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Virtual Mentor
American Medical Association Journal of Ethics
April 2008, Volume 10, Number 4: 235-241.
HISTORY OF MEDICINE
Medical Examination of Immigrants at Ellis Island
Alison Bateman-House, MA, MPH, and Amy Fairchild, PhD, MPH
SARS, avian flu, bioterrorism: such threats to national security at the dawn of the
21st century have renewed anxieties about controlling disease at the nation’s borders.
Control of infectious agents also provided the impetus for immigrant medical
inspections along the U.S. coasts in the late 19th century, but, in practice, it was the
weeding out of chronic disease and disability that actually motivated public health
officers on “the line” at Ellis Island and other U.S. immigration stations during the
first 30 years of federal control of the nation’s borders.
From the colonial era to the end of the 19th century, each state had borne
responsibility for regulating immigration. But with the swelling numbers of
immigrants in the 1880s and 1890s, an increasingly complex industrial economy, and
mounting concern about the international spread of infectious diseases, the federal
government took control of the nation’s borders in 1891.
While admission decisions were made by the Immigration Service (IS), the law
required medical inspection of immigrants by the United States Public Health
Service (PHS). When a PHS medical officer formally diagnosed an immigrant with a
disease or defect, throwing his or her admissibility into question, that individual was
considered “medically certified.” The law required the PHS to issue a medical
certificate to those who suffered from a “loathsome or a dangerous contagious
disease” [1]. Exclusion of those diagnosed with infectious diseases such as
tuberculosis, venereal disease, trachoma, and favus was mandatory [2].
The PHS defined its mission rather narrowly—preventing the entrance of disease to
the nation—but PHS officers interpreted their job more broadly. In their eyes, the
goal was to prevent the entrance of undesirable people—those “who would not make
good citizens” [3]. In the context of industrial-era America, immigrants who would
wear out prematurely, requiring care and maintenance rather than supplying
manpower, would not make “good” citizens. By 1903 the PHS had elaborated two
major categories: “Class A” loathsome or dangerous contagious diseases and “Class
B” diseases and conditions that would render an immigrant “likely to become a
public charge.” A subset of Class A conditions included mental conditions such as
insanity and epilepsy.
Inspection on the “Line”
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Medical examination centered on the “line,” which became shorthand for the set of
techniques and procedures that medical officers used to examine thousands of
immigrants quickly. Ellis Island—where roughly 70 percent of immigrants entered
the United States—set the standard. After an arriving ship passed the quarantine
inspection in New York Harbor, IS and PHS examiners boarded and examined all
first- and second-class passengers as the ship proceeded up the harbor [4]. Upon
docking, PHS officers transferred steerage or third-class passengers to Ellis Island by
barge. Proceeding one after the other and lugging heavy baggage, prospective
immigrants entered the station and moved slowly through a series of gated
passageways resembling cattle pens. As they reached the end of the line, they slowly
filed past one or more PHS officers who, at a glance, surveyed them for a variety of
serious and minor diseases and conditions, finally turning back their eyelids with
their fingers or a buttonhook to check for trachoma.
The diagnostic protocol emphasized the physician’s “gaze,” demonstrating the
conviction that disease was written on the body. Dr. Albert Nute, while stationed in
Boston, argued that “almost no grave organic disease can have a hold on an
individual without stamping some evidence of its presence upon the appearance of
the patient evident to the eye or hand of the trained observer” [5]. Exemplifying this
notion, PHS regulations encouraged officers to place a chalk mark indicating the
suspected disease or defect on the clothing of immigrants as they passed through the
line: the letters “EX” on the lapel of a coat indicated that the individual should
merely be further examined; the letter “C,” that the PHS officer suspected an eye
condition; “S” indicated senility; and “X,” insanity [6].
In practice the PHS focused on those diseases and conditions that were transparent
not only to highly experienced medical examiners but also to ordinary immigrants.
Everyone could see that the elderly were turned aside for further inspection.
