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 tuberculosis.' 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 antibiotic 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 antibiotics, 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.