Immigration and The Public Health - 1905
By Dr. Allan McLaughlin, U. S. Public Health and Marino Hospital Service
The relation of immigration to public health is dependent upon three factors:
- The physique of the immigrant
- His destination
- The presence or absence of infectious disease
The most important of these factors is the physique of the immigrant. The first requisite of a desirable immigrant is a good physique. Without a robust constitution and average physical strength, the immigrant can not cope successfully with the hardships he will be called upon to endure in his new home.
The large employers of labor expect and demand men physically strong enough to do a fair day's work. The only place the immigrant with a poor physique can make a living is in the large city, where he becomes either a parasite or a competitor of American skilled labor.
One can better understand the unfair competition of this type of immigrant if one considers their standard of living and their system of sweat-shop production. The aliens of poor physique, who are usually skilled laborers, go to the crowded city, to the dark, poorly ventilated, and disease-infected tenement. The thousands of these city dwellers arriving every year perpetuate the tenement-house problem and retard the work of sanitation and reform.
With the change in the racial character of immigration, most marked in the last decade, a pronounced deterioration in the general physique of the immigrants and a much higher percentage of loathsome and dangerous diseases are noticeable.
Doctor's Inspection of Suspects for Skin Diseases. Etc. The Maltine Company, Quarantine Sketches, 1902. GGA Image ID # 14ac9c01b3
Thousands of immigrants of a poor physique are recorded by the medical inspectors at Ellis Island. The immigration authorities admit the vast majority of them because it does not appear that the physical defect noted will make the immigrant a public charge. A card to this effect is sent to the registry clerk or immigrant inspector with the immigrant, but this mere note of physical defect has little significance under the present law.
When the physical defect or poor physique is so marked, it seems to the medical inspector the second factor to be considered, his destination. The destination is scarcely less important than physique. It is the rule that aliens of a race with a low physical standard will invariably herd together in our great cities' overcrowded, unsanitary tenement districts. In contrast, the sturdy races of unskilled laborers are scattered over a vast territory. They tend to establish tiny homes in the country or the suburbs of manufacturing towns or cities.
Insanity is analogous to tuberculosis since the actual disease or condition does not exist at the time of landing, although in many instances predisposing factors are present in the physical or nervous makeup of the individual. Together with the exciting causes met within this country after landing, these predisposing factors are sufficient to develop the active disease or condition.
Mr. Goodwin Brown, attorney for the New York state commission of lunacy, stated before the senate committee on immigration, Washington, 1902, that although only twenty-five percent of the population of the state of New York were foreign-born, fifty percent of the inmates of the state insane asylum were foreigners. He also stated that this excess is not alone exhibited in New York statistics, but that an excess of seventeen percent existed throughout the entire country of foreign-born insane over the percentage of the foreign-born population.
The significant number of foreign-born inmates of insane asylums throughout the country indicates that in the past, immigration officials placed too little restriction on the mentally defective and that the opportunity afforded by an inspection at the port of entry was too scanty to be of much value.
A man mentally oblique, or subject to periods of insanity, would, without doubt, pass the inspectors at the ports of landing if he was at that time rational and quiet. People with epilepsy, too, had an excellent chance of being admitted, their rejection depending upon the remote possibility of their having a paroxysm while passing the inspectors. An anarchist, while passing the officers, would, of course, be belle and quiet, and his detection extremely difficult.
Regarding insane aliens, at present, we are, in reality, protected much more effectively than is generally known. One hears much of the enormous number of alien inmates of insane asylums. As intimated before, most of these insane aliens were probably sane upon landing, though possessing the predisposing factors of the disease.
The conditions of life here, possibly nostalgia or homesickness, or other exciting causes, unbalance such an alien. The remedy is provided by the law of 1903. That these mentally defective persons were sent formerly in large numbers by persons living in Europe is scarcely open to question, but the period of government supervision of, and of power to deport, the landed alien has been extended to two years (Act of 1903).