Everyone could see a stooped back or a pregnant women traveling alone. Everyone
could see the attention that was given to eyes and could thus gauge the importance of
vision. And everyone could see that the young (except those too young to work), the
muscular, and the robust were not turned aside.
Among the immigrants’ many apprehensions, the fear of rejection loomed foremost
as they undertook passage from abroad. Prospective immigrants were forewarned of
the medical examination through immigrant aid guides, steamship brochures, and the
initial steamship company medical and quarantine examinations needed to secure
passage to America. The PHS faced the immigrant as an adversary of sorts, for the
PHS officers encountered “the shrewdest evasion and concealment” [7]. Aware of
some of the conditions for which PHS officers searched, immigrants attempted to
hide deformities of the arms and hands and to mask disease either physically or
pharmacologically. They may not have been able to decipher the code that the PHS
officers inscribed on their clothing, but the meaning of the writing was clear, as each
marked individual was turned off the line, separated from friends, family, and fellow
passengers, and directed into cage-like areas.
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PHS officers immediately transferred those bearing chalk marks—typically 15 to 20
percent of arrivals—to either the physical or mental examination rooms. In the semiprivate, single-sex physical examination rooms, immigrants partially disrobed and
were examined with stethoscopes, thermometers, and eye charts. Sometimes height
and weight were measured. Those suspected of having mental defects met with a
PHS officer who asked them simple questions, such as their name or age, and gave
them tests that required manipulation of cubes or puzzles or interpretation of events
depicted in photographs. At the conclusion of the medical or mental examination, the
immigrant would receive an OK card or a medical certificate.
Treatment for the Medically Certified
The PHS encouraged its officers to spend as much time as necessary to make
accurate diagnoses of those “turned off the line” [8]. Some were confined, often for
many months and sometimes years, in the isolation units in the southernmost wing of
Ellis Island. Over time, the IS granted medical treatment to more and more
immigrants, often justifying it on humanitarian grounds. Of those who applied for
hospitalization after 1907—which included not only the medically certified but also
those in need of treatment for a condition not covered under the immigration law,
such as diarrhea—only 13 percent were denied treatment. Most did not apply for
treatment of Class A conditions because, if the request was granted, the immigrant
was required to pay all medical expenses. Immigrants granted hospital treatment at
Ellis Island and other ports were often deported for inability to pay hospital expenses
associated with Class A conditions [9].
Each medically certified individual received a hearing before an IS Board of Special
Inquiry (BSI). Here, a panel of three IS officers questioned the immigrant about his
or her occupation, finances, and family residing in the United States. In most
instances the BSI overruled the medical certificate and did not reject the immigrant.
From approximately 1906 to 1930, only a handful (1.6 percent) of the medically
certified ever appealed an excluding decision; the odds of success for those
launching an appeal were, at best, even [10]. Deportation could split up families;
husbands and wives were often separated, and children could be deported without
their parents (though a parent might decide to go back with a child).
The procedure was intimidating, and, indeed, between 1891 and 1930 nearly 80,000
immigrants were barred at the nation’s doors for diseases or defects. Yet the vast
majority were allowed to enter the country—on average, fewer than 1 percent were
ever turned back for medical reasons [11]. Of those who were denied entry, most
were certified, not with “loathsome and dangerous contagious diseases,” but with
conditions that limited their capacity to perform unskilled labor. Senility (old age),
varicose veins, hernias, poor vision, and deformities of the limbs or spine were
among the primary causes for exclusion. That so few of the more than 25 million
arriving immigrants inspected by the PHS were excluded sets into bold relief the
country’s almost insatiable industrial demand for cheap labor.
