Alan Kraut's Silent Traveler

Introduction

Kraut's Silent Traveler is a work documenting the treatment of US immigrants in terms of health-related issues. Thus the Silent Traveler of the book's title refers to the many disease-causing pathogens that may have traveled with immigrants from their native countries to their adopted one. This paper will examine this work and the various issues it raises, such as nativism and racism, with reference to nine separate journeys.

First Journey

The Cholera epidemic of 1832 began in Asia and the measures undertaken by health authorities failed to prevent its disastrous epidemiological spread across the continental US. Eventually, the disease made its way to cities along the eastern US. Cholera then became particularly prevalent among poor, foreign-born Americans who were heavily of Irish origin. Thus American whites decided that there was a connection between areas of Irish settlement and disease.

The Irish were blamed because large numbers of them had immigrated to the US. Nearly 2 million Irish left their homeland during the period 1840-1860. The pattern of Irish resettlement was to cluster in northeastern cities such as New York, Providence and Boston. By 1860, roughly one-quarter of the residents of New York City was an Irish immigrant. This heavy urban concentration made the Irish easily recognizable. In addition, the devotion of the Irish to Catholicism made them special targets for scorn and derision. This is because native-born Americans of the period were mainly Protestant and English.

Some reports, during the middle of the 19th century, seemed to suggest that Irish immigrants had a disproportionately high incidence of insanity. For instance, during the period 1849-1859, roughly 75 percent of all admissions to the Blackwell's Island lunatic asylum were foreign-born. In addition, about 66 percent of these admissions were of Irish origin. This led the resident physician at the facility to conclude that US natives had lower rates of insanity than immigrants. The more plausible explanation is that native-born Americans were keeping their mentally ill out of the asylums and treating them at home. In contrast, immigrants were using the asylums in disproportionately large numbers to treat their mentally ill. These distortions provided an additional rationale to discriminate against Irish immigrants.

St. Vincent's Hospital was founded by Irish Catholic immigrants. It was established because existing Anglo-Protestant institutions were discriminating in providing proper health care to the Irish. Thus St. Vincent's was thought to be a facility where Irish immigrants could obtain proper and sympathetic consultations. This is because the facility was staffed by individuals who shared similar ethnic and cultural backgrounds.

Second Journey

Annie Moore was an adolescent Irish immigrant. Moore arrived at Ellis Island with her two brothers. The account of her medical evaluation is notable because of the paucity of any real information that was collected. That is, her experience with the attending physicians was a brief one. She was quickly pronounced mentally and physically fit for admission to the US.

But Moore's experience was atypical for most immigrants entering the US through either Ellis or Angel Islands. The majority of immigrants were detained at Ellis Island for up to a few hours. The recollections of these individuals give credence to the notion that their experiences were traumatic. Each immigrant was given an identification tag not long after arrival. Individuals were then taken to a line inspection. This inspection involved climbing a set of stairs with heavy baggage. As individuals climbed the stairs, physicians would observe their performance for signs of stress. The individual's heart was deemed strong enough if they managed the climb without succumbing to exhaustion or worse. Physicians also believed this exercise could reveal other information such as physical deformities or poor posture.

In addition, each individual's eye, throat and hands were closely examined. Many immigrants described the eye examination as especially distressing. Physicians examined the eyes by everting the lids to check for sores. Sores under the lids are a sign of trachoma. Scalps were checked for lice or scabs. These symptoms can be indications of the presence of a contagious disorder known as favus. Once the examination was complete, immigrants were taken to a registry room. In this room, some individuals were marked with chalk. The use of chalk was an indication that the physicians wanted to conduct a second more in-depth examination with these individuals. These unfortunate ones were usually segregated from others in wire mesh chambers that took on a strong semblance to a prison cell.

Later, these detainees would be taken to semi-private rooms. Once in these rooms, they would be asked to strip. Individuals suspected of carrying a contagion were treated at the facility. The treatment process included the delousing of the body. In addition, all clothing and other belongings would be burned. Once they were finally released, this procedure effectively left immigrants with no belongings. It should be noted, that not all immigrants passed inspection and some were denied entry to the country.

