack on civil Although commentators across the treated persons might be allowed to infect health in American history."10 A series of public to decry the "careless other Seattle residents.23 Similarly, turn-of-the-century nativist fears country continued consumptive," few such patients were studies performed at Firland, moreover, that immigrants were vectors of infection that as many as 47% of Not only was had revealed led to the arbitrary use of quarantine detained after 1920.16 left against advice.24 difficult and expensive to admin- patients against specific ethnic and racial groups.11 detention Of particular concem were alcohol- was often no clear end As with health officials selecting ister, but there ics, who, in one study, constituted 74% of persons for quarantine, administrators point: tuberculosis was a chronic disease all unapproved male discharges.25 Major involved in the day-to-day implementa- with no specific cure. In addition, al- changes in the definition of alcoholism tion of enforced isolation have also en- though acknowledged as infectious, tuber- had begun to occur in the 1940s as it joyed broad authority. Scholarship in this culosis never produced the alarm gener- became conceptualized as a disease rather area has focused on what Erving Goffman ated by epidemics.'7 than a moral transgression.26 Neverthe- termed "total institutions." Goffman After World War II, however, there less, Firland staff continued to reserve the stressed that facilities such as mental was a major nationwide change in philoso- label for down-and-out winos or tramps, hospitals and prisons, whatever their phy, which Seattle well exemplified. Be- thereby reinforcing stereotypical notions underlying purpose, ultimately emphasize fore the late 1940s, Seattle had not about alcoholism. Evidence of drinking the "bureaucratic organization of whole forcibly segregated a single tuberculosis among middle-class patients was basically blocks of people."112 Although the expan- patient, preferring to use its limited ignored.27 sion of due process after 1960 provided funding to treat cooperative patients. In Those Firland patients characterized inmates with legal recourse, administra- 1948, however, officials instituted a formal as alcoholics most often lived on Seattle's tors and staffs of such institutions have quarantine policy. Factors that contrib- Skid Road, a run-down area just south of had-and continue to have-broad au- uted to the adoption of this new strategy downtown. (Skid Road appears to have thority to make routine decisions regard- included a general postwar revival of been an earlier version of the term skid ing disciplinary and custodial issues. Such tuberculosis control efforts, the introduc- row. )28 Due to the marked economic management issues would quickly become tion of antibiotics, and growing concem growth experienced by the city during a primary concern of Seattle officials with discharges against medical advice.18 World War II, Seattle had attracted a confining tuberculosis patients. As Seattle and Washington under- growing number of transient males, mostly went major economic development dur- White, who traveled the West Coast and ing World War II, funding for tuberculo- Alaska looking for odd jobs. These men, Confinementfor Tuberculosis sis control increased markedly. The city who were often heavy drinkers, spent Before 's 1882 discovery also benefited from the 1947 acquisition much of their time on Skid Road, travel- of the tubercle bacillus, most doctors of a 1350-bed surplus naval hospital that ing from bar to flophouse.29 believed that pulmonary tuberculosis, of- enabled Seattle to house all of its tubercu- Not only did tuberculous Skid Road ten known as consumption, was not losis patients for the first time.'9 Named alcoholics have high rates of discharge contagious. Rather, they claimed that the Firland Sanatorium, the facility remained against advice, but health officials be- disease resulted from a combination of open until 1973. lieved that they were also unlikely to

258 American Journal of Public Health February 1996, Vol. 86, No. 2 Public Health Then and Now comply with outpatient therapy. As a result, these officials concluded, such persons often relapsed and were thus #1 #2 #3 likely to spread tuberculosis in the commu- nity. In addition, their erratic antibiotic UNAPPROVED UNAPPROVED ALCOHOL use fostered drug resistance.30 Both Health LEAVE LEAVE Department and Firland staff agreed that a mechanism was needed to ensure that alcoholics remained hospitalized long enough to receive adequate therapy.

