"Compelled to Behave: 
The Treatment of Tuberculous Alcoholics in Seattle 1949-1960, 

The discovery of antibiotics for the treatment of lung tuberculosis in the late 1940s dramatically changed the management of the disease. Mortality rates fell and the average length of stay in sanatoria declined considerably. Yet the successful advances made in tuberculosis control after World War II also served to highlight the continuing problems among socially disadvantaged members of the population. Of particular concern were skid row alcoholics, whose lack of cooperation with medical therapy and increased the likelihood that they would spread tuberculosis in the community. 

Alcoholism itself was undergoing a major transformation at this time. Both medical and lay groups were attempting to redefine alcoholism as a medical disease as opposed to a moral transgression. This new paradigm explicitly rejected the standard legalistic approach to alcoholism on the skid row, which basically consisted of repetitive arrests and jail sentences for public drunkenness. What was needed, argued critics, was a series of sociomedical interventions designed to treat the alcoholism in the context of its attendant social problems. 

It was this approach to alcoholism that a group of researchers and clinicians sought to introduce at Seattle's Firland Tuberculosis Sanatorium in the 1950s. Firland instituted a pioneering program of social and rehabilitative services that sought to address the issue of alcoholism while patients were hospitalized at the sanatorium. Simultaneously, however, Firland also established a locked ward to forcibly detain those alcoholic patients who, despite all other interventions, remained persistently "recalcitrant" and thus potential threats to the public's health. Originally meant only for the occasional "bad actor," Firland's locked ward ultimately housed close to 1000 patients between 1949 and 1960. This paper will explore the fate of Firland's efforts to construct a disease its staff termed "tuberculosis-alcoholism." 

THE PROBLEM OF AMA DISCHARGES 

Firland--like other tuberculosis sanatoria--had long been plagued by patients who insisted on leaving "against medical advice" (AMA). AMA discharges frustrated health officials, who believed that these patients had received inadequate medical care and thus often spread infection. Faced with chronic shortages of funding and sanatorium beds until the 1940s, however, Seattle officials did little about AMA discharges. By 1947, however, the city's tuberculosis control program had significantly expanded, thanks to funding increases and the acquisition of a 1250-bed surplus naval hospital that could house all of Seattle's tuberculosis patients. This facility was called Firland. 

Another important development occurred in 1946 when Firland began to use streptomycin, the first antibiotic agent that could treat tuberculosis. By 1952, two additional medicines, PAS and isoniazid, were also available. These drugs enabled doctors to shorten the average hospital stay from two years in the early 1940s to six months by 1960. Yet Firland staff believed that the combination of antibiotics, bed rest and surgery--in a supervised setting--provided the best chance to cure tuberculosis, and thus recommended at least a six month hospital stay. Discharged patients were expected to complete their antibiotics at home. 

With adequate funding and beds as well as powerful drugs, Firland began to tackle the problem of AMA discharges. A series of studies performed at the sanatorium revealed very high AMA rates, comprising up to 47 percent of all discharges. Of particular concern were alcoholics, who, in one study, comprised 74 percent of all AMA discharges among men. The majority of such alcoholics lived in the "Skid Road" section of Seattle. (Skid Road was the prototype of urban areas across the country that ultimately earned the name "skid row.") Due to the marked economic growth experienced by the city during World War II, Seattle had attracted growing numbers of transient males, mostly white, who traveled the West Coast and Alaska looking for odd jobs. Often unemployed, these men drank heavily and spent their nights either on the street or in flophouses. 

Not only did Skid Road alcoholics have high AMA rates, but health officials believed that they were unlikely to comply with outpatient therapy. As a result, these officials concluded, such persons often relapsed, and thus spread tuberculosis in the community. It became clear to both the Health Department and Firland staff that they needed to develop a strategy for improving the ability of tuberculous alcoholics to successfully complete their prescribed treatment. The strategy consisted of two components: rehabilitation and forcible detention. 

ADDRESSING THE ISSUE OF ALCOHOLISM 

As had tuberculosis workers for centuries, officials in Seattle stressed that tuberculosis was a "social disease" that resulted from poverty, malnutrition and homelessness. Skid Road alcoholics, it was clear, had more of these social problems than anybody. As a purely practical matter, many tuberculosis workers argued, it was necessary to address the issue of alcoholism concurrently with that of tuberculosis. As one physician wrote: 

It is a very rare case indeed where a true alcoholic recovers from tuberculosis unless he stops all drinking, and it is almost unheard of for anyone who has an arrested case of tuberculosis, and who goes back to being a chronic alcoholic, to remain well. 

Others, however, had a larger vision, hoping to use tuberculosis as an opportunity to better the lives of alcoholics. What was the point of curing tuberculosis, such individuals asked, if the alcoholic simply returned to the same "[p]oor living conditions, sense of oppression, and lack of educational and recreational activities" that initially drove him to drink? 

