SOCIAL: IMMIGRATION AND HEALTH1

ALFRED C. REED, M.D., UNITED STATES PUBLIC HEALTH AND MARINE HOSPITAL SERVICE

ERHAPS no question is of more paramount and continuing interest to the American people than immigration in all its phases and relations to public welfare. The history of the United States is the history of alien immigration. The earliest pioneers were themselves alien immigrants. Our institutions, political, religious, and social, have been founded and supported by aliens or their near descendants. Our country is indeed a melting pot, into which have been poured diverse varieties of peoples, from all nations and races. Yet in the face of this, these variant elements have been fused into a more or less homogeneous nation. A national life and character we have. This national or American character is not exemplified in those places where the large streams of immigration are pouring in, but farther away where the waters have mixed. Such a condition, unique in the history of nations, is responsible for certain problems which are also unique in history, and consequently do not admit of solution according to precedents.

The first rule of national life is self-preservation, and since immigration has had and still has so important a rôle in American national life, it must be carefully scrutinized to determine which immigrants are desirable, and vice versa, from the standpoint of the betterment and continuance of the American nation. The choice between free immigration, restricted immigration, and absolute exclusion is increasingly difficult to make, and does not enter our field of inquiry, except to recall a principle which is as valid from the medical standpoint as from the economic or social. Only those peoples should be admitted whom experience has shown will amalgamate quickly and become genuine citizens. The period of residence necessary for citizenship should be raised 1 From The Popular Science Monthly, April, 1912.

from three to five years, during which time the immigrant should be literally on probation, and subject to deportation if found wanting, or if unable to meet the qualifications of citizenship at the end of that time. The government should decide where the immigrant may settle and the immigration current should be directed to the Western and farming districts, and not allowed to stagnate in Eastern cities.

The great mass of popular literature on the subject of immigration is singularly deficient in discussion and analysis of its medical features. It is true, the United States government bestows on public health and preventive medicine nowhere near the attention it finds necessary for the prevention of disease in stock and for agricultural improvement, but none the less there are certain well-organized and efficiently operated agencies which have for their function the improvement of public hygiene and sanitation, the eradication of preventable disease, and the study of causation and methods of control of diseases. Most of these functions are exercised by the Public Health and Marine Hospital Service, which, strangely enough, constitutes a bureau under the Treasury Department. Some of this work is done under the Department of Agriculture, and other minor lines are scattered elsewhere through the national machinery. It is easily seen how much more efficient would be the work were all these agencies for national health protection united under one administrative head, and their various activities carefully coördinated.

The Public Health and Marine Hospital Service operates all national quarantine stations where inspection is made for yellow fever, typhus fever, smallpox, bubonic plague, leprosy, and cholera; maintains hospitals throughout the country for sailors of the American merchant marine; conducts the Hygienic Laboratory at Washington for the study of the causation and treatment of diseases; exercises numerous minor functions of a national board of health; and conducts the medical inspection of immigrants. Certain diseases are found so frequently among immigrants, and others are so inherently dangerous, as to merit special mention because of their important relation to public health.

First among these might be placed trachoma, a disease of the eyelids characterized by extreme resistance to treatment, very

chronic course, and most serious results. Most of the immigrant cases occur in Russians, Austrians, and Italians, although it is of common occurrence in oriental and Mediterranean countries. It causes a large percentage of the blindness in Syria and Egypt. Its contagious nature, together with the resulting scarring of the lids and blindness, make its recognition imperative. The hookworm (Uncinaria) has received much attention lately since it has been found so widely distributed through the mountains of the South, the mines of California, the middle West, etc. It is a minute parasitic intestinal worm about three fifths of an inch long, and under the microscope shows relatively enormous and powerful chitinous jaws by means of which it attaches itself to the intestinal walls. The saliva of the hookworm has the curious property of preventing coagulation of blood like leech extract, and when it is remembered that the worms may vary in number from several hundred to a thousand or more, and that each worm moves frequently from place to place on the intestinal wall, it is apparent how excessive and continuous is the drain on the blood and lymph juices. The result is an extreme anemia which brings in its wake. a varied multitude of bodily ills, and may eventuate fatally, meanwhile having incapacitated the victim for mental or physical work. Infection can spread rapidly from a single case. Not many hookworm carriers have been discovered among immigrants, probably because the facilities for their detection are so meager. But the heavy immigration from countries where uncinaria is abundant, as well as the recent suggestive work of Dr. H. M. Manning at the Ellis Island Immigrant Hospital, indicates that there is a constant stream of fresh infection pouring in. Indisputably routine examination for hookworms should be instituted. The same can be said of other intestinal parasites as tapeworms, pinworms, whipworms, eelworms and others. One of the tapeworms, the so-called fish worm (Dibothriocephalus latus), leads to an anemia fully as severe as that from the hookworm.