Quarantine and Detention POLICE FIRLAND in Practice Health Health Medical The first step in such a process, Officer Officer Director according to Washington State Tuberculo- sis Control Officer Cedric Northrop, was to clarify existing quarantine regulations. QUARANTINE QUARANTINE Northrop, who had come to Washington from North Dakota in 1941, had played a crucial role in reviving Seattle's tuberculo- County Medical sis work. An integral part of such efforts, Judge Director he believed, was to provide health officials with the means to isolate the recalcitrant WARD6 WARD 6 person with tuberculosis.3' WARD6WARD6 ~(2 WEEKS) (2 WEEKS) In 1948, building on a state law empowering health officers to restrain Medical Medical infectious persons, Northrop drafted two Director Director regulations enabling the local health of- ficer to quarantine to Firland any persons with active tuberculosis who were "unco- WARD 6 WARD 6 operative" and "refused to observe the (1 MONTH) (1 MONTH) [necessary] precautions to prevent the spread of the disease."32 Those quaran- tined were to remain at Firland until ETC. ETC. approved discharge. Local prosecutors aided Northrop in drafting these regula- FIGURE 1 -Three scenarios by which patients were sent to the locked ward tions, which were subsequently approved (Ward 6) at Firland Sanatorium. by the State Board of Health. When early efforts at quarantine did not prevent unapproved discharges, Firland established a 27-bed locked ward housed "only a handful" of patients. formula established by Firland deter- in June 1949. Known as Ward 6 and There were no beds for women.36 mined how long patients remained on located in the old naval brig, the unit was The earliest efforts to employ quaran- Ward 6 before returning to the unlocked equipped with both locked doors and tine and detention focused on patients, portion of the sanatorium: the first stay heavily screened windows. All patients generally Skid Road alcoholics, who left was 2 weeks, the second was 1 month, and admitted to Ward 6 (most of whom were the unlocked portion of the sanatorium the third was 2 months.38 intoxicated) spent the first 24 hours in one without permission. Many such patients Frequently, patients who had left the of seven locked cells, which contained were quickly found by the police, often sanatorium without permission returned only concrete slabs covered by thin mat- when arrested for drunkenness (Figure 1, by themselves, often after drinking sprees. tresses.33 Although the ward remained #1). If there was no past history of Many had overstayed 24- or 48-hour locked at all times, the staff let any recalcitrance, the patient had likely not passes. When these patients returned to potentially violent patients leave. In prac- been on quarantine. In this case, the local Firland, they too were quarantined and tice, however, such departures occurred health officer quarantined the patient to detained (Figure 1, #2). That is, the infrequently.34 Firland and returned him to the unlocked health officer quarantined to Firland Firland stafforiginally planned to use portion of the sanatorium. (Jail sentences those patients without previous offenses Ward 6 sparingly. "If coercion is needed for drunkenness were suspended.)37 and sent those already on quarantine to frequently," Medical Director Roberts If a patient was already on quaran- Ward 6. In these cases, however, deten- Davies wrote, "it is a sure sign that tine, however, he was guilty of an actual tion bypassed the formal legal system.39 something is wrong."35 In fact, the early offense: violation of quarantine. In this The medical director directly sent pa- use of Ward 6 was limited. Northrop situation, a King County judge sentenced tients to Ward 6, the duration of the stay observed in December 1949 that the ward the individual to the locked ward. A again depending on whether they had

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Washington State health officer Cedric Northrop, whose plan for reviving tuberculosis control In Seattle included the use of detention. The Administration Building at Firland Sanatorium, circa 1960. Photo courtesy of the American Lung Association of Washington. previously spent time there. This ability to detain patients in Ward 6 without a weeks of the mandatory 12-month hospi- As noted above, patients who left judge's ruling stemmed from the quaran- talization-and thus at times had inactive Firland without permission often drank tine order, which read that the patient was tuberculosis-were also sent to the locked while away and thus were drunk when to remain "in that section of the Sanato- ward. Indeed, the staff thought nothing of they returned to the sanatorium. Firland rium designated by the Medical Direc- discharging patients to home directly officials justified the detention of such tor."40 from Ward 6, a practice that belies the persons-even those with inactive dis- Northrop's 1948 regulations had notion that detention was reserved for ease-by the need to maintain order. The specified that only patients with active true public health threats.43 Clearly, the staff believed that merely allowing such tuberculosis could be quarantined. This ward had begun to serve a purpose persons, once sober, to return to the term, however, did not directly correlate beyond simply preventing the spread of regular wards encouraged such behavior. with infectiousness. The National Tuber- tuberculosis. Keeping such persons on the locked ward, culosis Association defined pulmonary conversely, potentially served as a deter- disease as active until there were negative Maintaining Order at Firland rent.47 sputum samples and healed x-ray lesions Firland also used this same justifica- for 6 months.41 Health officials employed To understand why Firland used tion-the need to maintain order-to this broad definition of active tuberculosis public health powers to discipline nonin- send to Ward 6 any patients caught because healing was a slow process that fectious patients, it is important to look at drinking or selling alcohol at the sanato- continued long after the sputum was no its institutional needs. Because the sanato- rium. This situation is shown in Figure 1, longer infectious. Nevertheless, this stan- rium housed hundreds of persons in close #3. Patients sent to the locked ward for dard ensured that quarantined and de- quarters for long periods of time, staff drinking or bootlegging need not have tained patients were often noninfectious. members saw "utter chaos" as a persistent been previously quarantined (although Yet even if it was reasonable to possibility; they frequently cited past they were subsequently quarantined). define active tuberculosis so broadly, episodes in which patients had started Rather, they were