Many public health ethics debates are construed as the rights of the collective versus the rights of the individual. This essay demonstrates that in the context of diseases which are transmitted by healthy carriers, the issue is more complex than this. Instead of arguing about competing rights, this essay argues that such debates are first about competing visions of reality, in which the individual is asked to substitute a collective understanding of their body for their own personal experience of their body. Understanding this first layer of the ethics debate in such healthy carrier situations allows us to redirect persuasive energies, moving away from a beginning-point of compliance to one of understanding, which may ultimately find a more willing public audience.
At the risk of being hackneyed, I’d like to start, like so many ethical case studies do, with a thought experiment. You are a lecturer of English at a midsized institution. In this day of precarity and fading job markets, you feel fortunate to have a renewable contract and health insurance. Perhaps it is this gratitude-guilt that keeps you, more often than not, uncomplaining about your rather overwhelming teaching load and the paltry pay. You’re better off than some, in other words, but you work hard. You are typing at your computer in your (shared) office one day, enjoying the spring sunshine that has just begun to usher out the winter gloom, trying to take a breather between courses, when a man storms into your office. He seems . . . official-looking but a bit harried. Before you can ask what he is doing there, he announces that you, while seemingly healthy, are in fact killing people around you in great numbers with a disease you don’t know you have (you vaguely recall some outbreaks around the country), verified by a new-fangled form of viral-genotyping software you’ve never heard of. He tells you it is crucial you quit your job—today—or risk killing more people. He threatens you with forced quarantine if you don’t oblige.
What is the ethical choice for you to make as an employee who needs income and as a human being who might feel violated by these very suggestions? What is the ethical choice for the doctor? Can he, ethically, turn a blind eye to what he has discovered?
This conflict of rights—a public health dilemma—is at least two centuries old, dating from at least the 1720s, when vaccination (preventive medicine for currently healthy people that involves injecting unhealthy particles into the body) was debated hotly (Sudan 2016: 113). Vaccination debates are often cast as the rights of the individual (to deny treatments and to consent to any medical interventions) against the rights of the public (to avoid encountering preventable diseases in the community). Like so many ethical debates, the question is generally framed as being less about who is “correct” and more about whose rights take precedence when two sets of stakeholders’ rights are in direct conflict and mutually exclusive. This is indeed so. However, as I will show, it is difficult to persuade people about rights when they fundamentally disagree about the lived realities factoring into these rights. The healthy carrier narrative makes this abundantly clear, and this narrative offers a potential means of bridging gaps between ethical obligations on one hand and effective public health communication on the other.
Although the novel coronavirus is more frequently framed as having a long incubation period, this period is in fact so long, and the majority of the infected so mildly ill, that COVID-19 is necessarily a disease with many healthy carriers. In fact, diseases like this become pandemics much more readily than others. Highly virulent diseases such as the seasonal flu and Ebola tend to be readily visible and therefore more readily avoidable. By mid-March 2020, it became apparent that COVID-19 was often being spread by people who were not yet manifesting symptoms or who might never know they were ill with coronavirus at all. One by one, countries around the world began issuing stay-at-home orders, the only way feasible to simply wait out the virus in a world where anyone could be a healthy carrier. However, people the world over have struggled with the concept that they must restrain their personal activities because of something that isn’t, apparently, currently affecting them.
This tension has been thrown in even sharper relief in America, the land of rugged individualism. As Nancy Berlinger, et al. have written, crisis care ethics holds that in times of public health emergencies, health work shifts from a focus on individual needs to a focus on the public’s needs. In response to the 2020 COVID-19 pandemic, The Hastings Center explains:
Clinical care is patient-centered, with the ethical course of action aligned, as far as possible, with the preferences and values of the individual patient. Public health practice aims to promote the health of the population by minimizing morbidity and mortality through the prudent use of resources and strategies. Ensuring the health of the population, especially in an emergency, can require limitations on individual rights and preferences (Berlinger, et al. 2020: 2).
America was built on a stubborn skepticism surrounding complacent submission to authority, however, especially concerning limitations on individual liberties. Thus, the fight of rights against rights has been hard-fought (I hesitate to say “-won”) in America, a country where a large number of people still espouse states’ rights, with a populist leader who caters to a party of anti-authoritarian gunslingers.
