The Political Economy of Immigrant Medical ...

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The Rise and Fall of the Medical Gaze: The Political Economy of Immigrant Medical Inspection in Modern America Amy L. Fairchild Science in Context / Volume 19 / Issue 03 / September 2006, pp 337 - 356 DOI: 10.1017/S0269889706000962, Published online: 03 October 2006

Link to this article: http://journals.cambridge.org/abstract_S0269889706000962 How to cite this article: Amy L. Fairchild (2006). The Rise and Fall of the Medical Gaze: The Political Economy of Immigrant Medical Inspection in Modern America. Science in Context, 19, pp 337-356 doi:10.1017/ S0269889706000962 Request Permissions : Click here

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C Cambridge University Press Science in Context 19(3), 337–356 (2006). Copyright doi:10.1017/S0269889706000962 Printed in the United Kingdom

The Rise and Fall of the Medical Gaze: The Political Economy of Immigrant Medical Inspection in Modern America Amy L. Fairchild Columbia University Mailman School of Public Health

Argument In this paper I examine the mass medical inspections of immigrants to the United States from the 1890s through the 1920s. I show how, framed as it was not only by nativism and eugenics but also by national industrial imperatives and priorities, scientific medicine served dual purposes. On the one hand, the medical exam was a tool for managing cultural and biological threats to the nation. There were regional variations in medical inspections that reflected the politics of race. On the other hand, the medical exam played an important role in the process of building an unskilled, highly mobile labor force. The industrial demands of the nation provided a rationale for drawing and absorbing millions of European immigrants into the labor force. It was thus a distinct product of the political economy of immigration. It was this second function that characterized the exam for the majority of immigrants entering the nation.

In the context of immigration, historians have often viewed science as a tool for either rationalizing or realizing the exclusion of undesirable immigrants from the national body. The current political context makes this perspective highly appealing. But the exclusionary impulse has a long history of tension with inclusion in immigrantreceiving nations, be it into the population, the workforce, or the culture. In this paper I examine the role of science at a critical moment of mass immigration in the United States, as the nation was building an unskilled, highly mobile labor force. It covers the period from the last decade of the nineteenth century to the enactment of federal legislation restricting immigration in the 1920s. It was during these years that commissioned officers in the Public Health Service (PHS), in response to federal immigration legislation, created the machinery for physically examining all arriving immigrants at the nation’s ports. Framing immigrant medical inspection as a nation-building tool underscores the extent to which public health and medicine were intimately intertwined with national political visions and priorities. Perhaps the most prominent of the political and intellectual discourses related to immigrants and their fitness for entry into the nation were nativism and eugenics. Both were based in scientific racism and considered some particular immigrant groups as being inherently, genetically unfit for American

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citizenship. Indeed, these ideas help to explain the enormous regional differences in medical inspection and exclusion when the nation as a whole is taken into account (Fairchild 2003; Shah 2001; Craddock 2000; Stern 2006). The medical exam along the Pacific coast and Mexican border involved routine microscopic examinations for parasitic infections and more intensive physicals that enabled officials to turn back more immigrants on the basis of disease than the examination that was put into place along the East coast. Without discounting nativist fears and paranoid anxieties about the degree to which foreigners – particularly the “new” southern and eastern European immigrants – threatened to taint the American gene pool or undermine its civic integrity and the ways in which those apprehensions fueled immigration restriction in the 1920s (Jacobson 1999; Kraut 1994; Ludmerer 1972; Markel 1997), in the context of regulating the borders in the Progressive era, the agents of science and the State largely managed these dual demands by differentiating between European immigrants as a whole and Latin American or Asian immigrants. If along the Mexican border and Pacific coast, then, the nation sought to manage cultural and biological anxieties, along the East coast it addressed primarily economic demands. My focus here is on the changing social and economic context in which medical inspection developed and was carried out. My emphasis is on the East coast imperative to build the industrial labor force. Between 1891 and 1930, nearly 80,000 immigrants were barred at the nation’s doors for diseases or defects under federal immigration law. Most were denied entry due to chronic diseases that limited their capacity to perform unskilled labor. But despite this focus on diseases that made the immigrant unfit for industrial work, the immigrant medical exam as it was conducted in the East served more of a processing than an exclusionary function. The industrial demands of the nation, I argue, provided a rationale for drawing and absorbing millions upon millions of European immigrant laborers. A handful of immigrants were deported for medical reasons but all 25 million arriving immigrants, most of them bound for the unskilled labor force, were brought in under the scrutiny of the PHS. While regional variations reflected the politics of race, the form of the immigrant medical exam that touched the vast majority of immigrants reflected the national imperative to build a highly mobile unskilled labor force and was, thus, a distinct product of the political economy of immigration.