Interest in alcoholism had increased during the 1940s as it gradually became redefined as a disease as opposed to a sin. This philosophy was popularized by researchers at the Yale University Center for Alcoholic Studies as well as Alcoholics Anonymous, which had become the most visible treatment strategy for alcoholism. By 1948, the Washington State Health Department urged that the alcoholic be recognized "as a sick person, not a menace, a delinquent immoral character, or police problem." 

Beginning in the early 1950s, a group of researcher-clinicians introduced this new medical concept of alcoholism to Firland, themselves contributing pathbreaking work on the care of tuberculous alcoholics. Foremost among this group were Thomas Holmes, a psychiatrist at the University of Washington, and Joan Jackson, a sociologist who was already conducting research on the Skid Road. Under Holmes's tutelage, Jackson undertook multiple studies that examined the cultural norms of the Skid Road alcoholic and his adjustment to life at the sanatorium. 

Although appearing chaotic to the outsider, Jackson found that life on Skid Road was actually quite structured. Alcoholics lived according to a well-established routine, traveling between saloon, flophouse, and the city jail, where they were often held on public drunkenness charges. Crucial to an understanding of the Skid Road alcoholic was an appreciation of the pride he took in his independence. 

Upon entrance to Firland, according to Jackson, the alcoholic's lifestyle underwent severe disruption. For example, his mobility was greatly restricted, and the staff encouraged him to be dependent. Moreover, Jackson found that despite the recent efforts to define alcoholism as a disease, Firland staff could not "maintain an objective attitude such as they show in dealing with the diabetic and his diabetes." Rather, alcoholism continued to be ignored. Given this inattention, Jackson believed that alcoholics, after an initial period of compliance, resumed their old lifestyle. Meeting other Skid Road denizens at the sanatorium, they began to drink and gamble on the premises. These friendships, Jackson added, promoted AMA discharges. Meanwhile, the staff not only grew increasingly exasperated, but also became convinced that all Skid Road alcoholics necessarily behaved in this manner. 

What was to be done about this situation? The key, Jackson believed, was to encourage communication between staff and Skid Road patients. In order to accomplish this, Jackson and similarly-minded colleagues across the country constructed a disease that they termed "tuberculosis-alcoholism." Implicit in this disease concept was the notion that alcoholism needed to be addressed openly at the time of admission to the sanatorium, and treated as both a medical and social problem. At Firland, Holmes and Jackson initiated an extensive program of alcoholism education for both patients and staff, and offered psychiatric and supportive counseling to alcoholics. Concurrently, social workers addressed alcoholics' social problems, such as unemployment and homelessness. Of great help in this regard was a vocational rehabilitation program for "marginally employable" alcoholics, established by the local National Tuberculosis Association affiliate, the King County Anti-Tuberculosis League. These services, plus an active Alcoholics Anonymous chapter located at Firland, enabled the sanatorium to serve, in Jackson's words, as a "transitional community" which helped alcoholics to once again become productive citizens. 

THE OPENING OF WARD SIX 

Tuberculosis workers in Seattle in the 1950s never intended to rely solely on rehabilitation in order to improve the compliance of their alcoholic patients. This was particularly true given the perceived public health threat that these men represented. Thus, even as Firland staff and the Anti-Tuberculosis League established their elaborate program to rehabilitate Skid Road alcoholics, they worked with local health officials to strengthen public health measures aimed at controlling this population. 

As a first step, Washington State Tuberculosis Control Officer Cedric Northrop clarified the state's ability to quarantine the tuberculous. In 1948, Northrop drafted two regulations that enabled the local health officer to quarantine to Firland any persons with active tuberculosis who were "uncooperative" and "refused to observe the [necessary] precautions to prevent the spread of the disease." Those quarantined were to remain at Firland until they were formally discharged. Local prosecutors assisted Northrop in drafting these regulations, which were subsequently approved by the State Board of Health. When early efforts at quarantine did not prevent AMA discharges, Firland, in June, 1949, established a locked ward. 

What was the appearance of the locked ward? Known as Ward Six, the 27-bed unit was equipped with both locked doors and heavily screened windows. The ward was furnished like the rest of the hospital, with individual rooms, a nursing station, and a common room. However, all admitted patients (most of whom were intoxicated) spent the first 24 hours in one of seven locked cells, which contained only concrete slabs covered by thin mattresses. 

Firland staff originally planned to use Ward Six sparingly. "If coercion is needed frequently," Medical Director Roberts Davies wrote, "it is a sure sign that something is wrong, either in the sanatorium or in the administration of the public health part of the program." In fact, the early use of Ward Six was limited. Cedric Northrop observed in December, 1949 that the ward housed "only a handful" of patients. There were no beds available for women. 