The case study of Mary Mallon, or Typhoid Mary, elucidates the dilemma of the healthy carrier narrative quite well.1 In 1907, Mallon, an Irish immigrant living in New York City, was working as a cook for a local family when a public health official, Doctor George Soper, swooped into her place of employment, pronounced she was killing those around her with typhoid fever, and demanded a sample of her fecal matter. Mallon shooed him away with a carving fork. Relentless, Soper returned. This time Mallon hid. She later absconded completely, finding work under an assumed name. To this day, aside from some revisionist histories which are generally scholarly texts, Mallon is often invoked in popular public memory as a selfish and irresponsible woman, indifferent to the fact she was killing others. I, however, tend to see her more in line with recent historical revisions as someone who, in just a decade or so after germ theory became widely accepted as scientific fact, may or may not have been able to believe what Soper was telling her. To her knowledge, she had never had typhoid, so the new theory of a so-called healthy carrier, justified by the fairly new science of germ theory, understandably seemed preposterous to her. I imagine she might have been justly horrified a man had stormed into her place of employment demanding to look at the contents of her chamber pot. Victorian decorum would have only heightened what even today would be seen as a rather gross violation of one’s privacy and work space.
Yet, from what we can tell, it is likely Soper was right. Mallon does seem to have been—for all the historical records can attest (and there are of course some limitations)—a healthy carrier of typhoid fever, and her job as a cook was the most dangerous one she could have had with her condition. Soper ordered Mallon to stop working as a cook, but this sort of employment was quite well paying (relatively speaking) for a first-generation Irish immigrant. Racial prejudices at the time were high against the Irish-American population, moreover, leaving few options for them. Lacking other skills, hence no other way to make a living, Mallon kept working as a cook under an assumed name. Eventually, Soper found her and consigned her to quarantine for what was essentially the rest of her life. However, while this last fact might seem to stack the decks in favor of Soper’s righteousness, the historical record indicates Mallon’s imprisonment-quarantine was virtually unprecedented before or after. Many other healthy carriers were identified who then disappeared from the public registers. These were rarely tracked down, and when they were, they were usually let off lightly. It’s difficult to discern exactly why she was confined because of her healthy carrier status when others were not.
To some extent, of course, her nationality and sex may explain these facts. Beyond this, it is cheaper and simpler to pinpoint one villain to neutralize than to invest in preventive public health infrastructures. It is cheaper and simpler still (for the state, at least) to promote a national ideology that upholds individual responsibility (rather than government-funded social systems) for cleanliness and hygiene. Indeed, in this period, “social welfare was the responsibility of individuals” (Wald 2008: 72). Making an example of Mallon promoted the idea of public health progress while avoiding the necessity for larger state investments, as well as sidestepping more nuanced ethical issues inherent to the case. These ethical considerations are thorny indeed: if Mallon truly refused to stop working as a cook, the rights of the public to be protected from her might have taken preeminence. Typhoid was indeed sporadically epidemic at the time, and so crisis care ethics would suggest protection of the public over one individual’s rights. However, in an existential sense, if Mallon truly didn’t believe Soper’s claims (which used cutting-edge and possibly confusing evidence), was she therefore morally obligated to obey his demands? Such a question perhaps exceeds the realm of public health crisis ethics. Yet, the question is worth considering in order to approach more effective means of promoting compliance with such public health recommendations. Outside of academic texts, Mallon has fairly universally been portrayed as someone who did not care she was infecting others. How does the ethical scale shift if we suppose she cared but did not believe?
This last question yields particular insight into the issue plaguing America today: we might portray those who oppose social distancing as MAGA-hat-wearing, gun-toting individualists, unconcerned with the public good, but what if the healthy carrier narrative is one that fundamentally pits not only two sets of rights but also two lived realities—embodied realities, at that—against one another? Setting aside for the moment the important issue of economic realities, for those who cannot live without the income leaving their house provides, what of those who simply cannot believe that the evidence of their own individual senses, evidence of their own perception of their own bodies—should take a backseat to scientific data? Aside from being an ethical dilemma, of the Schrödinger’s disease variety, this is also a public health and scientific communication dilemma of great import to future generations, foreshadowed by the healthy carrier narrative of Mallon. Indeed, beginning with Mallon’s case, public health expectations began to “introduce . . . experts, such as the epidemiologist, who would serve as a mediating role between citizens and the state,” and which individual(istic) Americans were asked to substitute for their own perceptions of their bodies and the environment (Wald 2008: 70).
