The Stubborn Women: Typhoid - Mary and Sara
In 1906, Mary Mallon was employed as a cook to a wealthy banker and his family who had taken residence in Oyster Bay, Long Island for the summer. Mary loved cooking and had worked in this occupation since emigrating from Ireland 13 years prior. The Warrens needed a cook during their summer stay and decided to take Mary. The Warrens particularly loved Mary’s desserts, one being an ice-cream with fresh peaches cut up and frozen in it. Mary had worked in Oyster Bay before, but when the family she worked for fell ill her employment fell through and she worked for other families and eventually, the Warren family. Her peaceful stint ended abruptly when the Warrens started coming down with typhoid fever. To prevent herself from getting ill, she sought another employment and ended up moving to Manhattan.
It was there that Mary started being visited by George Soper, a sanitation engineer investigating the outbreak in Oyster Bay. Mary wanted nothing to do with Soper, especially since she was healthy and it had been six months since she left the Warrens. Soper had been studying the outbreak in the family diligently, documenting dates of attacks, diagnoses, and other information. Soper noticed that the Warrens were only visiting Oyster Bay for the summer, possibly carrying the disease there with them. He suspected that someone was infected with the disease but was not showing any symptoms, and his suspicion fell onto the cook that disappeared after the outbreak.
The first case of a typhoid carrier was reported in 1902 by famous scientist Robert Koch after an earlier investigation in Germany found a seemingly well person was actually carrying the bacteria. No case of asymptomatic carriers had ever been reported in the United States, but Soper suspected Mary might be harbouring and transferring typhoid bacteria by failing to properly wash her hands after her toilet visits. Cooking meals properly would usually kill these bacteria – however, some dishes like her famous dessert didn’t require any heating and hence only helped preserve the bacteria. Soper also found records that she had left trails of typhoid fever in all the places she had worked at in the five years prior. Soper kept searching for Mary at her workplace, trying to corner her for samples for him to test the carrier theory.
Worried that his constant nagging might cause Mary to run away once again, Soper contacted The New York City Health Department and asked for their assistance in taking Mary into custody. The Department sent a female inspector Dr. Sara Josephine Baker who tried reasoning with Mary but had the door literally and figuratively slammed in her face. The following morning, Dr. Baker enlisted the help of police officers to arrest Mary at her employer’s residence. It took the authority three hours to find Mary who hid in an outdoor closet. They captured Mary and quarantined her in the hospital for almost three years. However, they failed to convince Mary to undergo treatment including surgery to remove her gall bladder where they suspected the bacteria lived. It was confirmed through testing her stools that she was the first typhoid carrier in the United States.
In 1910, Mary was released from quarantine after vowing she would not work as a cook. Mary became a laundress but hated the lower wage and went back to cooking under an alias. This decision caused more outbreaks all over the city. The last known outbreak occurred when she brought food to a friend staying in a hospital, and she was rearrested in 1915. Both Soper and Dr. Baker again helped in this second arrest, and Mary Mallon’s case stayed with them for a long time. Mary Mallon was found to be responsible for at least 120 cases of typhoid fever, including 5 deaths, and spent the rest of her life in quarantine in Riverside Hospital.
Typhoid fever is an infection caused by a specific type of bacteria called Salmonella enterica subsep enterica. This group of bacteria is related to the Salmonella bacteria that cause poisoning through uncooked meat or raw eggs. Typhoid fever, is however more severe, with various symptoms including high fever over several days, weakness, abdominal pain, headaches, constipation, and vomiting. The bacteria grow in the intestines and blood, spreading through poor hygiene and entering hosts through the gastrointestinal tract. The concept of hygiene was very different in the early 20th century – it was only in 1846 that a Dr. Semmelweis published his finding that handwashing was crucial for medical practitioners before handling patients. The incidence of typhoid fever has reduced significantly nowadays thanks to improved hygiene practice, development of vaccines, and use of antibiotics to kill the bacteria. However, typhoid is still a big concern in some parts of the world and vaccinations are highly recommended when travelling to such places.
