# Popular Science Monthly/Volume 64/January 1904/Immigration and the Public Health

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* IMMIGRATION AND THE PUBLIC HEALTH.
By Dr. ALLAN MCLAUGHLIN,
U. S. PUBLIC HEALTH AND MARINE HOSPITAL SERVICE.
THE popular belief that immigration constitutes a menace to the public health is not without foundation. Newspapers and magazines contain graphic accounts of the squalor and insanitary conditions of the tenement districts of our great cities. Recent newspaper reports and comments upon the remarkable spread of trachoma in the public schools of New York and other great cities add to the popular feeling of distrust, and the opinion is gaining ground everywhere that more stringent means must be devised for keeping out the undesirable class of immigrants which augments the frightfully overcrowded population of the tenement district of New York and other large cities.
In the consideration of danger to the public health from immigration, three factors must be taken into account: (1) The physique of the immigrant; (2) his destination, and (3) the presence or absence of communicable disease.
The first mentioned, the physique of the immigrant, is by far the most important factor. Good physique was much more general among immigrants a quarter of a century ago than among the immigrants of to-day. The bulk of the immigrants previous to 1880 came from the sturdy races of northern and western Europe, and, not only was good physique the rule, but loathsome, communicable or contagious disease was extremely rare. The immigration from Ireland, Germany and the Scandinavian countries is insignificant to-day compared with the thousands of Slavs, Italians, Hebrews and other immigrants from southern or eastern Europe, which now crowd American-bound vessels and pour through the ports of this country in an ever-increasing stream.
With the change in the racial character of immigration, most marked in the past decade, a pronounced deterioration in the general physique of the immigrants, and a much higher per cent, of loathsome and dangerous disease is noticeable. Thousands of immigrants of poor physique are recorded as such by the medical inspectors at Ellis Island, and a card to this effect sent to the registry clerk or immigrant inspector with the immigrant, but this mere note of physical defect carries little significance under the present law, and the vast majority of them are admitted by the immigration authorities, because it does not appear that the physical defect noted will make the ​immigrant a public charge. When the physical defect or poor physique is so marked that it seems to the medical inspector likely to make the immigrant a public charge, the immigrant is detained, and a certificate is made stating his disability, which certificate goes to the board of special inquiry with the detained immigrant. About two thirds of the immigrants so certified as likely to become a public charge are admitted because of the latitude allowed by the phrase, 'likely to become a public charge.' Under the present law, therefore, the immigrant certified as suffering from a loathsome or dangerous contagious disease, or as being idiotic or insane, is deported. The immigrant recorded as having a 'poor physique' or other physical defect is usually admitted.
Destination is scarcely less important than physique, and it is the rule that aliens of a race having a low physical standard will invariably herd together in the overcrowded insanitary tenement districts of our great cities, while the sturdy races of unskilled laborers are scattered over a wide territory and tend to establish little homes of their own in the country or in the suburbs of manufacturing towns or cities.
The following table indicates the relative physical strength of the various races under discussion, and also the percentage of each race giving New York as their destination. Statistics of the Irish and Scandinavian races are given in this table for the purpose of comparison.
| Race. | Ratio Sent to Hospital on Arrival to Total Number Landed. | Ratio Deported on Medical Certificate to Total Number Landed. | Percentage Remain ing in New York. |
| Hebrew | 1 to 90 | 1 to 393 | 70 per cent. |
| Italian | 1 to 177 | 1 to 535 | 50 |
| Slav | 1 to 200 | 1 to 575 | 15 |
| Irish | 1 to 645 | 1 to 1450 | 33 |
| Scandinavian | 1 to 715 | 1 to 3280 | 18 |
The third factor to be considered is the presence of communicable disease among immigrants. The ordinary quarantinable disease are eliminated from the question by efficient quarantine methods, but certain communicable maladies, classed as loathsome or dangerous contagious diseases, exist among immigrants, and constant vigilance and considerable skill are necessary on the part of medical inspectors of immigrants to detect these cases and separate them from the healthy immigrants.
The most important of these diseases, because of its frequency, is trachoma. Of the total number of cases of loathsome or dangerous contagious disease found in immigrants, 87 per cent, are due to trachoma and 10 per cent, to favus.