Third Journey

Chick Gin was a 41-year-old Chinese immigrant. Gin complained of fever, fatigue, and widespread body pain. Upon seeing a Chinese physician, he was prescribed medication which seemed to alleviate many of his symptoms. However, later on, he experienced new symptoms including swelling. He also experienced symptoms consistent with a sexually transmitted disease. As a result, this time Gin refused to seek medical attention. His symptoms continued to worsen and he died within two weeks. A post-mortem seemed to turn up evidence that Gin had died from the bubonic plague. This was, even around 1900, a still not entirely well-understood disease. Nevertheless, as word of the likely cause of death spread to San Francisco health authorities, it set off a panic. This panic led to the quarantine of the city's Chinatown. In addition, local authorities prohibited anyone, from either China or Japan, from either leaving or entering San Francisco. Eventually, the cordon impacted the freedom of movement of thousands of the city's Asians. These individuals were not even permitted to travel to their jobs.

Mary Mallon was a 40-ish Irish immigrant. She is now known to history, rather infamously, as Typhoid Mary. Mallon worked as a cook in the homes of wealthy New York area individuals. Her case first attracted the attention of local authorities when a curious pattern was discovered. It was found that in a number of homes in which she had been employed, the residents came down with Typhoid. However, Mallon herself was not symptomatic and appeared to be completely healthy.

A medical inspection did seem to confirm she was a carrier of the disease. New York health authorities decided to detain Mallon to prevent her from infecting any new clients. However, she was able to convince the health commissioner of New York City to let her go free. Her argument was that a defenseless woman, who was completely healthy, was being unfairly treated by the city's bureaucracy.

Mallon was released, on the condition she did not work again in an occupation that could facilitate disease transmission. She did the opposite however, and worked under a number of assumed names. When typhoid cases again began appearing, wherever she worked, health authorities again had her detained. This time she was forced to spend the remainder of her days in confinement.

The instructive difference between the two cases is clearly racism. Gin was a member of an easily identifiable, and not especially welcome, racial group. The hysteria associated with one Chinese individual's illness was taken as just cause to revoke the freedoms of all members of the same ethnic group. Mallon was Irish American. Thus by this time in US history, the Irish had become much more assimilated and less identifiable than in decades past. As a result, her case didn't deteriorate into one of generalized discrimination against all things Irish.

Fourth Journey

As was the case with the Irish and cholera in the mid-19th century, Italian immigrants were associated with such diseases as typhoid and polio in the early 20th century. This correlation was made even though the incidence of both diseases in Italy was actually lower than its incidence in the US (Kraut, 1995). The cause of disease among Italians was traced to conditions native to the US cities where they relocated. That is, many Italians migrated from rural areas in Italy to urban areas in the US. It was in the US where the pattern of dense concentrations of people made disease transmission more efficient.

In addition, many Italian-Americans commuted to farms where they came in contact with polluted water. Indeed, this was believed to be the source of infection by many observers. Thus the mediation between culture and environment is an exhortation to understand how diseases can spread in unsanitary conditions. The way to prevent infection was through improved sanitation and less dense concentrations of population. It was also a lesson that immigrants are not by definition carriers of disease.

Dr. Antonin Stella was an Italian-born American physician. He emerged as an early advocate for Italian Americans in the US. He observed that members of his own group were often the target of nativist and racist vitriol. He also realized many of the accusations were lacking in scientific merit. He was popular with other Italians because he understood the language of US natives and yet could also easily communicate with Italian immigrants. Thus Stella was important as a mediator between the Italian immigrant community and the nativist US mainstream. His ability to facilitate communication between both groups is relevant to the modern immigrant experience as well. This is because modern-day immigrants are as mistrustful of native US health authorities as Italian immigrants were. Thus a mediator can help facilitate the transmission of useful health information and treatment to immigrants in a way a native US physician likely couldn't.

Fifth Journey

The Jewish disease, or the tailors' disease, is tuberculosis. It became associated with Jewish immigrants because a large number of Jews, who suffered from the disease, made their living as tailors. Of course, it was specious to associate tuberculosis with Jews or the tailoring profession. Yet this provides more evidence that disease was used by US natives as a means to stigmatize immigrants.

Jewish immigrants were different than other groups in their adaptation to the US. This is because most Jews migrated to US cities from urban centers in Europe. Thus unlike other European immigrants, Jews were already adapted to life in urban settings. Also, their segregation in ghettoes in Europe meant they had to develop their own private medical institutions. These institutions were a crucial resource that supported the health needs of other Jews. This was important because Jews would not need to seek out the services of Anglo-Protestant health care institutions. The long history of Christian discrimination in European settings had prepared them to establish their own independent health care resources wherever they lived.