The mechanism in which typhoid fever progresses turns out to be rather complex. When bacteria invade the body, the immune system responses by deploying their soldiers - the white blood cells. In most infections, the white blood cells replicate more to ensure there are enough of them for this fight. In typhoid fever, however, we see the opposite - white blood cell count is unusually low. It turns out that in typhoid fever, the bacteria hide in a type of white blood cells called macrophages. The bacteria patiently waits for the body’s immune system to stop reacting aggressively to the infection before hijacking the macrophages and staying quietly within the body. Here they take-over the cells’ metabolism to replicate and spread the disease. This strategy allows the typhoid fever to trick the body - the disease seems to be under control but is actually infectious. Some of the patients, the carriers, do not even notice that they're ill. The asymptomatic carriers pose a danger to public health, and Mary Mallon was the first known carrier in the USA - for which she earned the nickname ‘Typhoid Mary'.
Mary Mallon was notorious and for the longest time was ostracised for being the source of the outbreaks. She was mocked in newspapers and cartoons, and both Soper and Baker later admitted that The Department of Public Health didn’t do enough to educate Mary the first time she was quarantined. She didn’t understand how the disease was transmitted and thought that she was prejudiced because of her working-class background. She refused to learn about the disease as she was forcibly quarantined, and she rejected the surgery that could’ve saved her life because she didn’t trust the doctors.
Dr. Sara Josephine Baker went on to become a great figure in public health, working to improve conditions to immigrant communities in New York City. Immigrants at the time lived in poverty amongst unsanitary conditions. Children mortality rate was high, even in well-off families. Dr. Baker once told a journalist that the babies born in the US had worse survival chance than soldiers fighting in the World War I. Her experience with Mary Mallon taught her that communicating with and educating the community was crucial – this became an important factor in her work. She initiated a training program where she and a group of nurses taught mothers how to take care of their infants. Baker also set up a milk station where she gave out formula to help mothers who struggled to breastfeed or needed to leave their babies at home to work. Her other work included midwife training and health education in school.
As a woman, Dr. Baker repeatedly faced prejudice from her colleagues who still believed that women doctors were not as capable as their male counterparts. She was the first woman to earn a doctorate in public health from NYU and in 1908 was appointed as the first director of the NYC Bureau of Child Hygiene. She adopted a masculine way of dressing to distract attention from her as a female in a male’s profession, but it was later acknowledged that she was one of the first prominent LGBTQ figures in the field. She openly lived with her partner, novelist Ida Wylie, and joined a luncheon discussion club of free-thinking and free-spirited women.
It has been more than a century since Mary and Sara crossed paths and scientists are still trying to understand this complex disease. By being stubborn, Mary created dangerous situations in the city but her history taught Sara that communication is extremely important between doctors and patients. These two strong-willed women, Mary and Sara, are forever tied together in the history of typhoid fever.
References/Further Reading:
Dinner with Typhoid Mary. Ridely Ochs. Newsday.
Filio Marineli, Gregory Tsoucalas, Marianna Karamanou, and George Androutsos. Mary Mallon (1869-1938) and the history of typhoid fever. Ann Gastroenterol. 2013; 26(2): 132–134.
George A. Soper. The Curious Career of Typhoid Mary. Bull N Y Acad Med. 1939 Oct; 15(10):698-712
NA Eisele et al. Salmonella require the fatty acid regulator PPARδ for the establishment of a metabolic environment essential for long-term persistence. Cell Host Microbe. 2013 Aug 14;14(2):171-182. doi: 10.1016/j.chom.2013.07.010.
NYBooks. The Doctor Who Made a Revolution.
'TYPHOID MARY' DIES OF A STROKE AT 68. New York Times (1857-Current file); Nov 12, 1938; ProQuest Historical Newspapers The New York Times (1851 - 2006) pg. 17.