sent to the locked ward sanatorium officials paid little or no fires or attempted mass escapes.44 for having broken the 1947 resolution attention to whether detained patients Alcohol, in particular, disrupted sana- prohibiting such behavior. Once again, actually had active disease. This phenom- torium routine. Although a 1947 King Firland staff handled these cases entirely enon had its major impact beginning in County resolution made the "giving or at the sanatorium without formal legal the mid-1950s when Firland adopted an selling of intoxicating liquors" at Firland a proceedings.48 Whether the tuberculosis informal policy requiring all alcoholics to misdemeanor,45 patients who had ob- was active made no difference. Thus, a remain hospitalized for 12 months, regard- tained liquor while on a pass often tossed patient who had never eloped, had com- less of their medical condition.42 This bottles over the fence and retrieved them plied with his medical therapy, and had 1-year rule was another mechanism to once on the inside. "Bootlegger" patients been noninfectious for 6 months could be ensure that Skid Roaders received ad- smuggled in large quantities of liquor; sent to Ward 6 for drinking. equate supervised antituberculous therapy. loud, raucous drinking parties often fol- The Firland staff used public health Because officials ignored the criterion of lowed in the open wards. Such incidents, criteria not only to punish patients, but active disease, alcoholics who took unap- one doctor claimed, led other patients to also to reward them.49 When quarantined proved leaves during the last days or request early discharge.46 patients exhibited both medical improve-

260 American Journal of Public Health February 1996, Vol. 86, No. 2 Public Health Then and Now ment and "good behavior," they often qualified for a status of "modified" quar- antine.50 Patients in this latter category were permitted to have short passes away from Firland. Not surprisingly, negotia- tions often ensued between patients, who requested frequent leaves, and health officials, who feared that such patients were likely to drink while away, bring liquor back to the premises, or not return at all. These fears were well founded. It was not uncommon for Skid Road alcohol- ics to have four or five stays on Ward 6: many simply committed another infrac- tion shortly after returning to an unlocked ward. How can we best understand what transpired at Firland in the 1950s? The experience appears to have represented the confluence of two themes discussed earlier: the broad power of twentieth- century health officials to isolate the "diseased" and the ability of total institu- tions to control their inmates.51 What is crucial to note in the case of Firland is how these two functions overlapped. Health officials in Seattle originally estab- lished policies of quarantine and deten- tion to protect the community from recalcitrant patients with active tuberculo- sis. Yet the larger goal turned out to be custodial: to keep Skid Road alcoholics institutionalized and reasonably well be- haved for 12 months of antibiotic therapy. Once this goal was established, it became necessary to legitimate the disruption of institutional order as a public health violation punishable by quarantine and detention.52 Given the great disciplinary authority of the medical profession, it is little wonder that Firland successfully blended these public health and institu- tional imperatives.53 Reactions ofPatients One of the locked "cells" used for acutely inebriated tuberculosis patients at As anticipated, Ward 6 housed mostly Firland Sanatorium, 1949 to 1960. Photo by author, 1993. alcoholics. A 1953 study, for example, found that 88% of locked-ward patients carried the diagnosis of alcoholism.54 The vast majority of these individuals either bilitative services. In addition, Firland had tive sputum for months may be placed lived on or frequented Seattle's Skid hired special staff to address issues of under quarantine."58 Road. Most Ward 6 patients registered no unemployment and alcoholism among The same patient also objected to the objections. The ward staff was committed Skid Road patients.57 locked ward. "Ward Six," she stated, "is a to the care of alcoholics and treated them Nevertheless, in a series of letters jail in every sense of the word; heavily with more tolerance and respect than they sent to state officials in 1956 and 1957, screened windows, locked doors, cells received in jail or in public hospitals.55 In several patients objected to quarantine with mattresses on concrite [sic] slabs and fact, certain locked-ward patients pre- and detention procedures. One patient, restrictions that are to be expected in a ferred Ward 6 to the unlocked portions of for example, questioned why the health regular jail."59 Others criticized the lack Firland with their constant temptations of officer was able to quarantine noninfec- of legal proceedings. The doctors, claimed alcohol and gambling.56 By the early tious patients. "[C]ontagiousness," she one patient, "may sentence a patient from 1950s, the sanatorium had also developed wrote, "has nothing to do with the one day to six months, as they see fit. We an extensive program of social and reha- quarantine. People who have had nega- want to know by what right, and on what

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United States visited Ward 6. Not surpris- ingly, policies similar to those at Firland existed elsewhere. For example, other states detained noncompliant patients who had violated sanatorium rules.71 As patients in several states were confined for 6 to 12 months, many of these persons likely also had inactive tuberculosis or had been noninfectious for several months.72 The vast majority of tuberculosis workers in the 1950s advocated some use of detention. A 1958 editorial in the Journal of the American Medical Associa- tion, while noting the controversial nature of enforced isolation, agreed that for persistently obstinate patients it was nec- essary to "resort to available legal mea- sures."73 Nevertheless, a few commenta- tors decried detention altogether, terming it a "misapplication of police authority" that led health officials to treat patients like criminals.74 Heavily screened windows on the outside of Firland Sanatorium's locked ward. Photo by author, 1993. Conclusion Seattle health officials designing a plan to confine uncooperative tuberculo- authority this is being done."60 Patient reached 30% by 1960.56 In 1954, Ward 6 sis patients drew on a long tradition dissatisfaction culminated when a former expanded from 27 to 54 beds, including 6 permitting the isolation of contagious Firland employee collected 51 pages of beds for women.67 By 1960, Washington persons to