Many other diseases might be mentioned, but these are sufficient to illustrate the importance of careful medical inspection of immigrants.

The total immigration into the United States through all ports of entry for the year ending June 30, 1911, was 1,052,649. Of

these 22,349 were debarred for various reasons, leaving a net increase of 1,030,300. The chief port of entry is, of course, New York, where 749,642 aliens were examined. Next in order of importance came Boston, Baltimore, and Philadelphia, and at a greater distance Galveston, Tampa, San Francisco, Honolulu. Miami, and Portland, Maine. As the laws are uniform and the methods of inspection the same at all ports, consideration of methods and results at Ellis Island, New York, will give a clear idea of the entire subject.

The medical inspecting service at Ellis Island is divided into three branches, the hospital, the boarding division, and the line, The hospital division presents an excellently equipped and managed institution, and an isolated set of buildings for contagious diseases. The hospital service is limited exclusively to immigrants, and the patients are those acutely ill upon arrival, those taken sick during their stay on the island, and cases of acute sickness among aliens already landed who for some reason have been brought to the island for deportation.

The boarding division of the medical inspection on Ellis Island has for its particular function the inspection of aliens in the first and second cabins on board the incoming vessels. Those who require more detailed examination are sent to Ellis Island.

The routine inspection on the line is that part which the visitor sees, and is the most important feature of the medical sieve spread to sift out the physically and mentally defective. The incoming immigrants pass in single file down two lines. Each of these lines makes a right-angled turn midway in its course. At this turn stands a medical officer. He sees each person directly from the front as he approaches, and his glance travels rapidly from feet to head. In this rapid glance he notes the gait, attitude, presence of flat feet, lameness, stiffness at ankle, knee, or hip, malformations of the body, observes the neck for goitre, muscular development, scars, enlarged glands, texture of skin, and finally as the immigrant comes up face to face, the examiner notes abnormalities of the features, eruptions, scars, paralysis, expression, etc. As the immigrant turns, in following the line, the examiner has a side view, noting the ears, scalp, side of neck, examining the hands for deformity or paralysis, and if anything about the individual seems suspicious, he is asked several

questions. It is surprising how often a mental aberration will show itself in the reaction of the person to an unexpected question. As the immigrant passes on, the examiner has a rear view which may reveal spinal deformity or lameness. In case any positive or suspicious evidence of defect is observed, the immigrant receives a chalk mark indicating the nature of the suspicious circumstance.

At the end of each line stands a second medical officer who does nothing but inspect eyes. He everts the eyelids of every person passing the line, looking for signs of trachoma, and also notes the presence of cataract, blindness, defective vision, acute conditions requiring hospital care, and any other abnormalities. All cases which have been marked on the line are separated from the others and sent to the medical examining rooms for careful examination and diagnosis. When it is remembered that often 5000 immigrants pass in a day, it is clear that the medical officers not only are kept busy, but that they see an unusually wide variety of cases.

After careful examination, the nature of the defect or disease found is put in the form of a medical certificate which must be signed by at least three of the physicians on duty. It is not within the province of the medical officers to pass judgment on the eligibility of the immigrant for admission. The medical certificate merely states the diagnosis, leaving to the immigration inspector in the registry division the duty of deciding the question of admission. In the inspector's consideration are included not alone the medical report, but all other data concerning the applicant, such as age, money in his possession, previous record, liability to become a public charge, and his sponsors. Most cases of trachoma and mental or organic nervous disease are sent to the hospital and kept under care and observation to facilitate an accurate diagnosis. Seldom indeed does the alien suffer from too harsh a medical judgment. He is given the benefit of a doubt always. For example, if a case of defective vision is found to be 3/20 normal, it would be certified as perhaps 5/20 normal.

The immigration law as it stands since the legislation of 1907 divides all defective immigrants into the following classes: Class A, aliens whose exclusion is mandatory because of a definite and