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Origin-Related Differences in Inspection Procedures
Yet the demand for labor conformed to racial ideology. Influenced by scientific
racism, the medical examination procedures differed for European, Latin American,
and Asian immigrants. On the East Coast, the medical exam served more of a
processing than exclusionary function for European immigrants. Non-Europeans
faced more considerable medical obstacles to entry at the nation’s Pacific Coast and
Mexican border immigration stations. At Texas border stations, PHS medical
inspectors stripped, showered, disinfected, searched for lice, and physically
examined large groups of immigrants. All second- and third-class Asians immigrants
arriving in San Francisco endured a physical exam similar to that conducted along
the Mexican border in addition to routine laboratory testing for parasitic infection,
which required detention at Angel Island for one or more days. Disease, health
officials argued, was not so easily “read” in the “inscrutable” Asians, particularly the
Chinese [12].
But while the demand for labor had assured that the flow of European immigrants to
the U.S. would continue relatively unrestricted, in the years after World War I
political elites successfully argued that the immigration of “undesirable” southern
and eastern Europeans had to be cut off at the source. The Immigration Act of 1924
restricted immigration numerically and made national origin the basis for admission
into the U.S. On the European front, the 1924 Act transferred immigrant medical
inspection abroad and established the visa system: immigrants could no longer depart
for the United States until an American consular office abroad had granted them
visas. Medical inspection, which was now conducted along the lines of private
medical exams, became a prerequisite for consular approval. One of the
consequences of this shift was an increase in the percentage of immigrants denied
entry on the basis of disease. Between 1926 and 1930, nearly 5 percent of those
examined abroad were ultimately refused visas for medical reasons—a significant
increase over the medical exclusion rate of less than 1 percent that had prevailed in
the United States since 1891 [13]. As a result, the medical exam came to be viewed
as more “scientific” and “objective.”
Medical Screening Today
Today guidelines for the medical screening of aliens seeking permanent residency or
certain categories of temporary residency in the United States are set by the Centers
for Disease Control and Prevention’s Division of Global Migration and Quarantine
(DGMQ). Health-related grounds for barring admission to the United States include
having a “communicable disease of public health significance,” including chancroid,
gonorrhea, HIV infection, infectious leprosy, infectious stage syphilis, and active
tuberculosis [14].
Tuberculosis (TB) provides a vivid example of the complexities that continue to
bedevil immigrant medical screening. After decades of decreasing incidence, a TB
epidemic occurred in the United States during the late 1980s and early 1990s,
reawakening the nation to the presence of what had been considered a conquered
disease. Not surprisingly, links between TB and the foreign-born spurred calls for
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more screening of immigrants, both before and after their arrival in the United States
[15]. By law, an applicant for a visa or permanent residency who has TB is
inadmissible only if the disease is clinically active, and waivers for prospective
immigrants with active disease are available. Individuals with latent TB infection
(LTBI) are not barred; however, such infections lead to active disease in about 5
percent of cases, and reactivation of latent TB is believed to account for the majority
of active cases in immigrants [16]. The possibility that latent cases will reactivate has
led immigration policy to address LTBI. In 2000, the Institute of Medicine (IOM)
called for an overhaul of TB screening procedures for prospective immigrants in
order to enable more accurate detection of LTBI [17]. The IOM also proposed that
aliens with LTBI complete treatment for the infection before receiving a permanent
residency card [18].
In keeping with the IOM’s recommendations, the DGMQ’s updated Technical
Instructions for Tuberculosis Screening and Treatment for Panel Physicians, released
in 2007, includes a new classification (Class B2 TB) for applicants with suspected
LTBI [19]. No such classification was in the previous Technical Instructions (1991).
Prospective immigrants with Class B2 TB are cleared for travel to the United States
but are to be evaluated for LTBI once in the country [20]. Contemporary screening
for TB is thus following the historical trajectory of immigrant medical screening:
expanding its scope from infectious agents to chronic ones, but, importantly, not
strictly for the purposes of excluding immigrants with disease.
Notes and References
1. Fairchild A. Science at the Borders: Immigrant Medical Inspection and the
Shaping of the Modern Industrial Labor Force
. Baltimore, MD: Johns
Hopkins University Press; 2003.