Under this wise provision, an insane person of foreign birth, upon admission to an asylum, is investigated, and if landed within two years, can be deported. The same clause covers the deportation of idiots and epileptics so that we are now much better protected against these burdens than ever before.
Additional protection is given by that part of Section 2, Law of 1903. which places in the excluded classes "persons who have been insane within five years previous, and persons who have had two or more attacks of insanity at any time previously." The third factor to be considered is communicable diseases among immigrants.
Immigrants established years ago a reputation for bringing in epidemic diseases. They have played their part in outbreaks of typhus, smallpox, and cholera in the past. Still, with the disappearance of the old immigrant sailing ships, the advent of the fast, clean ocean steamships, and efficient modern methods of quarantine and prevention of disease, the immigrant today as a carrier of epidemic diseases no longer causes us apprehension.
The quarantine law of 1893 placed all matters about national quarantine in the hands of the public health and marine hospital service. It provided for the formulation of uniform regulations to be observed by all state and local quarantine authorities in preventing the introduction of epidemic diseases from foreign countries and the spread of such diseases from one state or territory to another.
The secretary of the treasury promulgated the regulations, and the surgeon-general of the public health and marine hospital service is charged, under the secretary's direction, with the performance of all the duties in respect to quarantine and quarantine regulations, which were provided for by the act. The law further provides that if the states or municipalities fail or refuse to execute the quarantine regulations, the president should appoint a proper person to implement them.
Most important is the provision in this act, by which ships from infected ports or from ports suspected of being infected are inspected by an officer of the public health and marine hospital service attached to the consulate. Under the provisions of sections 2, 3, and 4 of the act, medical officers of the public health and marine hospital service have been detailed to serve. They are now on duty, in connection with the consulates at various foreign ports. All necessary information is received relative to the sanitary condition of vessels, cargoes, crews, and passengers about to depart for the United States.
By this means, the ordinary consular bill of health is made to be a certificate of actual observation by a responsible officer whose sole duty is to aid in preventing the introduction of contagious diseases into the United States.
The common quarantinable diseases are eliminated from the question by efficient quarantine methods. Still, specific communicable maladies, classed as loathsome or dangerous contagious diseases, exist among immigrants, and constant vigilance and considerable skill are necessary for medical inspectors of immigrants to detect these cases and separate them from them the healthy immigrants.
Of these, trachoma, a contagious form of granular lids, is one of the eye's most obstinate and destructive diseases. Oculists from all parts of the country claim that this disease was introduced by immigrants and spread by them in this country. The condition is now epidemic in the poorer districts of many of our cities, but since 1897 has been one of the causes for the exclusion of aliens. About the same time, favus, a loathsome, contagious disease of the scalp, was made a cause for exclusion. Favus is a typical immigrant disease and can not spread among persons of clean habits.
Trachoma a Constant Danger
Because of its frequency, the most important of these diseases is trachoma. Of the total number of cases of loathsome or dangerous contagious disease found in immigrants, eighty-seven percent are due to trachoma and ten percent to favus. Several years ago, the prevalence of trachoma in the poorer districts of our large cities, particularly among the foreign-born population, caused numerous medical men engaged in eye work in various parts of the United States where trachoma is placed in the list of excluded affections. This was done in 1897, with the result that great many suffering from the disease were taken from among the steerage immigrants and deported.
Immigration officials then discovered that ordinary steerage aliens suffering from trachoma were being transferred to the cabin while en route or after being refused passage in the steerage at the port of departure would be sold a cabin passage, with the assurance that officials did not inspect cabin passengers at the port of arrival. To check this practice and to make the inspection of aliens complete, Immigration officials instituted an inspection of cabin passengers in the fall of 1898.
The cabin inspection has been very successful in preventing evasions of the law. However, many steamship companies were still apparently careless of the diseased condition of immigrants to whom they sold tickets. By the last immigration Law (1903), a penalty of $100 is imposed upon the steamship companies for each diseased alien brought to our ports, provided the disease existed at the time of the immigrant taking a passage and could have been detected by ordinary medical skill.