Over time, however, the use of both quarantine and detention at Firland increased dramatically. While these strategies had originally been designed for so-called "recalcitrant" patients in the community who threatened the public's health, local officials soon realized that most problems actually occurred at Firland. That is, while many Skid Road patients did go AMA, they often willingly returned to the sanatorium by themselves. Many just left temporarily to get drunk. Others overstayed 24-hour leaves. 

As these infractions began to mount, city officials began to use their public health powers more aggressively. Thus, patients who had left AMA were quarantined after they returned. Those who then violated quarantine were forcibly detained, spending an increasing amount of time on Ward Six depending on the number of previous offenses. The first stay on the locked ward was two weeks, the second stay one month, and the third stay two months. 

Decisions regarding the use of detention, moreover, took place entirely at the sanatorium. The medical director himself decided which transgressions warranted punishment. Not surprisingly, non-Skid Road patients who overstayed a leave--even if they returned drunk--were rarely detained. While this system of quarantine and detention was entirely legal, it nevertheless had begun to bypass any scrutiny by the courts. 

Northrop's 1948 regulations had specified that only patients with active tuberculosis could be quarantined. Persons with active disease were still believed to represent an infectious threat; inactive disease, while still potentially requiring hospitalization, signified that this infectious threat had passed. This distinction between active and inactive disease became particularly significant in the early 1950s when Firland adopted an unwritten policy requiring all alcoholics to remain hospitalized for one year, regardless of their medical condition. This policy represented another mechanism to ensure that Skid Road patients received adequate supervised antibiotic therapy. Since alcoholics who had temporarily gone AMA from Firland were often sent to the locked ward during the last days or weeks of their mandatory twelve-month hospitalization, it was common for persons whose tuberculosis had become inactive to be quarantined and detained. 

MAINTAINING ORDER AT FIRLAND 

Why did Firland use the public health powers of quarantine and detention to discipline patients with inactive tuberculosis? The explanation can be found by examining the institutional needs of Firland. Because the sanatorium housed hundreds of persons in close quarters for long periods, staff members saw the possibility of disorder as a persistent problem. For example, they frequently cited past episodes in which patients had started fires or attempted mass escapes. 

Alcohol, in particular, disrupted sanatorium routine. Although a 1947 King County resolution made the "giving or selling of intoxicating liquors" at Firland a misdemeanor, patients who had obtained liquor while on a pass often tossed bottles over the fence and retrieved them once on the inside. "Bootlegger" patients smuggled in large quantities of liquor; loud, raucous drinking parties often followed in the unlocked areas of the sanatorium. 

As noted above, patients who temporarily went AMA or returned late from passes often had been drinking while away, and were drunk on arrival at Firland. Sanatorium officials justified the detention of such persons--even those who had inactive disease--by the need to maintain order. The staff believed that merely allowing such persons, once sober, to return to the regular wards, encouraged such behavior. Keeping such persons on the locked ward, conversely, potentially served as a deterrent. 

Firland also used this same justification--the need to maintain order--to send to Ward Six any patients caught drinking or selling alcohol at the sanatorium. Such persons were placed on the locked ward for having broken the 1947 county resolution prohibiting such behavior. As with the AMA patients, Firland officials handled these cases entirely at the sanatorium; no formal legal proceedings were undertaken. Similarly, whether or not the patient had inactive tuberculosis or had been entirely compliant with his medications made no difference. 

In his work on prisons, mental hospitals and other "total institutions," Erving Goffman has described how privileges and punishments--while ostensibly reflecting the degree of recovery or rehabilitation--actually represent efforts to manage groups of people in a restricted space. Seattle officials instituted quarantine and detention to ensure that recalcitrant patients completed their therapy, and thus did not endanger the public's health. In practice, however, these public health measures came to include a custodial purpose: the control of patients with either active or inactive tuberculosis who broke sanatorium rules. As a result, the maintenance of order at Firland became legitimized as an appropriate justification for invoking public health powers. 

Of note, neither Joan Jackson nor her associates saw the use of a locked ward as conflicting with their program of research and rehabilitation. Not only was alcoholism notoriously difficult to treat, but noncompliant patients clearly represented a public health threat. 

REACTIONS OF PATIENTS 

As anticipated, Ward Six housed mostly alcoholics. A 1953 study, for example, found that 88 percent of locked ward patients carried the diagnosis of alcoholism. The majority of these individuals either lived on or near the Skid Road. Although such patients often had several stays on the locked ward, many did not object. The Ward Six staff was committed to the care of alcoholics, and treated them with more tolerance and respect than they received in jail or in public hospitals of the era. 

Nevertheless, in a series of letters sent to state officials in 1956 and 1957, several patients did object to quarantine and detention procedures. One patient, for example, questioned why the health officer was able to quarantine noninfectious patients. "[C]ontagiousness," she wrote, "has nothing to do with the quarantine. People who have had negative sputum for months may be placed under quarantine." 