2. Fairchild, 32.
3. Robert Leslie: an oral history—interviewed by Dana Gumb [transcript].
Ellis
Island Oral History Project
. August 15, 1985. Library at Ellis Island
Immigration Museum.
4. Doty AH. Modification of present port inspection.
Public Health Pap Rep.
1905;31(pt 1):260.
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2222505&blobtype=
pdf. Accessed March 6, 2008.
5. Nute A. Medical inspection of immigrants at the port of Boston.
Boston
Medical and Surgical Journal
. 1914;170:644.
6. Geddings H. Letter to the Surgeon General. November 16, 1923, Record
Group 90. Records of the Public Health and Marine Hospital Service, Central
File, 1897-1923, Box 36, File No. 219. College Park, MD: National Archives
and Record Administration.
7. Reed A. Immigration and the public health.
Popular Science Monthly.
1913;LXXXIII:319.
8. Dr. Victor Safford in Boston coined this phrase. See Surgeon General of the
Public Health Service. Annual report. 1904:199. PHS regulations specified
“The examiner should detain any alien or aliens as long as may be necessary
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to insure a correct diagnosis.” US Treasury Department Bureau of Public
Health and Marine-Hospital Service.
Book of Instructions for the Medical
Inspection of Immigrants
. Washington, DC: Government Printing Office;
1903:6.
9. Fairchild, 40.
10. Fairchild, 55.
11. Fairchild, 4.
12. Fairchild, 135.
13. Fairchild, 261.
14. Public Health Services, HHS. Code of Federal Regulations. Title 42, Chapter
I, Part 34.2,
http://a257.g.akamaitech.net/7/257/2422/16nov20071500/edocket.access.gpo.
gov/cfr_2007/octqtr/pdf/42cfr34.2.pdf. Accessed February 28, 2008.
15. Sachs S. More screening of immigrants for TB sought.
New York Times.
January 3, 2000:A1.
16. MacPherson DW, Gushulak BD. Balancing prevention and screening among
international migrants with tuberculosis: population mobility as the major
epidemiological influence in low-incidence nations.
Public Health.
2006;120(8):716.
17. Geiter L, ed.
Ending Neglect: The Elimination of Tuberculosis in the United
States
. Washington, DC: National Academies Press; 2000:87-97.
18. Geiter, 9.
19. Centers for Disease Control and Prevention Division of Global Migration and
Quarantine.
Background on the 2007 Technical Instructions for Tuberculosis
Screening and Treatment
.
http://www.cdc.gov/ncidod/dq/titb_background_2007.htm. Accessed
February 28, 2008.
20. Immigrant, Refugee, and Migrant Health Branch of the Division of Global
Migration and Quarantine, Centers for Disease Control.
CDC Immigration
Requirements: Technical Instructions for Tuberculosis Screening and
Treatment.
Washington, DC: Centers for Disease Control; 2007.
http://www.cdc.gov/ncidod/dq/pdf/ti_tb_8_9_2007.pdf. Accessed February
28, 2008.
Alison Bateman-House, MA, MPH, is a student in the joint sociomedical
sciences/history doctoral program at Columbia University in New York City. She
works at the interface of ethics and the history of medicine and public health. Her
dissertation will be on government-sponsored human subjects research during World
War II.
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Amy Fairchild, PhD, MPH, is an associate professor in the Department of
Sociomedical Sciences and assistant director for scholarly and academic affairs at the
Center for the History and Ethics of Public Health at the Joseph L. Mailman School
of Public Health, Columbia University in New York City. Her work addresses broad
questions about the functions and limit of state action in the realm of public health.
She is a coauthor of
Searching Eyes: Privacy, the State, and Disease Surveillance in
America
(University of California Press, 2007).
The viewpoints expressed on this site are those of the authors and do not necessarily
reflect the views and policies of the AMA.
Copyright 2008 American Medical Association. All rights reserved.
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