The Rise of the Medical Gaze in an Age of Industrial Capitalism With the immigration law of 1891, the United States government created the machinery for federal officials to inspect and exclude immigrants. The PHS defined its mission rather narrowly, in terms of preventing the entrance of disease to the nation. The law required medical officers of the PHS to issue a medical certificate, which represented a brief diagnosis of diseases or defects that medical officers believed to be present, to any immigrant suffering from a “loathsome or a dangerous contagious

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disease” (Williams 1926). By 1903, the PHS had elaborated two major categories of infectious and chronic disease. Exclusion for Class A conditions such as tuberculosis, venereal disease, trachoma, and favus was mandatory; it was also mandatory for mental conditions such as insanity, idiocy, or feeblemindedness. Exclusion for Class B diseases “affecting ability to earn a living” was discretionary (Fairchild 2003). But PHS officers interpreted their job as being more than preventing the entry of infectious immigrants into the nation. In their eyes, the goal was to bar undesirable peoples – those “who would not make good citizens” (Gumb interview 1985). In the context of industrial era America, this meant excluding immigrants who would not make good industrial citizens, who would wear out prematurely and require care and maintenance that the nation could ill afford. Between the ends of the Civil War and the First World War, the United States was transformed from a society of artisans, who largely controlled the pace of production, into the world’s leading industrial power. By the 1880s and 1890s, mechanization swelled the ranks of the unskilled labor force (Montgomery 1987). Dramatic changes in industrial production and management not only allowed the unprecedented expansion of American industry, but also generated great economic fragility. As workers increasingly located in urban areas and the labor supply expanded to accommodate the demands of a rapidly growing industrial power, hundreds of thousands of unskilled workers became “utterly dependent upon their industrial earnings in order to survive” (Keyssar 1986). But workers could not rely on industrial earnings. Thirteen “minor” recessions and depressions accompanied the six “major” economic downturns that the nation experienced from 1870 to 1921 (ibid.). In this kind of work economy, sickness could mean the difference between survival and destitution (Unemployment Committee of the National Federation of Settlements 1931). Although most of the laboring class relied primarily on the resources of family and friends rather than public or private charity or relief organizations during lean times (Cohen 1990), illness, rather than the nature of the economy, was viewed as the “outstanding problem which led to dependency” (American Council for Nationalities Services 1911). Thus, PHS officers excluded the vast majority of immigrants for chronic diseases affecting an immigrant’s laboring capacity. Old age, varicose veins, hernias, poor vision, and deformities of the limbs or spine were amongst the primary causes for exclusion (Fairchild 2003). The causes for exclusion reflected the industrial expectation that immigrants would engage in physical labor. That so few were excluded set into bold relief an insatiable industrial demand for cheap labor. One labor poet wrote: Here in the land of far famed liberty Men are treated as part of a machine; Hired and fired without necessity According to set rule, and set routine. By younger men the old were soon replaced, Because they had outlived their usefulness;

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Fig. 1. Immigrants awaiting further processing at Ellis Island. Photo: New York Public Library.

Cast off like some worn part in discard placed, Without regard to those it brought distress. (Miceli 1950)

But the means by which immigrants were examined also reflected an industrial imperative. Immigrant medical examinations were centered on the “line,” which became shorthand for techniques and procedures for quickly examining thousands of immigrants. And Ellis Island – where roughly 70 per cent of immigrants entered the United States – set the standard for examination. After an arriving ship passed quarantine inspection in New York Harbor (Doty 1906), PHS medical examiners boarded and examined all first- and second-class passengers as the ship proceeded up the harbor. Upon docking, steerage or third-class passengers were transferred to Ellis Island by barge. Proceeding one after the other and lugging heavy baggage, prospective immigrants entered the often-congested immigration station and proceeded slowly through a series of gated passageways resembling cattle pens (fig. 1). The winding passage toward the PHS officers who waited at the end of the line ensured that each could witness the inspection of dozens of immigrants ahead. As they reached the end of the line, immigrants slowly filed past one or more PHS officers who, at a glance, quickly


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Fig. 2. Making a snap diagnosis on the line at Ellis Island. Photo: National Park Service, U.S. Department of Interior.

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 (fig. 2). The regulations for inspecting immigrants promulgated by the Surgeon General described the diagnostic protocol PHS line officers were to follow, which emphasized the physician’s “gaze.” Sometimes officers referred to the “glance.” The allusion to the “medical gaze” described by Foucault is striking. Foucault’s anatomo-clinical gaze had as its focus not disease, but lesions, pathology. Prior to the advent of pathology in the nineteenth century, the medical gaze was redirected toward reading the visible symptoms (which, once properly read, became signs) of disease toward the end of the eighteenth century. Pathology focused the gaze to the ultimate seat of disease in the tissue, the lesion. Rooted as it was in an effort to establish power and authority, Foucault argues that this anatomo-clinical gaze rejected mediation by the microscope or chemical analysis (Foucault 1973). The 1910 Book of Instructions for the Medical Inspection of Aliens, likewise, underscored the ability of the PHS to determine the “general physical development” of immigrants and diagnose a multitude of disorders or impairments related to skin, lungs, brain, circulatory and skeleto-muscular systems without the aid of diagnostic technology (Bureau of Public Health 1910).