This penalty has had a beneficial effect in causing the steamship companies to institute a more rigid medical inspection at the European departure ports. Formerly the presence of a diseased alien in the steerage was a matter of more or less indifference to the steamship companies, as they could carry him back to Europe if deported and still make a profit on the price of his original passage.
Favus for several years has been included in the list of excluded diseases. If the condition has existed for any time, it is, of course, easily detected by the loss of hair and changed the character of the individual follicles and scalp. But in cases of recent origin, detection is often difficult because of the tricky efforts at concealment. The immigrants are usually prepared for inspection, the tell-tale yellow crusts carefully removed, and the scalp cleansed.
Little Tuberculosis among the Newcomers
Tuberculosis of the lungs is rarely found among immigrants on arrival. Thousands of immigrants are examined, whose poor physique suggests the possible existence of tuberculosis to the medical examiner. Still, out of many thousands thus inspected at Ellis Island last year, only twelve cases were certified as suffering from tuberculosis of the lungs.
This apparent freedom from tuberculosis is partly explained by the fact that tubercular diseases are notoriously diseases of the cities, while the bulk of our immigrants conic from the agricultural communities and small towns.
The remarkable prevalence of tuberculosis among recently landed immigrants is the effect of overcrowding in infected, filthy tenements by immigrants whose poor physique makes them ready prey for infectious diseases. In addition to the congestion of the tenements, insufficient food, fuel, and clothing, especially among immigrants from Mediterranean countries, must be considered factors in tuberculosis development.
The factors or conditions prevailing among aliens are likely to prove a menace to public health. The remedies are apparent:
- Insistence upon a higher standard of physique, or rather, more respect for the doctor's certificate of poor physique, which at present, in a majority of instances, is not considered sufficient to exclude,
- Wider distribution of our aliens to deflect them from the tenement districts to the country.
- Inspections of aliens at the foreign ports of embarkation helps to prevent the spread of infection on shipboard and obviate the unnecessary hardship to which an alien is now subjected.
There should be but one standard of physique for the immigrant, whether his destination is the Pennsylvania mines or the New York sweat-shops. The skilled laborer should be expected to possess the same rugged physique as is now expected of the unskilled laborer.
The standard of the physique should be prescribed by law so that the medical certificate of failure to reach the standard would be final, as it is now in loathsome or dangerous contagious diseases, idiocy, epilepsy, or insanity. The standard required of recruits for the United States army, with a fixed minimum height and chest measurement, could be employed for this purpose.
Every male immigrant between the age of eighteen and forty-five should be required to pass such a physical test. Immigration requirements should direct each family to possess at least one male, supposedly the breadwinner, who could meet these requirements.
An aged person, if unaccompanied, should not be permitted, to land, unless they possess a son, daughter, or other near relatives in America, who is willing and able to care for such aged dependent. The requirement of a high, definite standard of physique would have minimal effect upon the most desirable alien races.
It would fall heavily upon the parasitic and competitive classes. While it would not stop all the yearly alien reinforcement of the foreign quarters and slums, it would at least ensure that the reduced number of additions should be of a physique rugged enough to withstand the influence of such an existence. It would not materially reduce the number of agricultural and industrial unskilled laborers. It would permit the admittance of plenty of men physically able to do a fair day's work for their employers.
In the matter of distributing aliens over a wider area, one must consider two distinct classes—the aliens already established in colonies in our cities, and aliens in general who, through ignorance of opportunities offered in different sections of the country, in many instances go to the congested areas rather than to the places where their labor is needed. No plan for the relief of tenement congestion, by better distribution of aliens already established there, can be successful without reducing the number of yearly steerage arrivals, particularly of those classes that tend to congest the cities.