protect the community. Yet "patients' grievances," which he sent to State had detained approximately 1000 those implementing the new policies of the governor.6' patients.68 The vast majority of these were quarantine and detention saw their goal These complaints were generally held at Firland. Detention, initially meant as larger than simply segregating infec- greeted with skepticism or hostility. Health for the occasional recalcitrant individual, tious persons. The availability of antibi- officials were particularly critical, terming had become standard management of the otic agents raised the hope that, for the the missives "typical 'crank' letters which Skid Road alcoholic patient. first time, recalcitrant tuberculosis pa- we have been accustomed to seeing tients could be cured of their disease once and for all. In Seattle, the individuals that produced by the paranoid type of person- Detenfion across the Country ality."62 Eventually, however, the patients' caused the most concern were Skid Road complaints reached the Washington State Seattle's increased use of compulsory alcoholics. chapter of the American Civil Liberties public health powers after World War II Thus, health officials and the staff of Union. American Civil Liberties Union epitomized developments across the Firland Sanatorium instituted an informal members who investigated conditions at . Between 1948 and 1955, 22 policy that kept all Skid Road alcoholics the sanatorium in 1957 generally con- states passed new laws regarding the hospitalized for 12 months of supervised firmed the allegations: Firland used quar- isolation of recalcitrant tuberculosis pa- antibiotic therapy, roughly 6 months longer antine as punishment and incarcerated tients. By 1960, 31 states employed some than the average stay. Alcoholics at patients on Ward 6 without due process. type ofcompulsory hospitalization. Deten- Firland were thus "temporarily detained" Yet after pointing out these problems to tion policies varied greatly. For example, with the hope of effecting permanent the Firland staff, the union let the issue although certain states required extensive cures. Implementation of this plan, how- drop.63 legal proceedings, including the provision ever, required sanatorium staff to address Indeed, by the end of the 1950s, the of lawyers to potential detainees, others custodial issues such as unapproved leaves use ofquarantine and detention at Firland did not. Most health departments kept and drinking in the unlocked portion of had become formally institutionalized. In patients in locked hospital wards, al- Firland. To discourage or punish such 1959 the staff drafted an 18-page docu- though three states and three cities used behavior, the staff used the public health ment that codified the policies described actual prison facilities.69 powers of quarantine and detention. As a above.64 Meanwhile, the use of quaran- Although detention protocols dif- result, whether patients were infectious, tine and detention at Firland rose, reflect- fered widely, Seattle's system served as a had active tuberculosis, or had been ing the fact that tuberculosis was increas- model for the country. Northrop and noncompliant with their medications was ingly becoming a disease of the poorest Firland staff published several articles often irrelevant. Maintenance of order at members of society, such as Skid Road describing the "practical management of the institution had itself become a legiti- alcoholics.65 Whereas 10% of patients had the recalcitrant tuberculosis patient."70 mate reason for invoking public health been quarantined in 1952, the figure Numerous health officials from across the powers.

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Firland initially planned to use quar- carrying out public health policies. Al- sarily result in longer detention for public antine and detention for the occasional though acting in an era before the due health purposes; conversely, good behav- bad actor, as only one portion of a process revolution, officials in Seattle ior may not signify that earlier release is comprehensive program to address the nevertheless attempted to delineate-and appropriate. Avoiding the conflation of multiple sociomedical problems of alco- limit-the power of the health officer to institutional and public health goals re- holic patients. By 1960, however, quaran- confine the uncooperative patient. In quires not only acknowledging that such tine and detention had become a routine practice, however, the broad authority of conflicts exist, but also determining how part of the care of Skid Road alcoholics. those implementing quarantine and deten- responsibility for discipline, treatment, Most decisions regarding confinement tion permitted the established limits to be and detention should be allotted among were made at the sanatorium by the stretched. Thus, even as they comply with health officials, institutional staff, and the medical director and his staff. In defer- the letter of the law, modem administra- courts. ence to the authority of public health and tors must also avoid the use of unwar- Throughout this century, tuberculo- medicine, the local legal community gave ranted coercion in the day-to-day opera- sis workers have struggled with the diffi- its full approval. Even the American Civil tion of programs such as directly observed cult task of balancing patients' liberties Liberties Union scarcely objected. It was therapy. Such a goal requires both the with the protection of the public's health. not until 1964 that growing concern with solicitation of feedback from patients and If they have erred at times on the side of due process led a local judge to come to constant reexamination of the system.81 coercion, they have done so with broad Firland to hear patients' complaints.75 These safeguards will be particularly societal approval. Although modem laws Due process issues have become important if declining rates of tuberculo- and regulations represent a more sophisti- paramount as modern officials fighting sis shift attention and funding away from cated approach to the uncooperative the resurgence of tuberculosis establish control programs. tuberculosis patient, we must closely policies and facilities for the detention of Second, public health officials should examine how these new policies are noncompliant patients.76 Drawing heavily employ coercion, when necessary, based implemented. Ol on legislation regarding the confinement on the actual likelihood that an individual of mentally ill patients, these officials are is at risk for spreading infection-not more laws based on any category to which that Acknowledgments fashioning much sophisticated The author, currently an Arnold P. Gold and regulations that respect patients' civil