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In part, the medical gaze was emphasized in the context of immigrant inspection because the microscope – the most basic laboratory tool, the very emblem of scientific acumen and authority – was unavailable at many immigration stations across the nation. Stations began requesting microscopes and other laboratory equipment beginning in the 1890s (Fairchild 2003). One PHS officer asked how he was to perform his duties without a microscope: “by what means shall they [PHS officers examining immigrants] determine the presence of certain pathological conditions, which up to this time can be discovered only by the use of the microscope?” (Bailhache 1893). Here was a question that might have rocked the scientific foundation of immigrant medical inspection. In the 1880s and 1890s, medical schools successfully began to incorporate bacteriology and basic science – the hallmarks of a new scientific medicine – into their curricula as a means of transforming medical education and increasing the status of the medical profession (Fee 1987). Scientific medicine promised to shore up the professional authority of the physician and fortify him against irregular medical practitioners: homeopaths, herbalists, osteopaths, Eclectics (Latour 1988; Ludmerer 1985; Warner 1986). The PHS officer was one of a new cadre of public health professionals who readily embraced bacteriology and championed the laboratory (Fox 1975; Rosen 1958; Fee 1987; Leavitt 1992; Rosenkrantz 1972). But in 1891 Surgeon General Walter Wyman flatly stated that he had no intention of establishing bacteriological laboratories at immigration stations (Wyman 1891). But why was the microscope refused to the PHS officers at the nation’s immigration ports? The most obvious reason was financial. Microscopes and bacteriological laboratories required funding. But the United States was a wealthy nation. Had microscopes been deemed essential they could have been provided. And, indeed, over time the microscope became a critical tool at Ellis Island, by far the nation’s largest immigration station (Fairchild 2003). In the East, however, its uses were always limited to confirming diagnoses made on the line (Bureau of Public Health 1903). It is not so much that the equipment was too expensive to provide, but that the delays would have been too costly: immigrants subjected to bacteriological testing would have to be detained until results were available. It might take days of repeated testing to get back a reliable result (Osler 1916). More important than identifying all possible pathologies was getting immigrants through the process. Officials conducted immigrant medical inspections swiftly so as not to interfere with shipping and trade. The sheer numbers of immigrants arriving in New York and other ports prevented extensive examination in most cases. Ellis Island officers were known to examine several thousand immigrants a day. As one Ellis Island physician recalled, “The invaders were arriving in such numbers that individual physical examination with our meager staff was out of the question. A snap diagnosis which stood a reasonable chance of proving correct had to be made in a few seconds” (Heiser 1936). It was a system suited to the mass processing of industrial laborers in a society that had begun thinking “in terms of a complex social technology, of a mechanized and systematized factory” (Wiebe 1967). Industry relied on a constant supply of labor to draw on at a moment’s


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notice and then discard when the need for immediate production diminished, and Congress accordingly formulated immigration law “along conservative lines [in order to] avoid measures so drastic as to cripple American industry” (Congressional Record 1902). Outspoken nativists, eugenicists, politicians, and labor leaders would argue that the immigrant medical exam must serve as a means of defending the nation, of denying entry to unwanted, undesirable immigrant groups. Accordingly the procedure became the subject of frequent attack. Congressmen, the press, and physicians often claimed that it was cursory and that stations like Ellis Island were understaffed and overburdened. But while it sometimes became the subject of investigation, as it did in New York following the typhus epidemic of 1892, a Congressional committee investigating the immigration protocol failed to find fault with “the inspection procedures, bills of health, or other practical matters concerning the flow of immigration into the United States” (Markel 1997). The phrase concerning the flow of immigration into the United States was most telling, for it indicated that the aim was not to impede this flow but rather to direct it. Indeed, between 1910 and 1917, it was hoped that the Immigration Bureau, the organization that made final decisions regarding immigrant medical deportations, could help to ensure the “beneficial distribution of aliens admitted into the United States” (Smith 1926). The goal was to prevent “the congestion in our larger Atlantic seaport cities that has attended the immigration of recent years” and “to supply information to all of our workers, whether native, foreign born, or alien, so that they may be constantly advised, in respect to every part of the country as to what kind of labor may be in demand, the conditions surrounding it, the rate of wages, and the cost of living” (Department of Commerce and Labor 1908). The need for workers made imperative a very rapid, factory-like inspection, which had a counterpart in the philosophy of scientific management. But if it drew its form from industry, as I argue elsewhere (Fairchild 2003), it was grounded in the scientific conviction that disease was apparent, that it was written on the body. Dr. Albert Nute, while stationed in Boston, argued, “it can be safely stated 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” (Nute 1914). 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 an immigrant should merely be further examined, the letter “C” that the PHS officer suspected an eye condition, “S” indicated senility, “X” insanity (Geddings 1923; Mullan 1913). The layman, like the PHS officer, also believed that disease displayed itself on the body – that immigrants and laborers could be judged on the basis of their appearance. Terence Vincent Powderly, the first Commissioner General of Immigration, declared: “Vice may come in the cabin or the steerage, in rags or fine raiment, and escape detection, but . . . diseases . . . proclaim their presence and are their own detectors”