Many schemes for distributing the aliens congregated in cities have been proposed; some are chimerical, others more practical, but the consensus among philanthropic individuals and representatives of charitable societies is that the process of distribution is necessarily a slow one. The city-dwelling immigrant must be here some three or four years before he knows enough of our language and customs to enable him to be self-supporting away from his race. It also seems that distribution must be effected individually rather than by colonies.
The experience of the great Hebrew charitable societies at least bears out this view. Their efforts at wholesale rural colonization have almost in every instance failed, and the colonies established, with few exceptions, required the paternal aid of the society constantly. On the other hand, the same organizations have distributed several thousand Jews in various parts of the country, who have been here some time and have learned something of American ways. These have been almost uniformly successful.
Cut Off the Supply of Slum Dwellers
When one considers how slowly the work of distributing the excess alien population of the tenement districts goes on despite the best effort of societies, individuals, or municipal officers, the necessity is at once apparent either of stopping altogether the annual reinforcement of this tenement population, or at least of so reducing the number of additions that the work may make some progress.
As it is now, the excellent work done each year by charitable organizations and by philanthropists goes almost for naught. The splendid work of the New York tenement house and street cleaning departments is nullified to a large extent by the yearly addition of thousands of these alien tenement dwellers, for whom educators must repeat the tedious work of education in sanitary matters from the beginning.
After all, these two problems of exclusion of undesirable immigrants and distribution of aliens are closely associated. The class that clings most persistently to the crowded city is the undesirable class, and, if because of its poor physique, the majority were excluded, as it would be if we had a definite standard of physique, the problem of distribution would be very greatly simplified.
The rejection of the alien at the port of embarkation is of such obvious advantage to the rejected alien, to the steamship company, and (in the case of a diseased alien being rejected), to the other passengers who would be exposed to infection on shipboard, that it is likely that provision will be made for maintaining a foreign inspection at all the principal European ports. It is no longer an experiment.
Officers of the public health and marine hospital service, stationed abroad in the American consulates under the quarantine law of 1893, have examined aliens embarking for the United States in addition to their quarantine duties. They recommend to the steamship companies the refusal of passage to such immigrants as would be likely to be rejected at United States ports under our laws.
Italy; Kobe, Nagasaki, and Yokohama, Japan; Hongkong, and other ports in the orient. This foreign inspection is now being made by officers of the immigration service on duty in the American consulates at Naples. As a result of this examination, thousands of aliens are rejected at Naples and the above-named oriental ports each year.
The extension of our immigration service to the Canadian and Mexican frontiers and the splendid work done on the immigration officers' borders have closed the last gateways open to violators of our immigration laws.
Not only are the laws enforced rigidly at United States ports and border towns, but by an agreement with the Canadian steamship authorities. American officers are stationed at Quebec, Montreal, Halifax, St. John, and Victoria, BC, to inspect immigrants destined to the United States through Canada.
Foreign inspections will stop undesirables before they reach the ship. The efforts of Commissioner-General Sargent and various philanthropic societies and individuals to distribute aliens over a wider area will be successful if given proper support. The recognition of a definite physical requirement will do more than any other one thing to reduce the menace to public health due to immigration, to say nothing of the beneficial effect upon some of our social and economic problems.
It will reduce the quantity and improve the quality of immigration, thus allowing the adjustment of conditions in the overcrowded sections. If the yearly reinforcement of the sweat-shop army could be cut off for some years, the elimination of slums and the sanitary education of their residents would be made easy of accomplishment. The numerical reduction and improved physical status of the immigrants resulting from more stringent physical requirements would affect this result.
Dr. Allan McLaughlin, DENIED THEIR CHANCE IN THE NEW WORLD: Italian emigrant, rejected by the steamship company on the advice of the American health officer stationed in Naples, PUBLIC OPINION, Founded in 1886, V0L 1. 3,4 NEW YORK, SATURDAY, SEPTEMBER 23, 1905. Edited for grammar, punctuation, and sentence structure.