Finally, Jews had a number of cultural practices which, many observers believed, provided obstacles to the transmission of disease. The dietary laws of Kashrut demanded a close inspection of all meat and other food before it was prepared for consumption. The Kosher tradition also provided prescriptions for how the food was to be prepared in a safe and healthy manner. Jewish childcare practices were held as evidence that other immigrants didn't look after their children quite as effectively. Jewish mothers had higher rates of breastfeeding their infants. There were also fewer Jewish mothers who worked in factories. Jewish rates of illegitimate birth were lower than those of other groups and Jews had lower rates of sexually transmitted disease. It also appears many Jews observed religious prescriptions against excessive alcohol consumption. Moreover, Judaism prescribes frequent hand washing before and after preparing or eating meals.

Sixth Journey

Both immigrants and US natives worked in many of the same factories. As a result members of both groups were exposed to the same work-related health risks. During much of the era under discussion, 1890-1930, American business practices were not closely regulated by the government. As a result, many labor abuses were permitted. But where the experience between the two groups differed was in the use of language. Many of the warnings concerning unsafe workplace conditions were provided in English. During the early immigrant experience, language was still an effective barrier to communication. Thus much crucial safety information was just not communicated to immigrants. There were roughly 345,000 industrial accidents in New York State during the year 1919-1920. The cause of any of these cases was identified as the fault of the worker. This is because workers did not observe posted safety warnings. Moreover, the proportion of workers filing workers' compensation claims, and who needed an interpreter, was over 70 percent.

Homework refers to the pursuit of such professional occupations as sewing, cigar rolling, hat-making, and lacework, among others. These occupations could be undertaken in the factory setting, or they could be undertaken in the home. As a result, the use of one's home for such gainful employment was referred to as homework. It was engaged in by both men and women of eastern and southern European origin. However, it was not any less hazardous than undertaking such work in a factory setting. It could also be a source of considerable emotional and physical stress. The term sweatshop is likely an apt description of such homework conditions (Kraut, 1995). Some immigrant groups observed strict gender roles and this included prohibiting married women from working outside the home. Thus homework setups could allow such women to earn an income while not leaving the home.

One of the key events in the area of unsafe working conditions was the March 1911 Triangle Shirtwaist Fire. This fire occurred at the 10 story building owned by the Triangle Shirtwaist Company in New York City. As a consequence of the fire, 146 workers, most of whom were women, died. An investigation of the cause of the deaths found that the limited number of exits trapped many of the workers on the building's top three floors during the emergency. The result of this tragedy was the passage of legislation that included more stringent building codes and provisions for factory inspection. Another outcome of the fire was its role in advancing workers’ compensation laws in certain jurisdictions. Thus, if an employee of a negligent work site could provide evidence of employer malfeasance, the result could involve significant recompense to the aggrieved.

Seventh Journey

A key complaint of many immigrants seeking assistance from native US health professionals were language barriers, nativism, and racism. These problems needed to be overcome in order to obtain adequate treatment. This prompted Michael M. Davis, Jr., an academic specializing in political economy, to pursue social reform in the provision of health care to immigrants. Davis was the director of the Boston Dispensary, a century-old moribund health care institution. He developed this institution, into a first-class medical facility that provided a holistic approach to health care. This approach involved giving equal weight and attention to both a patient's medical and social needs. This allowed the patient to focus on recovery with a clear mind.

Visiting nurses, visiting physicians and neighborhood pharmacies were each important in different ways in the provision of health care to immigrants. Visiting nurses often traveled from rooftop to rooftop, instead of up and down the stairs of tenement buildings. Immigrant families often turned to such nurses because they couldn't afford to see physicians for long hospital stays. The Visiting Nurse Service of New York was an institution that hired such nurses to provide care in non-traditional health care settings, such as homes.

The work of these nurses was often appreciated by the sick, but not always by physicians. That is, some physicians, felt these nurses were taking away their patients. Thus, to compensate, some physicians began making house calls as well. However, immigrants had the same problems with visiting physicians as they did with physicians in traditional settings. That is, the physicians didn't seem to communicate well with immigrants. Also, because many of these kinds of patients were poor, they attracted doctors who were often thought of as quacks.

Pharmacists were held in much higher esteem than doctors. This is because neighborhood pharmacies were often run by individuals of the same or similar origin as the neighborhood's residents. Thus a more useful rapport could be established between patient and pharmacist. The pharmacist could also provide many of the types of treatments that were familiar to immigrant patients in their native countries.