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(Powderly 1902). Non-medical immigration officials, however, claimed no such skills for themselves. Rather, they respected greatly the ability of the PHS officer to detect that which the lay observer could not see: the PHS officer could identify the presence of “loathsome or dangerous contagious diseases . . . without causing the aliens to undress or without laboratory tests” (Douglas 1923). PHS officers were unwilling to concede that any but the seasoned officer could accurately diagnose disease at a glance. Indeed, the medical gaze was an art that could not be taught; it must be learned through experience: “You saw what the doctors were doing – there was no training, except a few words of instruction” (Kempf 1977). Looking back on a long career in the PHS that began on the line at Ellis Island, Dr. Samuel Grubbs recalled his sense of admiration for the diagnostic wizardry of the experienced PHS officer: “I wanted to acquire this magical intuition but found there were few rules. Even the keenest of these medical detectives did not know just why they suspected at a glance a handicap which later might require a week to prove; but I lost money when I began giving odds on the field, so to speak, against their hunches” (Grubbs 1943). Most physicians valued the medical gaze as highly as intensive physical and laboratory examination. Dr. Victor Safford, who served at both Ellis Island and Boston, insisted that “Defects, derangements and symptoms of disease which would not be disclosed by a so-called ‘careful physical examination,’ are often recognizable in watching a person twenty-five feet away.” Safford thus argued that “A man’s posture, a movement of his head or the appearance of his ears, requiring only a fraction of a second of the time of an observer to notice, may disclose more than could be detected by puttering around a man’s chest with a stethoscope for a week.” But, significantly, Safford added that after an immigrant was pulled off the inspection line for more intensive examination, “a week might be required to demonstrate what was really wrong with the man” (Safford 1925). But if the microscope was complementary yet subordinate to the medical gaze within the PHS officer’s diagnostic armamentarium along the East coast, where the imperative to admit large numbers of unskilled immigrant laborers was lacking, the usefulness of the gaze broke down in other regions were the pressures to admit large numbers of unskilled immigrants into the labor force were not as great. Immigrants faced more considerable medical obstacles to entry at the nation’s Pacific coast and Mexican border immigration stations. At Texas border stations such as Brownsville and El Paso, PHS medical inspectors stripped, showered, disinfected, searched for lice, and physically examined large groups of immigrants. Fear of diseased Syrians and Chinese, whom officials believed might approach the border “dressed as a Mexican” and “pass” as local “peons,” help to explain the shape of the medical exam in this region (Braun 1907; Seraphic 1908). Clothing, among the “Mexicanized” races might deceive the medical inspector. He must, therefore, insist on its removal. Likewise, all second- and third-class Asian immigrants arriving in San Francisco consistently endured a physical exam similar to that conducted along the Mexican


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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” Asian immigrant, particularly the Chinese (Crewdson 1904). In 1911, Dr. W. C. Billings made clear that the medical gaze could not penetrate the Asian body: “at least when dealing with oriental races, it is quite impossible to detect on primary examination anywhere near all the cases of hookworm, and a microscopical examination is therefore indicated” (Bureau of Public Health 1911). In a critical reversal of the principal of the medical gaze, the officer stationed along the Pacific coast had to remind himself, “‘I am not sure that this alien has not hookworm disease, therefore he must not be released until I can determine positively that he is not infected’” (Bureau of Public Health 1914). At issue in these different regions was the suitability of immigrants – Mexicans and Chinese in particular – for the American labor force. The diseased Asian immigrant, for example, did not merely represent a drain on the economy, but an alteration of the economy (Berry 1913). Asian nations, like their African counterparts, represented “backward countries” (Foner 1998) and Asian labor was equated with Black labor, neither of which was deemed desirable (Mink 1986). Despite these variations along the nation’s southern and western borders, the imperative to admit unskilled European immigrants would persist in the northeast into the 1920s and, thus, the Office of the Surgeon General remained firmly supportive of the traditional practice of East coast immigrant medical inspection – of the gaze. Officials considered the value of possible alterations to the gaze in the exam in light of both the effectiveness and overarching intent of the exam. During World War I, Ellis Island physicians experimented with conducting a more intensive physical examination. Though the station experienced staff reductions as a result of the War, because of the considerable depression in immigration, the station actually enjoyed something of a surplus of medical officers for the first time in its history. With more time on their hands, the staff began to turn as many immigrants as possible aside into more private examination rooms; some days they were able to examine all arriving immigrants intensively. The Chief Medical Officer at Ellis Island reported that the certification rate rose from 2.29 per cent in 1914 to 5.37 per cent in 1915. When all of the immigrants were turned aside for such clinical scrutiny, the certification rate rose to 9.37 per cent (Bureau of Public Health 1919). The Surgeon General, however, rejected proposals to make intensive examination routine for all arriving immigrants (Kerr 1921). True, the certification rates had increased, but he underscored that this amounted to a mere handful of additional rejections: “it should be clearly evident from a study of the . . . figures and the methods employed during past years in the medical examination of immigrants that the procedure as carried out is reasonably satisfactory for the purpose for which it is employed” (Stella 1922; Bureau of Public Health 1921). And the purpose of the exam would not change until the industrial and political context was altered in the 1920s.