Several years ago the prevalence of trachoma in the poorer districts of our large cities, and particularly among the foreign-born population, caused numerous requests from medical men engaged in ​eye work in varous parts of the United States that trachoma be placed in the list of excluded affections. This was done in 1897, with the result that a great many suffering with the disease were taken from among the steerage immigrants and deported. It was 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 cabin passengers were not inspected at the port of arrival. To check this practise and to make the inspection of aliens complete, an inspection of cabin passengers was instituted in the fall of 1898. The cabin inspection has been very successful in preventing evasion of the law, but 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 company for each diseased alien brought to our ports, provided the disease evidently existed at the time of the immigrant's taking passage and could have been detected by ordinary medical skill. This penalty has had a salutary effect in causing the steamship companies to institute a more rigid medical inspection at the European ports of departure. 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.
Two points about trachoma have occasioned considerable discussion. These are its contagiousness and its likelihood of causing permanent injury to sight. The contagiousness of trachoma is recognized and conceded by those who have seen a sufficient number of cases of the disease to form an accurate impression. Striking examples of its contagious character can be seen any day on Ellis Island. The Annual Conference of State and Provincial Boards of Health, held at New Haven, October, 1902, placed trachoma in the category of diseases communicable and dangerous to the public health.
Permanent injury to sight is most likely to occur in cases where early treatment is neglected. Among immigrants with trachoma, ignorance of personal hygiene and inability to secure proper treatment make the spread of this disease alarming and the consequences to sight disastrous.
The area in Europe where trachoma is most prevalent extends from the Gulf of Finland on the north to the Black Sea and the Mediterranean on the south, and from Moscow and the Volga on the east to the Carpathian Mountains on the west. In addition, it is prevalent in Greece and southern Italy, probably because of commercial intercourse with Syria, Egypt and the Barbary States. The first-mentioned area is occupied by Finns, Lithuanians, Russians, Poles, ​Russian-Germans and Hebrews. The statement is made in some text-books that trachoma is prevalent among the Irish. Observation of immigrants shows that this statement is not true. There is less trachoma among the Irish than any other race of immigrants. The table given below indicates the ratio in which this disease was found among the immigrants landed in 1902.
| Race. | Ratio of Cases of Trachoma to Number Immigrants Landed. | Ratio of Cases of Trachoma to Number Immigrants Landed. |
| Syrian | 1 to | 66 |
| Armenian | 1 to | 192 |
| Lithuanian | 1 to | 375 |
| Finn | 1 to | 496 |
| Hebrew | 1 to | 539 |
| Greek | 1 to | 667 |
| Slav | 1 to | 758 |
| German | 1 to | 772 |
| Scotch | 1 to | 1,216 |
| Magyar | 1 to | 1,243 |
| Italians | 1 to | 2,066 |
| Scandinavians | 1 to | 3,486 |
| English | 1 to | 3,623 |
| Irish | 1 to | 4,173 |
Favus for several years has been included in the list of excluded diseases. If the disease had existed for any length of time, it is, of course, easily detected by the loss of hair and changed character of the individual hairs and the scalp, but in cases of recent origin detection is often difficult because of shrewd efforts at concealment. The immigrants are often prepared for inspection, the tell-tale yellow crusts carefully removed and the scalp cleansed.
Tuberculosis of the lungs is rarely found among immigrants on arrival. Thousands of immigrants are examined whose poor physique suggests to the medical examiner the possible existence of tuberculosis, but out of the many thousands thus examined at Ellis Island last year, only fifteen 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 immigration comes from the agricultural communities and small towns. The remarkable prevalence of tuberculosis among recently landed immigrants is the effect of horrible over crowding in infected, filthy tenements by immigrants whose poor physique makes them ready prey for communicable disease. In addition to the horrible congestion of the tenements, the insufficient food and insufficient fuel and clothing, especially among immigrants from Mediterranean countries, must be considered as factors in the development of tuberculosis.
The danger to the public health from immigrants suffering from communicable disease is at present comparatively slight. The United States Public Health and Marine-Hospital Service is charged by law with the medical inspection of all incoming aliens at ports of the ​United States. Officers of the service receive special training for their work as medical inspectors of immigrants. Ellis Island, New York, is used by the service as a great school of instruction where young officers, before being detailed for immigration duty at one of the other ports of entry, are trained in the detection of the particular diseases and defects likely to be found in immigrants. Canada has always been a favorite route for undesirable immigrants wishing to evade the law, and officers of the Public Health and Marine-Hospital Service are stationed for immigration duty at Quebec and other Canadian ports, and at various points upon the Canadian frontier. Certain steamship lines make a regular business of carrying to Canada, for subsequent entry to the United States, aliens who have been rejected and sent back from an American port, or who manifestly belong to the excluded classes, or who have been rejected by other steamship lines who have some regard for our laws.