individual belongs. In Seattle, the label Foundation Assistant Professor, began this liberties.77 First, civil commitment and "Skid Road alcoholic" meant a 12-month project as a Robert Wood Johnson Foundation confinement can occur only if a given sanatorium stay, based on a presumption Clinical Scholar. individual represents a "significant risk" that such individuals were likely to be Those who made helpful comments in- clude Nancy N. Dubler, Thomas R. Frieden, to the public. Second, this person must noncompliant. Today's "difficult" tubercu- David J. Rothman, Cathy Seibel, and the receive full due process of law, including a losis patients are also likely to have Journal's anonymous reviewers. The author prompt hearing and provision of counsel. multiple sociomedical problems, includ- also thanks former Firland staff members Finally, before requesting commitment ing homelessness, substance use, and Walter T. Miller, Joan K. Jackson, and Helen proceedings, health officials must employ psychiatric disease. Moreover, they are S. Marshall for sharing their experiences. "less restrictive alternatives" to improve likely to belong to groups more prone to compliance with outpatient antibi- be stigmatized, such as the poor, minori- References patient 1. Thomas R. Frieden et al., "The Emer- otic therapy.78 These include addressing ties, immigrants, and persons with human gence of Drug-Resistant Tuberculosis in patients' psychosocial problems, establish- immunodeficiency virus infection. Selec- New York City," New England Joumal of ing flexible clinic hours, using induce- tion of patients for directly observed Medicine 328 (1993): 521-526; Alan B. ments such as meals or subway tokens to therapy, which is carried out by health Bloch et al., "Nationwide Survey of Drug- formal Resistant Tuberculosis in the United improve clinic attendance, and, most officials without legal proceedings, States," Joumal of the American Medical notably, instituting directly observed should not reflect our preconceived no- Association 271 (1994): 665-671. therapy.79 In directly observed therapy tions about compliance in such groups.82 2. Nancy N. Dubler et al., "Tuberculosis in programs, outreach workers observe pa- Nor, more importantly, should recent the 1990s: Ethical, Legal, and Public Policy or reports touting the efficacy of directly Issues in Screening, Treatment, and the tients take their daily twice-weekly Protection of Those in Congregate Facili- medications, either in the clinic or other observed therapy83 discourage efforts- ties," in The Tuberculosis Revival-Indi- locations-such as apartments or park such as providing apartments for the vidual Rights and Societal Obligation in a benches-that are most conducive to homeless or rehabilitation for drug users- Time ofAIDS (New York: United Hospital that address the underlying causes of Fund, 1992), 1-41; George J. Annas, compliance.80 "Control of Tuberculosis-The Law and What does the Seattle experience noncompliance. the Public's Health," New England Joumal teach us? Clearly, much has changed Third, for patients detained in inpa- ofMedicine 328 (1993): 585-588; Lawrence since the 1950s. Today's uncooperative tient facilities, officials must not confuse 0. Gostin, "Controlling the Resurgent tuberculosis patients are not exclusively custodial or management issues with Tuberculosis Epidemic. A 50-State Survey institu- health goals. At Firland, bad of TB Statutes and Proposals for Reform," alcoholics, nor are most patients public Joumal oftheAmerican MedicalAssociation tionalized for prolonged periods. Drug behavior led to detention, and good 269 (1993): 255-261; Rosemary G. Reilly, resistance, formerly a minor concern, has behavior led to relaxation of quarantine. "Combating the Tuberculosis Epidemic: become a major problem. Despite these Although the use of punishments and The Legality of Coercive Treatment Mea- the historical record privileges will continue in total institu- sures," Columbia Joumal of Law & Social differences, however, Problems 27 (1993): 101-149. reminds us of three important points. tions, such institutional exigencies must 3. Recent work has demonstrated how lan- First, drafting more elaborate laws not co-opt the actual purpose of the guage may both reflect and promote the and regulations has never prevented the forced isolation.84 Thus, drinking alcohol ideological agenda of those who employ it. possible misuse of authority by those or breaking other rules should not neces- See, for example, JoAnne Brown, "Profes-

February 1996, Vol. 86, No. 2 American Journal of Public Health 263 Public Health Then and Now

sional Language: Words That Succeed," ton University Press, 1994). Lunbeck has Tuberculosis Was Won-and Lost (Boston, Radical History Review 34 (1986): 33-51; built on the work of Michel Foucault, as Mass: Little, Brown, 1993). James A. Trostle, "Medical Compliance as documented in Discipline and Punish: The 21. Annual Report, Firland Sanatorium, 1960, an Ideology," Social Science and Medicine Birth of the Prison (New York, NY: Pan- p. 12. 27 (1988): 1299-1308. This type of analysis theon Books, 1977). 22. William B. Tollen, "Irregular Discharge: likely applies to the events described in this 13. Henry I. Bowditch, "Consumption in The Problem of Hospitalization of the article. That is, health officials' use of the America," in From Consumption to Tuber- Tuberculous," Public Health Reports 63 pejorative term recalcitrant to describe culosis. A Documentary History, ed. Barbara (1948): 1441-1473; Godias J. Drolet and alcoholics who disregarded treatment rec- G. Rosenkrantz (New York, NY: Garland Donald E. Porter, A Study of "Why Do ommendations likely encouraged the adop- Publishing, 1994),57-96. First published in Patients in Tuberculosis Hospitals Leave tion of a particularly coercive approach to theAtlantic Monthly (January-March 1869). Against Medical Advice" (New York, NY: this population. Having stated this caveat, I 14. Michael E. Teller, The Tuberculosis Move- New York Tuberculosis and Health Asso- will continue to use the terminology em- ment. A Public Health Campaign in the ciation, 1949). ployed during the 1950s. Progressive Era (New York, NY: Green- 23. The discovery of antibiotics did not auto- 4. Cedric Northrop, "Field Activities Report wood Press, 1988), 93, 94; David F. Musto, matically change longstanding notions for January, 1954." Health Department "Popular and Public Health Responses to about the chronicity or incurability of Administrative Files, Washington State Tuberculosis in America after 1870," in tuberculosis. In this light, it is not surpris- Archives, Olympia, Washington (hereafter AIDS and the Historian, ed. Victoria A. ing that a concept such as compliance with cited as WSA), box 