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The End of the “Line”: Medical Inspection in the Age of “Prosperity” The Immigration Act of 1924 restricted immigration numerically and made national origin the basis for admission into the United States. It capped immigration at 150,000 per year and restricted immigration to two per cent of the number of each “race” recorded in the US Census of 1890, representing a deliberate attempt to limit dramatically immigration from southern and eastern Europe (Divine [1957] 1972). It left exclusion of Chinese laborers in tact and, to the chagrin of Japan, formalized the exclusion of all Japanese immigrants (Ngai 2004). Although the relatives of immigrants already in the United States and new immigrants from Mexico and Canada were not subjected to the numerical limitation under the quota law, Mexican immigration was limited by other means. For example, the fears of contagion and dependency enabled public health officials to use tuberculosis as a tool for repatriating Mexican immigrants and citizens in the west. As Emily Abel convincingly argues, it was a growing consensus regarding Mexican citizenship (or their lack of entitlement to it) that worked to make health officials emphasize the economic consequences of tuberculosis as a chronic disease (Abel 2003). On the European front, a key provision of the Immigration Restriction Act transferred immigrant medical inspection abroad and established the visa system: intending immigrants could no longer depart for the United States until an American Consular Office abroad had stamped a visa onto their passports. The legal precedent for the visa system was established during World War I as part of the Passport Control Act of May 22, 1918, which stipulated that no individual could depart from or enter the United States without approval from the State Department (Fink 1921). After 1924, consulates took on the responsibility of enforcing not only the quota law, but also all US immigration law. As quickly as they were able to establish the facilities, medical inspection became a prerequisite for consular approval for visas. The Rogers Act, passed subsequent to the Immigration Restriction Act of 1924, established the United States Foreign Service abroad. The Rogers Act gave the United States consulates the staff needed to inspect all immigrants overseas (Rogers Act 1924). It was not only the Immigration Act and the rise of the visa system that brought an end to inspection on the line. The line was forged in an America that attempted to rigidly, efficiently, scientifically manage the factory worker in the industrial plant as well as in the community. Fredrick Winslow Taylor’s “Principles of Scientific Management” – first published in the 1890s – had profoundly shaped the way that business thought about how to organize work in Progressive era of America. Industrial leaders saw scientific management as a process for removing “the manager’s brain” from “under the workman’s cap” (quoted in Montgomery 1987, 25). While scientific racists were concerned with ensuring that the nation’s inhabitants remain “well born,” those concerned with the labor half of the equation insisted that this was not enough: the worker “must be trained right as well as born right” (Taylor [1911] 1998). Industry, therefore, was interested in worker efficiency and discipline (Montgomery 1987).