If American individualism is currently poised—in part as an ironic result of American neoliberal individualization of healthcare mandates as seen in Mallon’s example—to become a snake eating its tail, it is not just because we are asking for a population steeped in individualistic culture to concern itself with the public good—for public rights to supersede individual rights, that is—but also and just as importantly because we are asking individuals to believe in a publicly defined reality and not in a personally informed one. In fact, we are doing more than this: we are asking individuals to deny a personally informed reality of a self, substituting in its place aggregated data about the global public. This is a tall order to say the least, one evidently exceeding the boundaries of merely lamenting that America, as a whole, cares too little for the public good (as I admittedly often do—I make no exceptions for myself). Science communication and public health ethics can be helpfully informed by the evolving legacy of the healthy carrier narrative to demonstrate that, in this case, we must think like those we wish to influence, however much we may want to lament their perceived lack of ethical concern for the common good.
A great deal of my public and academic work has been to highlight this lack of community-minded goals in modern Western society, so I’ll be the first to admit I’m less certain how to solve the problem of differing beliefs (as opposed to differing values). In general, the era of “fake news” as a concept has sowed a tendency to doubt not only expertise but also claims to reality. It seems difficult, despairingly impossible even, to ever find common ground when no one can agree on what “ground” is to begin with. Perhaps, if anything, COVID-19, a global public health crisis we all share, if unevenly, has demonstrated nothing if not the current situation in America, which is to deny any shared realities. Not this disease. Not here. Not in my body. I feel fine.
As we can see from Mallon, and from the earlier vaccination debates, issues of conflicting rights can get heated, indeed, but even Mallon eventually seemed to accept her confinement was in the public’s best interest, capitulating, therefore, to rights because she had eventually accepted some part of the reality framework presented to her by germ-theory science. Indeed, the archival evidence indicates she sent her fecal samples out for independent lab investigation, suggesting that as a basic framework for understanding the world, she ultimately accepted Soper’s version of reality defined by germ-theory and bacteriological science, even if she doubted his claims of where exactly those germs might be found in her seemingly healthy body.
Perhaps it does come back to valuing community, after all. Recent studies in science communication have suggested what I’ve sketched out here: scientific literacy is not the variable that determines whether or not a group will accept the reality of a public health issue like vaccination or global warming—social groups are. As Dan M. Kahan (2010) has shown, while individuals tested demonstrated a surprising ability to factually interpret scientific findings, they tended to revert to in-group thinking about the issue, siding with whatever their main social group already believed. We humans are social, after all. Our social nature is why solitary confinement is potentially a human rights violation, why just about all of us wish we weren’t having to stay home right now, why we are all clinging to Zoom happy hours—even as we dread another second of Zoom meetings—why children yell at one another across balconies, starved for the sound of another child’s voice. We’re all doing the same dance of retreating to our social safety spaces. And if our “safe” social group told us this was all a lie? Well, it seems we’d be more likely to believe our friends than science, because, as I’ve argued elsewhere (see Nixon 2020), and as Matthew Arnold famously proclaimed in “Dover Beach” (1867), in times of desperate calamity, all we humans really have is one another. I have no answer to this twisted dilemma that the healthy carrier narrative, via the vehicle of COVID-19, has presented to us in America, but understanding the dilemma is surely important. In ethics, we make algorithms. But humans are not algorithms. And perhaps understanding that will be a meaningful first step toward bridging the gaps in our current moment of hyperpolarization.
In this recounting of Mallon’s experiences, I draw upon both Leavitt 1996 and Wald 2008. Indeed, Wald notes that the tension between collective rights and individual rights in a time of “growing individualism” was always at the heart of the healthy carrier narrative (70).