The same patient also objected to the locked ward. "Ward Six," she stated, "is a jail in every sense of the word; heavily screened windows, locked doors, cells with mattresses on concrite [sic] slabs and restrictions that are to be expected in a regular jail." Others criticized the lack of legal proceedings. The doctors, claimed one patient, "may sentence a patient from one day to six months, as they see fit. We want to know by what right, and on what authority this is being done." 

These complaints were greeted with skepticism or hostility. Health officials were particularly critical, terming the missives "typical 'crank' letters which we have been accustomed to seeing produced by the paranoid type of personality." Eventually, however, the patients' complaints reached the Washington State chapter of the American Civil Liberties Union. ACLU members who investigated conditions at the sanatorium in 1957 generally confirmed the allegations: Firland used quarantine as punishment and incarcerated patients on Ward Six without due process. Yet after its representatives pointed out these problems to the Firland staff, the ACLU let the issue drop. Few changes were made in sanatorium guidelines until the mid-1960s. 

In fact, by the end of the 1950s, the use of quarantine and detention at Firland had become formally institutionalized. In 1959, the staff drafted a document which codified its quarantine and detention procedures. Ward Six became the model for similar locked wards, generating numerous articles in the medical literature and attracting visitors from across the country. 

Meanwhile, the use of quarantine and detention at Firland increased. While ten percent of patients had been quarantined in 1952, the figure rose to 30 percent by 1960. In 1954, Ward Six expanded from 27 to 54 beds, including six beds for women. By 1960, Washington State had detained approximately 1000 patients--more than any other state responding to a survey. The vast majority of these were held at Firland. Detention, initially meant for the occasional recalcitrant individual, had become standard management of the alcoholic patient. 

THE FATE OF REHABILITATION EFFORTS 

How did the rising use of the locked ward affect concurrent efforts to address the medical and social issues surrounding alcoholism? Although rehabilitation programs continued in various guises at Firland until it closed in 1973, much of the early enthusiasm for such interventions gradually waned. As in the Progressive Era mental hospitals and prisons described by David Rothman, the attempt to merge coercion with treatment and rehabilitation efforts proved unsuccessful. "[T]o join assistance to coercion, Rothman writes, "is to create a tension that cannot persist indefinitely and will be far more likely to be resolved on the side of coercion." 

Why had the concept of tuberculosis-alcoholism proven so hard to implement at Firland? Despite the entreaties of Joan Jackson and others, negative attitudes toward alcoholics at the sanatorium persisted. With little staff encouragement, Alcoholics Anonymous meetings were sparsely attended. Even those individuals who empathized with the problems of alcoholics emphasized that their primary duty was to cure tuberculosis. 

Firland's lack of progress in treating alcoholism did not go unnoticed. At a National Institute of Mental Health conference held in 1962, Medical Director Byron Francis noted that Firland "fails ... badly in treating the patient's alcoholism." Recidivism rates among alcoholics discharged from Firland, he noted, approached 100 percent. Part of the problem, Francis acknowledged, was the great reliance on quarantine and detention. "We feel these are useful measures in controlling tuberculosis, but do considerable soul-searching about the extent to which they are beneficial with respect to the patient's alcoholism." 

CONCLUSION 

Faced with a population of tuberculous Skid Road alcoholics who did not comply with their antibiotics, Seattle's Firland Sanatorium instituted a dual strategy. First, building on recent efforts to medicalize alcoholism, a group of researchers and clinicians at the sanatorium promoted the disease concept of "tuberculosis-alcoholism." By constructing this new "disease," the staff sought to stress that efforts to address tuberculosis among Skid Road alcoholics required both knowledge of the Skid Road culture plus a network of social and rehabilitative services. While some staff members saw such efforts merely as a mechanism to improve compliance with antibiotics, others saw the prolonged hospital stay as an opportunity to improve the lives of Seattle's most disadvantaged citizens. 

Second, health officials and Firland staff, understandably concerned with public health issues, established a program of quarantine and detention. While this strategy was designed only for persistently "recalcitrant" patients who threatened the public's health, over time it was used to maintain order at the sanatorium. As a result, the use of detention--especially for Skid Road alcoholics--accelerated markedly. The notion that Skid Road alcoholics needed to remain within the institution and to behave themselves while there had been redefined as a public health issue. Meanwhile, the elaborate efforts to rehabilitate Skid Road alcoholics were gradually forgotten. 

As in the past, the recent resurgence of tuberculosis primarily affects the disadvantaged of society: minorities, drug users, the homeless, and those with HIV infection. Health officials, while once again instituting coercive public health policies to ensure that persistently noncompliant persons take their medications, are also attempting to address the social problems that cause noncompliance among the disadvantaged. The history of Firland Sanatorium should remind us of the fundamental difficulty of merging these two agendas.