Eighth Journey

This journey involves an incident that occurred at P.S. 110 at Broome and Cannon Streets in New York's Lower East Side. The incident led to riots in which immigrant mothers believed that strange operations were being conducted on their children. The cause of the problem began when school teachers and nurses decided that it would be efficacious to use the schools to provide healthcare and treatment to students who were in need. School treatment was thought to be a practical means to stop any potential health care problems before they become a matter for the municipal or state public health authorities.

A small number of public school students were suffering from swollen adenoids. This affliction forced suffers to breathe through their mouths and it was thought to be a potentially harmful habit at the time. To reduce the swelling, school officials had adenoidectomies performed on the affected children. This procedure can produce some brief, heavy bleeding. However, the procedure led to rumors that school doctors had slashed the throats of the children. When a group of physicians and nurses visited the school they found a few students in distress. But the care the children received was reportedly only provided with parental consent. Indeed, one principal was quoted as saying that treating the students at school would save parents the trouble of taking their children up to Mt. Sinai Hospital.

It appears that certain doctors may have instigated a panic because they believed providing health care in non-traditional settings, without doctors, was a type of infringement on their practice. That is, some doctors argued that this method of health care was a type of socialism. This approach to health care undermined their medical authority and took away business from their practice. Also, some parents couldn't understand how their child's health was of any concern to public school officials at all.

Ninth Journey

There are two public health issues related to the period in question. The first is the AIDS epidemic. Two federal agencies, the CDC and the FDA, each identified Haitians as a major risk group for the spread of the AIDS epidemic. Thus this harks back to the association of Irish, Italian and Jewish immigrants with contagious disease in previous eras. The association was made on the grounds that large groups of individuals from Haiti and Sub-Saharan Africa had tested positive for the HIV. An outcome of this policy was that it prohibited members of these groups from donating blood in the US. This is especially notable for the FDA, the agency which oversaw the nation's blood banks. The policy was officially non-binding. But compliance with the policy from local blood banks was reportedly widespread.

The policy led to protests that included members of the Haitian community and concerned activists from other groups. As Dr. Compas argued, the policy suggests that Haitian blood is by definition poisonous. This indication is made even though there is no concrete evidence that Haitians are any more likely to carry the virus than any other ethnic group in the US (Kraut, 1995). The policy also opened Haitians up to unfair discrimination in all walks of life. The FDA rescinded its policy roughly a week later.

Another issue emerged in the late 1980s and 90s involving an association between the familiar disease tuberculosis and foreign-born persons, particularly from Latin America. Epidemiologists seemed to agree that this disease was no longer native to the US. Incidence data, reported for 1989, indicated that it was found among 9.5 per 100,000 US natives and 124 per 100,000 for foreign-born US residents. The year 1991 saw a nearly 40 percent increase in tuberculosis cases. The highest rates were found in the black American community at 112 per 100,000. In contrast, for Hispanics, the incidence rate was 52.3 per 100,000 and for Asians, the rate was 46 per 100,000.

Conclusion

In sum, Kraut's work provides an excellent overview of the history of the immigrant experience in the US. One conclusion of this history is how US nativism has often characterized immigrants as more diseased than natives. However, when the descendants of those first-generation immigrants assimilate into the cultural and social mainstream, they are no longer regarded as inferior. Instead, these descendants are accepted as essential members of the national mosaic. But this process appears to run in cycles as new groups of immigrants enter the US.

At the same time, there may be some immigrants who may never completely escape discrimination. This is likely true in terms of Asian immigrants. The cause is that Asians are more easily identifiable as different from other Americans. Asians have experienced multiple episodes where their freedoms were restricted for unfair rationales.

The book also documents the evolution of the US public health system and its responses to different outbreaks of disease. A thematic undercurrent to all of these responses is a deep-seated paranoia regarding the 'other' in US culture. There appears to be a great similarity, in the racist and nativist responses, by established institutions to public health crises. These health crises are always speciously associated with particular ethnic immigrant groups. This evidence is seen in the cases documenting the Irish and cholera, the Italians and Jews regarding tuberculosis and polio, and of the health of Haitian immigrants and the AIDS crisis during the 1980s.

However, when such crises are traced to assimilated group members, one finds much less of this paranoia. Indeed, there may even be a double standard present, as in the Typhoid Mary case. For a time, Mary was allowed the unsupervised freedom to continue spreading infection. If Chick Gin were in Mary Mallon's situation, it's hard to fathom that he would have been similarly released back into society.

Reference

Kraut, A. (1995). Silent Travelers. N.p.: Johns Hopkins University Press.