6, folder: tuberculosis Harden and Guenter B. Risse (Washing- one's antibiotic therapy may have re- control, 1953-54. ton, DC: US Department of Health and mained foreign to many patients and that 5. David F. Musto, "Quarantine and the Human Services, 1991), 14-20; Sheila M. discharges against medical advice per- Problem of AIDS," Milbank Quarterly 64, Rothman, Living in the Shadow of Death. sisted. supplement 1, (1986): 98. Tuberculosis and the Social Experience of 24. Cedric Northrop et al. "The Practical 6. Ibid., 104-106; George Rosen, A History of Illness inAmerican History (New York, NY: Management of the Recalcitrant Tubercu- Public Health, expanded edition (Balti- Basic Books, 1994), 191-193. On Biggs's lous Patient," Public Health Reports 67 more, Md: Johns Hopkins University Press, work in control, (1952): 894-898; Barbara Dike, "A Study outstanding tuberculosis to Determine Some of 1993), 251-254. see Charles E-A. Winslow, The Life of of Clinical Records 7. Allan Brandt, No Magic Bullet: A Social the Factors Involved in Irregular Dis- Hermnann Biggs, M.D., D.Sc., LL.D.: Physi- of Ninety-Four Patients Who Left History of Venereal Disease in the United cian and Statesman of the Public Health charges States Since 1880 (New York: Oxford Firland Sanatorium Against Medical Ad- (Philadelphia, Pa: Lea & Febiger, 1929). vice During the Period of January 1, 1950 University Press, 1987), 40-47, 94, 95; 15. Musto, "Popular and Public Health Re- Naomi Rogers, Dirt and Disease: Polio to June 30, 1950" (master's thesis, Univer- sponses," 17. sity of Washington, 1953),58-63; Evelyn N. before FDR (New Brunswick, NJ: Rutgers 16. Musto, "Quarantine," 107. One exception University Press, 1992), 106-137. Hadaway, "A Medical Social Study of was , which began a program of Fifty-Four Tuberculosis Patients Who Left 8. Rogers, Dirt and Disease, 30-44; Edgar A. in 1931. Jonas, "Law Enforcement in the Control of detention Firland Sanatorium Against Medical Ad- 17. Barron H. Lerner, "New York City's vice in 1952" (master's thesis, University of Tuberculosis," American Joumal of Public Histori- Health 13 (1923): 113-118; Stuart Gal- Tuberculosis Control Efforts. The Washington, 1953),52-57. ishoff, Safeguarding the Public Health. New- cal Limitations of the 'War on Consump- 25. Hadaway, "Medical Social Study," 32. ark 1895-1918 (Westport, Conn: Green- tion.' " American Joumal of Public Health 26. There is a large literature on changing 83 (1993): 75S,-76c Although detention concepts of alcoholism after the repeal of wood Press, 1975), 29-34. The most -, infamous case of enforced isolation is was infrequei:tv this era, public Prohibition. See Elvin M. Jellinek, The probably that of Typhoid Mary. See Judith sanatoria were IrX.-sly strict. Control Disease Concept ofAlcoholism (Piscataway, W. Leavitt," 'Typhoid Mary' Strikes Back. of daily activitic- .,as seen as crucial to NJ: Alcohol Research Documentation, Bacteriological Theory and Practice in "chasing the cure." 1960); Ronald Roizen, "The American Early Twentieth-Century Public Health," 18. Recent memories of World War II un- Discovery of Alcoholism, 1933-1939" Isis 83 (1992): 608-629. doubtedly contributed to the rejuvenation (Ph.D. diss, University of California at 9. Dorothy Porter and Roy Porter, "The of the "war on tuberculosis" in Seattle and Berkeley, 1991). Enforcement of Health: The British De- across the country. For an insightful analy- 27. Interview with Firland Sanatorium sociolo- bate," in AIDS. The Burdens ofHistory, ed. sis of how military language and metaphors gist Joan K. Jackson, December 5, 1992. Elizabeth Fee and Daniel M. Fox (Berke- have permeated tuberculosis control, see Firland physicians generally only labeled as ley, Calif: University of California Press, JoAnne Brown, "Playing the Game: Tuber- alcoholic those Skid Road patients who 1986),107. culosis, Medievalist Nostalgia, and the admitted to extensive past drinking or who 10. Allan M. Brandt, "AIDS: From Social Great War" (paper presented at the drank on the premises. History to Social Policy," in AIDS. The Organization of American Historians, At- 28. Skid Road earned its name because loggers Burdens of History, ed. Elizabeth Fee and lanta, Ga, April 1994). As we shall see, dragging lumber to the Seattle waterfront Daniel M. Fox (Berkeley, Calif: University Seattle's "new" sanatorium in 1947 was an greased the road so that the logs would of California Press, 1986), 151. old naval hospital, and detention of pa- skid. Skid Road later referred to the area 11. Musto, "Quarantine," 109-112; Alan M. tients occurred in the former naval brig. south of the original pathway. Kraut, Silent Travelers: Germs, Genes, and 19. Marcelle Dunning and Robert Heskett, 29. On the Skid Road alcoholic in Seattle, see the "Immigrant Menace" (New York, NY: "Diseases Through the Century: Public Joan K. Jackson and Ralph Connor, "The Basic Books, 1994); Howard Markel, "Lay- Health Becomes Involved," in Saddlebags Skid Road Alcoholic," Quarterly Journal of ers of Separation: Epidemics and the to Scanners. The First 100 Years ofMedicine Studies on Alcohol 14 (1953): 468-486; Quarantining of East European Jewish in Washington State, ed. Nancy Rockafellar James P. Spradley, You Owe Yourself a Immigrants in New York City During the and James W. Haviland (Seattle, Wash: Drunk: An Ethnography of Urban Nomads Late 19th Century" (Ph.D. diss, Johns Washington State Medical Association, (Boston, Mass: Little, Brown, 1970). There Hopkins University, 1994). 1989), 133-154. was also a large population of Native 12. Erving Goffman, Asylums: Essays on the 20. The history of preantibiotic therapeutics is Americans on Seattle's Skid Road, whose Social Situation ofMentalPatients and Other actually much more complex and includes experiences at Firland I will explore in Inmates (Garden City, NY: Anchor Books, the use of alternative remedies and nos- future work. 1961), 6. See also David J. Rothman, trums. See, for example, Linda Bryder, 30. Dike, "Clinical Records," 61; Annual Re- Conscience and Convenience. The Asylum Below the Magic Mountain. A Social History port, Firland Sanatorium, 1950, pp. 6-8; and Its Alternatives in Progressive America of Tuberculosis in Twentieth-Century Britain Daniel Widelock et al., "Public Health (Boston, Mass: Little, Brown, 1980), 324- (Oxford, England: Clarendon Press, 1988), Significance of Tubercle Bacilli Resistant 421; Elizabeth Lunbeck, The Psychiatric 157-198. For the triumphant story of the to Isoniazid," American Journal of Public Persuasion. Knowledge, Gender, and Power discovery of antibiotics, see Frank Ryan, Health 45 (1955): 79-83. in Modern America (Princeton, NJ: Prince- The Forgotten Plague. How the BattleAgainst 31. Northrop, "Practical Management," 895.