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By the 1920s, the nation was changing. Immigration restriction, consumerism and mass culture, growing social and racial cohesion, and critical shifts in America’s industrial economy all contributed to a fundamental shift in corporate managerial philosophy. Increasingly, explained economist and labor-relations expert Sumner Slichter, business found it impossible to follow the dictums of scientific management and suggested that the worker was more competent than previously imagined (Bernstein 1960). The historian Lizabeth Cohen concluded, “there is no denying that managerial ideology almost everywhere underwent a sea change during the 1920s” (Cohen 1990). A number of factors combined to alter corporate ideology including immigration restriction, technological advances, and the labor strikes of World War I. The impetus on the part of corporate America to try new means of organizing the workforce in the face of immigration restriction reflected an important shift in philosophy after 1921 – a shift that would have an impact on medical inspection at the nation’s borders (Brody 1980). Immigration restriction reduced the number of bodies entering the American industrial labor force, limiting the employer’s ability to reserve the newest immigrants for the most backbreaking and least desirable work, thus contributing to a cycle of upward mobility within the workforce. At the same time, industry began to view machinery itself and not the individual laborer as the key to production. Irving Bernstein attributes “the quickening pace of technological change” to the fact that “machinery was cheaper than labor,” making management eager to “replace workers with machines, to scrap old machines for new ones” (Bernstein 1960). Whereas Frederick Winslow Taylor almost casually dismissed the unskilled worker as an ignorant ox, the labor turmoil accompanying World War I forced corporate America to regard the worker’s thinking and organizational capabilities as a potential threat. Wrote Slichter in 1929, management techniques in the 1920s were geared towards “counteract[ing] the effect of modern technique upon the mind of the worker, to prevent him from becoming class conscious and from organizing trade unions” (quoted in Brody 1980; emphasis added). Indeed, Gerard Swope stressed to General Electric that the company’s workers “must be dealt with as thinking men” (quoted in Brody 1980; emphasis added). Employers in a variety of industries and businesses sought to counter the increasing power that unions demonstrated during World War I by establishing “personal” relationships with individual workers. They competed for worker loyalty with the various ethnic mutual aid, fraternal, banking, and charity societies and agencies. In addition, employers attempted to make the workplace a focus for social and leisure activity. Hand in hand with this shift came an increase in white collar employment – the number of nonmanual workers increasing over 38 per cent between 1920 and 1930, compared to under 10 per cent for manual workers – as large corporations adopted new policies of personnel management (Bernstein 1960). Of far more significance than welfare capitalism, however, was the reorganization of labor within the factory. Under pre-war systems of scientific management – or the “drive system” – corporations frequently moved workers around, from one department

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to another, from one place on the assembly line to another. Many companies observed during the wave of strikes gripping the nation following World War I that ethnic solidarity promoted worker unity and that by exploiting interracial tension and hatred a company might break a strike (Cohen 1990). In the 1920s, employers began to separate ethnic or racial groups within the workplace as part of the new strategy of segmenting labor. Corporations like Ford, General Electric, Westinghouse, Procter and Gamble, US Rubber, and International Harvester experimented with “the systematic allocation of different groups of workers to different plant divisions in order to embed job segregation into the job structure itself” (Gordon et al. 1982). This helped to reduce labor turnover rates to half the pre-war levels (ibid.). In addition to changes in corporate labor management strategy and the reorganization of labor came improvements in standard of living for the employed sector of the economy. Such improvements were measured not only in increased earnings between 1922 and 1929, but also in better living conditions. A 1929 Bureau of Labor Statistics study of Ford Motor Company employees found, for example, that industrial workers enjoyed far more salubrious conditions than they did at the turn of the century. Employed workers lived in houses that provided, on average, one room per person. They had access to electricity, central heating, toilets, and inside running water. That the achievement of this new standard of living came at the cost of deficit spending in the form of credit and payment in installment plans did not strike a chord of alarm as it did at the dawn of the twentieth century (Brody 1980). In the gloss of the productive economy of the 1920s, the worker ceased to be viewed as a potential dependent, as a drain on precious charity resources. The notion of abundance and consumerism became a means of establishing American unity (Wiebe 1967). A new inspection regime was needed for this new context. On August 1, 1925, consular officers at seven ports in Great Britain and Ireland began the first test of the visa system, which came to be known as the “British Plan” (Bureau of Public Health 1926, 186). British ports were selected for the test of the visa system because officials felt that they were more likely to get satisfactory cooperation from the British Government. If it reduced the number of immigrants examined who were sent to Ellis Island, and deported, US officials felt that other European governments would quickly provide similar facilities (Editorial 1925). From August 1 to October 31, 1925, nearly 20,000 prospective immigrants were medically examined. Of these, 1 per cent were “notified” (medical “certification” was now called “notification”) for Class A conditions and 9 per cent were notified for Class B conditions. All of the candidates with Class A conditions and 41 per cent of the candidates with Class B conditions were refused visas. Abroad, immigrants did not file past the PHS officer in a line. Instead, after an initial visit to the United States consulate, the prospective immigrant was referred to the PHS and given a private appointment: “The fact that the examinations of prospective immigrants abroad are made according to schedule and by appointment makes it possible for them to be more thorough and painstaking as compared with