The officers of the Public Health and Marine-Hospital Service stationed at Quebec, Halifax, N. S., and St. Johns, N. B., have authority to examine only those aliens manifested as destined for the United States through Canada. Immigrants so manifested do not differ materially from immigrants ordinarily received at United States ports, and are given certificates of physical fitness which admit them to the United States through any of the border points. Thousands of immigrants evade this inspection at Quebec, Halifax or St. Johns, by being falsely manifested as destined finally to Canada. They have no certificates of inspection by United States officers at Quebec, Halifax or St. Johns, and upon attempting to cross the border are sent back to Montreal for examination.
In order to show the quality of the immigration brought by the Beaver Line and other lines engaged in this nefarious business, it is only necessary to state that 50 per cent, of the immigrants attempting to cross the border in 1903 were rejected, whereas the usual percentage of rejection at United States ports is only one per cent.
A regularly organized system of smuggling diseased immigrants across the border has been exposed by the United States immigration authorities at Montreal, and although the border inspection maintained by the United States Immigration Service is doing splendid work, it is impossible to guard effectively every point of over 3,000 miles of frontier. A more perfect system of exclusion is now possible, and consists of a rigid inspection of all aliens landing at Canadian ports under an effective Canadian law similar in character to our own, which has recently been enacted.
The real danger to the public health from immigration lies in that class of immigrants whose physique is much below American standards, whose employment is in the sweat-shop, and whose residence is the East ​Side tenement in New York City. The Mediterranean races, Syrians, Greeks and southern Italians, who are unused to a cold climate, and who often have insufficient clothing, also establish in their crowded 'quarters' splendid foci for the dissemination of disease. The Hebrews, Syrians, Greeks and southern Italians, invariably crowd the most insanitary quarters of the great centers of population. And the various filthy and infected, though perhaps picturesque, foreign 'quarters' constitute to-day the greatest existing menace to the public health.
There are many view points from which our immigrant problem may be judged. There are extremists who advocate the impossible—the complete exclusion of all immigrants, or the complete exclusion of certain races. There are other extremists who pose as humanitarians and philanthropists and who advocate an act of lunacy—removing all restrictions and admitting all the unfortunate—the lame, the halt, the blind and the morally and physically diseased—without let or hindrance. Neither of these extreme positions is tenable. The debarring of all immigrants, or the unjust discrimination against any particular race, is illogical, bigoted and un-American. On the other hand, the indiscriminate admission of a horde of diseased, defective and destitute immigrants would be a crime against the body politic which could not be justified by false pretense of humanity or a mistaken spirit of philanthropy.
The sane, logical position must fall between these two extremes. It is necessary for us to restrict and debar, if possible, all undesirable immigrants. A jealous regard for the public weal may demand measures and standards which seem to the humanitarian and philanthropist selfish and inhuman; but charity begins at home, and it is the" right of Americans to exclude the undesirable and to employ whatever measures and set whatever standards may seem necessary to exclude any class which menaces the social or physical welfare of the country.
If we debar any undesirable class of immigrants under the law, we should endeavor to make the law as nearly perfect as possible and debar all undesirable classes. We debar the immigrant with trachoma, syphilis, leprosy or favus; also the insane, the epileptic and the idiotic, but we admit the immigrant with poor physique, unless it is so marked as to make him undeniably a public charge.
There should be but one standard of physique for the immigrant, no matter whether his destination be 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 should be fixed by law by comparison with other well-recognized standards of physique, and should be sufficiently high to exclude all who could not beyond doubt make a living at ​hard manual labor. The wording of the law should be definite enough to make the medical certificate of poor physique equivalent to deportation.
This requirement of a definite physical standard in immigrants could be exacted without undue hardship of all unmarried male immigrants within certain age limits, for instance eighteen to forty-five. In regard to families, comprising women, children and old men, in addition to males between the ages of eighteen and forty-five, each family should be required to have at least one member constituting its chief support who could comply with the physical requirements of the law. The law need not apply to parents coming here to join their children, provided the children had established a home here and presented evidence of ability to care properly for their parents.
If the thousands of recruits for the sweat-shop army which arrive each year could be thus checked for ten years, the present existing tenement house problem would solve itself. The terrible congestion of the tenements would be relieved; the scale of wages for the sweat-shop worker would be elevated, and the general sanitary conditions of life in such districts as the Lower East Side, New York City, could be improved sufficiently to reduce the menace to the public health from this cause to a minimum.