264 American Journal of Public Health February 1996, Vol. 86, No. 2 Public Health Then and Now

32. Ibid., 895, 896. Hospitalization" (editorial), American Re- 74. Sidney H. Dressler, "The Case Against 33. Ibid., 894-898; Roberts Davies, "Isolating view of Tuberculosis and Pulmonary Dis- Compulsory Isolation of the Recalcitrant the Recalcitrants," Bulletin of the National eases 79 (1959): 659-661. Tuberculous," Rhode Island Medical Jour- Tuberculosis Association 10 (1954): 121, 58. D.H. to Governor Albert Rosellini, Janu- nal 42 (1959): 651, 653. 122; Mark A. Linell, "The Detention Ward ary 21, 1957. State Department of Health, 75. Regarding the rise of due process, see and Its Place in the Control and Treatment Director's Files, 1954-57, WSA, box 1, David J. Bodenhamer, Fair TriaL Rights of ofTuberculosis,"Amencan Review ofTuber- folder: 59. the Accused in American History (New culosis and Pulmonary Diseases 74 (1956): 59. Ibid. York, NY: Oxford University Press, 1992), 410-416. 60. A.P. to To Whom it May Concern (no 113-125. I will discuss events in the 1960s 34. Linell, "Detention Ward," 411. date). American Civil Liberties Union of in subsequent work. 35. Roberts J. Davies, "The Prerequisites for a Washington papers, University ofWashing- 76. Sue Etkind et al., "Treating Hard-to-Treat Successful Campaign ofTuberculosis Eradi- ton Archives, Seattle, Washington (hereaf- Patients in Massachusetts," Seminars in cation," Health Pilot 29 (1947): 6-8, 11. ter referred to as ACLU-W), box 25, Respiratory Infections 6 (1991): 273-282; 36. Annual Report, Washington State Depart- folder: due process committee, Firland Mireya Navarro, "Confining Tuberculosis ment of Health, 1949, p. 9. Patients: Weighing Rights vs. Health Risks, Sanatorium. New York Times, 21 November 1993, pp. 1, 37. Northrop, "Practical Management," 895, 61. Harvey Hurtt to Governor Albert Rosel- 896; Interview with Firland Sanatorium 45; Donna Leusner, "State Drawing Plans lini, March 28, 1957. State Department of Uncooperative Tuberculo- staff physician Walter T. Miller, October WSA, to Quarantine 19,1992. Health, Director's Files, 1954-57, sis Patients," Star-Ledger (Newark, NJ), 28 38. Davies, "Isolating the Recalcitrants," 121, box 2, folder: 86.1. April 1994, p. 14; "Quarantine Center 122; Linell, "Detention Ward," 411. 62. Washington State Department of Health, Proposed for Recalcitrant Tuberculosis 39. Miller interview, October 19,1992. "Objectives of Tuberculosis Hospital Sur- Patients," San Francisco Chronicle, 14 June 40. Notices of Quarantine. Health Depart- vey Team, March 21, 1957." Department 1994, p. 17. ment Administrative Files, WSA, box 6, of Social and Health Services 300 Files, 77. See reference 2. folder: tuberculosis control, 1953-54. WSA, box 42, folder: consolidation (his- 78. A debate has arisen over what constitutes 41. Diagnostic Standards and Classification of tory). "less restrictive alternatives." See, for Tuberculosis (New York: National Tubercu- 63. Minutes of the Board of Directors, Febru- example, New York City Tuberculosis losis Association, 1950), 36,37. ary 7, 1957, and December 5, 1957. Working Group, "Developing a System for 42. Linell, "Detention Ward," 415. ACLU-W papers, box 15, folder: 1957. Tuberculosis Prevention and Care in New 43. Ibid., 411. 64. Byron F. Francis, "Policies Covering the York City," in The Tuberculosis Revival- 44. Davies, "Isolating the Recalcitrants," 121. Operation of the Detention Ward at Individual Rights and Societal Obligation in Quoted phrase is from Miller interview, Firland Sanatorium, 1960." Department of a Time ofAIDS (New York, NY: United October 19,1992. Social and Health Services 300 Files, WSA, Hospital Fund, 1992),51-58; Ronald Bayer 45. Resolution 10289, January 6, 1947, King box 40, folder: Firland (1968). and Laurence Dupuis, "Ethical and Legal County Commissioners, King County Ar- 65. Lerner, "New York City's Tuberculosis Issues in Tuberculosis Control," Annual chives, Seattle, Washington, box 29. Control Efforts," 672. Review ofPublic Health 16 (1995): 307-326. 