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the necessarily hurried examinations when large ship loads of immigrants arrive at US ports” (Medical Inspection of Aliens 1924–35). Here, the PHS officer reviewed each immigrant’s visa application containing information on race, age, marital status, birthplace, previous residences, and occupation (Fairchild 2003). As a procedure that placed the physician face to face with the individual immigrant, the exam – unlike that accorded immigrants at United States ports – was standardized along the lines of routine exams performed in the United States for life insurance or in industrial medicine. After 1924, PHS officers adopted a standardized medical examination form that required the officer to record detailed information on all parts of the body. A checklist now guided the PHS examiners through the medical exam; they recorded detailed information regarding the prospective immigrant’s general appearance, facial appearance, the condition of the head and scalp, the condition of the lungs, the presence of parasites, and the mental condition of the applicant. Thus, the PHS created a medical record of a host of conditions and medical observations. They did not merely issue a single medical certificate that stated only the causes for which the immigrant should be rejected. Between 1926 and 1930, twenty more consular inspection stations were opened throughout Europe. Overall, the PHS issued notifications to 10 per cent of immigrants applying for visas. Nearly five per cent of those examined were ultimately refused visas for medical reasons. The rejection rate abroad represented a 400 per cent increase over the medical exclusion rate of approximately one per cent that had prevailed in the United States since 1891 (Fairchild 2003). Significantly, however, it was not rejection that was emphasized: the exam was envisioned as a means of “improving the physical and mental types of immigrants coming to the United States” (Report of the Conference of Officers of the State, Treasury, and Labor Departments 1925). Consular notification, then, was heralded as an unparalleled success in selecting only the fittest immigrants (Fairchild 2003). The purpose of the old examination on the line at Ellis Island and other Atlantic and Gulf coast American ports had never been to select only choice immigrants. At best, it had been to weed out the very worst while meeting the overriding demand to admit vast numbers into a new industrial order. Obscuring the Medical Gaze Back in the United States, immigrant medical inspection on the “line” was gradually abandoned. By the mid-1920s, medical examination at Ellis Island and other immigration stations in the nation was but a shadow of what it had once been. Ellis Island was no longer crowded with thousands of arriving immigrants. Immigration at other ports dwindled, and, for expediency, immigrant medical inspection was increasingly conducted as part of the quarantine exam. Immigrants arriving in the United States from countries where the visa system was not yet in place still received an “intensive line examination,” in which they were “stripped to the waist” (Lavinder 1929a). And although the PHS was still required to examine all second- and third-class

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passengers carrying approved visas before they were officially landed in the United States, 90 per cent of these “confirmatory” exams were conducted aboard ship (Bureau of Public Health 1928). The PHS continued to carry out medical inspections at United States ports because approximately four months would typically pass between inspection of the immigrant abroad and his or her arrival in the United States. “Hence it is most essential for the protection of this country, as well as for that of the alien, that the final medical inspection be made just prior to landing in the United States according to law” (Lavinder 1929a). Only those immigrants carrying a medical memorandum indicating a potential medical problem issued by consuls abroad were taken to Ellis Island to be reexamined (ibid.). An immigrant arriving with an “unchecked visa and no accompanying medical memorandum” was cause for suspicion; it was assumed that the immigrant had destroyed his or her memorandum. These immigrants were almost always sent to Ellis Island for reexamination (Lavinder 1929b). In 1925, the chief medical officer at Ellis Island described the significance of the end of the line, voicing a new disdain for the old procedures: “This year, for the first time in the history of Ellis Island, it has been possible to abandon the old ‘routine’ examination entirely. It is doubtful whether a medical officer ever served at Ellis Island who did not appreciate the weakness of the only method of examination possible when numbers far beyond the capabilities of the station . . . were presented for examination, and it is probable that none ever served here who did not realize that it was impossible to carry out the examination of aliens in the manner expected and which the law contemplated.” The Chief Medical Officer was quick to dismiss the philosophy of the medical gaze. The only explanation for the existence of former inspection procedures, in his mind, was that “the remedy did not lie within our power. This was the situation: fifteen medical officers, well trained though they were, endeavoring to isolate from an avalanche of 5,000 persons a day all of the persons suffering from one or another of physical or mental conditions specified in the immigration law, and this by the simple process of having these aliens file past them all day long at a distance of about one rod apart. . . . Now, fortunately, this is a thing of the past, although its results will be with us for many years to come” (Bureau of Public Health 1925). As the form and philosophy of immigrant medical inspection was transformed, the PHS altered its perception of the value of the old Ellis Island tradition of medical inspection. Many long-time champions of the gaze endorsed new inspection standards, claiming even that inspection abroad raised inspection at United States ports to a new level. In 1925, for instance, Assistant Surgeon General Samuel B. Grubbs announced proudly that “At present a great majority of those passing our immigration stations receive an intensive medical examination that is one comparable to a periodic overhauling by a family physician or a life insurance examination” (Grubbs 1925). Yet, despite the rosy picture that Grubbs painted of the improved examination procedures, a new cadre of physicians working with or in the PHS in the 1920s began to express a certain scorn for both for medical inspection of immigrants and PHS officers, themselves.