46. Linell, "Detention Ward," 411; "Doctor's 66. Northrop, "Practical Management," 898; 79. Dubler et al., "Tuberculosis in the 1990s," Report. Only 20 Per Cent at Firland "Doctor's Report," 6. 22-25; Mindy T. Fullilove et al., "Psychoso- Diagnosed as Alcoholics," Seattle Times, 2 67. Davies, "Isolating the Recalcitrants," 121. cial Issues in the Management of Tubercu- September 1960, p. 6. 68. "Compulsory Isolation-Its Ingredients. losis," Joumal ofLaw, Medicine & Ethics 21 47. Linell, "Detention Ward," 415. New Mexico Reports on Questionnaire (1993): 324-331. 48. Northrop, "Practical Management," 896; Survey," National Tuberculosis Association 80. Michael D. Iseman et al., "Directly Ob- Miller interview, October 19,1992. Rehabilitation Events, 6, no. 1(1960): 1, 2. served Treatment of Tuberculosis. We 49. For a similar discussion of punishments Associa- Can't Afford Not to Try It," New England 69. Ibid., 1; National Tuberculosis Medicine 328 576-578. and privileges, see Goffman, Asylums, tion, "Report on Compulsory Isolation in Joumal of (1993): 51-53; Julius A. Roth, Timetables: Stnirur- 81. For a similar discussion, see Nancy N. the United States, December 1955," Ameri- Dubler, "Jail and Prison Health Care ing the Passage of Time in Hov-;'.i 1reat- can Lung Association Archives, New York, ment and Other Careers ('-...anapolis, Ind: Standards," in In Search of Equity. Health NY, folder: 2708. Needs and the Health Care System, ed., Bobbs-Merrill, I("' 52-56. 70. Northrop, "Practical Management," 894- 50. Notices ol Quarantine. Health Depart- Ronald Bayer et al. (New York, NY: 898; Davies, "Isolating the Recalcitrants," Plenum Press, 1983), 69-94. ..xclt Administrative Files, WSA, box 6, 121, 122; Linell, "Detention Ward," 410- folder: tuberculosis control, 1953-54. 82. Trostle, "Medical Compliance," 1299- 416; Cedric Northrop, "Compulsory Isola- 1308. 51. Others have characterized tuberculosis tion," Bulletin of the National Tuberculosis sanatoria as "total institutions." See Goff- 83. Stephen E. Weis et al., "The Effect of Association 42 (1956): 149-150. Directly Observed Therapy on the Rates of man, Asylums, 4; Rothman, Living in the and Anthony V. Cad- Shadow, 227; Bryder, Below the Magic 71. Andrew L. Banyai Drug Resistance and Relapse in Tubercu- den, "Compulsory Hospitalization of Open losis," New EnglandJoumal ofMedicine 330 Mountain, 200-214. Review 52. Goffman uses the term rationalization to Cases ofTuberculosis,"American of (1994): 1179-1184. Tuberculosis 50 (1944): 136-146; Robert L. 84. The "co-opting" of medical goals within a describe the process by which institutional Bulletin policies are justified on other grounds. See Kennedy, "Recalcitrant Patients," prison setting is discussed in Dubler, "Jail Asylums, 46, 47. of the National Tuberculosis Association 43 and Prison Health Care Standards," and 53. On the disciplinary authority of the medi- (1957): 55, 56. Nancy N. Dubler and B. Jaye Anno, cal profession, see Lunbeck, Psychiatric 72. Edward Kupka and Marion R. King, "Ethical Considerations and Interface with Persuasion, 81-96. "Enforced Legal Isolation of Tuberculous Custody," in Prison Health Care: Guidelines 54. Linell, "Detention Ward," 413. Patients," Public Health Reports 69 (1954): for the Management ofAn Adequate Delivery 55. Jackson interview, December 5, 1992. 351-359; Stuart Willis, "The Case for System, ed. B. Jaye Anno (Washington, 56. Davies, "Isolating the Recalcitrants," 122; Forcible Hospitalization of the Recalci- DC: U.S. Department of Justice, 1991), Interview with Firland Sanatorium staff trant Tuberculosis Patient, Rhode Island 53-69. For a recent example of custodial physician Helen S. Marshall, September 2, Medical Joumal 42 (1959): 650, 652, 654, problems at a detention center for tubercu- 1992. 655. losis patients, see Mireya Navarro, "Four 57. Northrop, "Practical Management," 896; 73. "The Recalcitrant Tuberculosis Patient" Patients at TB Center are Arrested in Emily B. Fergus and Joan K. Jackson, "The (editorial). Joumal ofthe American Medical Attack," New York Times, 27 January 1994, Tuberculous Alcoholic Before and During Association 167 (1958): 74. p. B8.

Health 265 February 1996, Vol. 86, No. 2 American Journal of Public