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Dr. Bernard Notes, who briefly served with the PHS as an Ellis Island intern, declined to take the exam to become a commissioned officer on the grounds that the organization was becoming too bureaucratic: “I was young and ambitious and full of vigor, and I wanted to make something of myself – I didn’t want to get a position and draw my check and that was it. Otherwise, I would have gone into business, or something else” (Notes 1977). Even by the end of the war, the prestige of the PHS line officer and the lure of the gaze had begun to diminish. Thus, Dr. T. Bruce H. Anderson, who worked in the Ellis Island hospital, no longer admired the officers who worked the line, speculating that perhaps they had been assigned there as a punishment of sorts: “The officer, frequently middle-aged, assigned to Line duty where the medical abilities were not actually used, and where the work physically was difficult, was not desirable” (Anderson 1977). The new PHS officer wanted to practice scientific medicine, not master the art of snapshot diagnosis that was so emblematic of a very different industrial era.

Conclusion: Immigration from the Inside Out The events of September 11, 2001, have reinvigorated the metaphors and language of disease – infections, terrorist cells, eradication – and renewed interest in tightening control of the nation’s borders. In the period since that attack, Congress has passed measures intensifying the scrutiny and surveillance of immigrants at the borders (Pear 2002). Both the House and Senate overwhelmingly passed legislation in March 2002 to increase the number of immigration investigators and inspectors and to establish a surveillance system for people entering with student visas. President Bush has signed “modern,” “smart border” agreements with Canada and Mexico aimed at further limiting the flow of illegal immigrants, drugs, and terrorists, without slowing the flow of goods (Baranauckas 2002). The shape of “the line” in the context of the ongoing political debates over border control very much follows the physical geography of the United States. In the most high-profile policy debates concerning immigration, we talk as if the critical point of decision-making and action is actually at the nation’s borders and we employ the rhetoric of preventing illegal penetration of those borders. But, as was the case at the turn of the century, our attention to the borders is highly selective. Further, our attempts to control the borders and define the nation, now as in the past, are as much a reflection of the nature of the United States economy as any kind of threat – genetic, cultural, or terrorist – that immigrants may represent at any given moment. But we cannot limit our analysis to policies that affect only the borders. We must also think about immigration from the inside out as well as from the outside in and look at the United States domestic policy as an equally significant nation-building tool. We must do so in the context of the transformation of the global economic playing field and the place of both legal and illegal immigrants not only in national rhetoric about national bodies and their defense but also about their place in those economies.

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There are some 17.7 million immigrants in the United States. Perhaps upwards of nine million of these immigrants are illegal (Minton 2001). A great proportion of illegal immigrants are from Mexico. In response to this situation, In January 2005, President George W. Bush began efforts to garner support for his guest worker program. A contested part of the Republican platform during the 2004 elections, the Bush proposal would offer temporary visas for immigrants, including illegal immigrants residing in the United States. Although he viewed work visas as a means of securing the border, the goal was to allow “people to come into our country in a legal way for a time, for jobs that Americans won’t do” (Fairchild 2004). Senator Edward Kennedy and Republican John McCain built on Bush’s agenda and have attempted to advance legislation that would allow the millions of illegal immigrants in the United States to gain six-year, temporary work visas in order to position them eventually to apply for citizenship. McCain decried the mainstream Republican alternative of simply deporting illegal immigrants (Reuters 2005). As Mel Martinez, a new Florida senator explained, “The little, unknown secret is that America needs the workforce that these people provide. Without them, this economy would grind to a halt” (Redelate and Martinez 2005). Republican Senator Arlen Specter advanced the progress of the McCain-Kennedy measure after it incorporated provisions requiring illegal immigrants to pay back taxes and fines before taking steps on the road toward citizenship (Editorial 2006b). The House, however, has taken a decidedly contradictory position, passing a measure that would make illegal immigration an aggravated felony, render the provision of charity assistance to illegal immigrants an act of alien smuggling, and grant state and local police the authority to enforce federal immigration laws (Editorial 2006a; Ferriss 2006). It is of a piece with new state-based efforts to deny drivers’ licenses to illegal immigrants (Ferriss 2006). The congressional debates have generated widespread protests, including a nationwide boycott of commerce and work, on the part of immigrants and those hostile to them (Broder 2006; Gorman. et al. 2006). The now furiously raging policy debate bears the patina of border control – one Republican Senator describes newly proposed measures as “turning off the magnet that brings people into the United States to work illegally” (Pabst 2006) – but at its core it is fundamentally about the place of immigrants within American economic and cultural life. We must, then, look through this veil at the larger backdrop against which immigration policy, medical or otherwise, plays out. Even when punctuated by sometimes vituperative debates over infectious diseases like AIDS and SARS, it is no longer the case that health and immigration intersect in a way that makes science the key nation-building tool that it was during the opening decades of the twentieth century. Domestic policy now represents our most powerful and meaningful tool for nation-building. Denying an immigrant a driver’s license, public education, or welfare benefits will not, to be sure, determine whether or not people emigrate from one country to another. They will thus not preclude immigrants’ abilities to live amongst us or contribute to the national body both economically and culturally. But they will


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