“What has been will be again, what has been done will be done again; There is nothing new under the sun. Is there anything of which one can say, “Look! This is something new”? It was here already, long ago; it was here before our time.” Ecclesiastes 1:9–10 (NIV)
“Whoever wishes to foresee the future must consult the past; for human events ever resemble those of preceding times. This arises from the fact that they are produced by men who ever have been, and ever will be, animated by the same passions, and thus they necessarily have the same results." Niccolò Machiavelli, The Prince[1]
There has been a surfeit of contemporary political rhetoric directed at immigration policy in the United States. This rhetoric reached a crescendo recently during a contentious election year. At times, the energy expended has generated considerably more heat than light. Lost somewhere in the debate, however, is the crucial role Christian-Hippocratism should be playing in the controversy. In this regard, one author observed, “there is no social problem that will not enter the healthcare system.”[2] What does the writer mean by this statement? What unique content might enrich discourse if the subject of immigration was deliberately reframed in a medical context? To begin with, some may inquire, prima facie, why a medical frame should be applied to immigration.
Engaging this question is disingenuous at best. It has been trenchantly observed that “at critical junctures in American history, immigrants have been stigmatized as the etiology of a wide variety of physical and societal ills. Anti-immigrant rhetoric and policy have often been framed by an explicitly medical language, one in which the line between perceived and actual threat is slippery and prone to hysteria and hyperbole.”[3] American society has become so used to a medical frame for immigration that its contemporary presence may pass unnoticed. The frame has often exaggerated the threat. Remember the panic afforded Ebola? So, from where exactly does the medical frame for immigration derive its power and durability?
In her paradigmatic book Illness as Metaphor, Susan Sontag detailed the accusatory potential of metaphors surrounding diseases.[4] She primarily focused on three diseases prominent for her personally and for history—tuberculosis, cancer, and AIDS. Although Sontag’s approach to illness metaphors did not specifically address immigrants and their illnesses, if one studies U.S. history, myriad diseases have been repeatedly encumbered by metaphors purposely utilized to stigmatize and dehumanize immigrants. Medicine has been leveraged as a tool for bias, prejudice, and exclusion. Unfortunately, in the past, utilization of illness metaphors in the context of immigration has been under the willing purview of physicians. These efforts have allowed medicine to sanction behaviors that have been anathema to Christian Hippocratism. In some instances the metaphors have also resulted in justification for poor care of immigrant persons.
This essay will focus on American medicine’s centuries-long role in generating and catalyzing intolerant attitudes—by fostering illness metaphors—to disparage immigrants. Unfortunately, the ethos exhibited today in the arena of immigration has become a mimic of the disturbing behavior exhibited by certain physicians throughout a lengthy span of U.S. history. Indeed, today, there is nothing new under the sun at the interface between medicine and immigration. Ignoring the historical context for physician complicity in the mistreatment of immigrant persons is a mistake. Contemporary surveys demonstrating a negative animus of the medical establishment toward immigrant humanity predict that this generation of healthcare workers is resuscitating something that was unfortunately troubling long ago and has importunely reappeared.[5]
We must erect a Wall of Brass around the country for the exclusion of Catholics.
John Jay, First Chief Justice, U.S. Supreme Court (1780)[6]
Few of their children . . . learn English . . . unless the stream of their importation could be turned . . . they will soon so outnumber us . . . even our Government will become precarious.
Ben Franklin on German Immigrants to Pennsylvania (1753)[7]
It is a mistake to assume that the contemporary contentious environment for immigrant persons in the United States is unique. The examples of John Jay and Benjamin Franklin document pejorative cultural attitudes dating back to America’s founding. However, since this study will concentrate on a medical-ethical frame for immigration, earlier historical examples of physician misbehaviors will be chronicled.
Beginning in the mid-nineteenth century, physicians led the way in efforts to exclude Chinese individuals from successful immigration to the United States of America.[8] Their armamentarium was comprised of falsehoods disguised as illness metaphors. The diseases chosen included smallpox, syphilis, leprosy, and that caused by the parasite Clonorchis sinensis.[9] Later, opium addiction would be viewed as a protean immigrant threat to Americans. The era was also a time to introduce an archetypal eugenics agenda into the debate, aimed at immigrant persons through the threatening specter of miscegenation and Social Darwinism. All these efforts were exerted under the aegis of physicians.[10]
Dr. Arthur B. Stout, infamous for his book Chinese Immigration and the Physiological Causes of the Decay of a Nation (1862), frequently used medicine and its metaphors as weapons in his anti-immigration arguments.[11] He blamed Chinese immigrants for smallpox epidemics, having said, “We manufacture smallpox in San Francisco.”[12] His claims were dubious from a scientific perspective. His medium for the transmission of smallpox from the Chinese to the “white” population were “miasmas.”[13] This “bad air” hypothesis (emanating from the purported “filth” of San Francisco’s Chinatown) as a source of infection was a common explanation for cellulitis and fasciitis during the American Civil War.[14] Miasmas preceded the germ theory of disease and were relegated to the dust bin of medicine shortly thereafter. In short, miasmas were never scientifically accurate and, thus, a pre-scientific myth.
Another disease-as-weapon in his war against immigration was syphilis. It was a poison “deeply engrafted” in the Chinese American community.[15] This banner was also unfurled by Dr. Hugh H. Toland who estimated—without any evidence—that 90% of syphilis should be attributed to the Chinese-American community.[16] Adding to that anecdote, the Chinese-American variety of syphilis was supposedly harder to treat. In an era void of any efficacious treatments for syphilis, this was a ridiculous claim. With the cultural stigma of syphilis, the disease effectively became a metaphor for the moral turpitude of persecuted immigrants. It would not have been deemed so without doctrinaire medical pressure exerted by physicians.
Leprosy also entered the fray. A San Francisco Health Officer, Dr. Bates, called Chinese immigrant persons “moral lepers in our community” equating Hansen’s disease with questionable sexual mores in the afflicted demographic.[17] Leprosy is not a sexually transmitted disease. In the 1870s, another physician, Dr. John L. Meares, made his “rounds” in Chinatown carrying a Bible.[18] He would open it to Leviticus chapters 13 and 14, and claim Moses as his diagnostic authority. He would then proceed to use the Biblical description of skin lesions to “diagnose” leprosy among the immigrants. Other inventive physicians like Dr. Charles C. O’Donnell determined that leprosy in Chinese immigrant persons was a consequence of pork in their diet. O’Donnell was viewed as a charlatan with a sketchy past. He was an abortionist who purportedly killed a young woman during an abortion. He escaped prosecution by falsifying records claiming she died from a “malignant fever.”[19] Needless to say, scientific inquiry after discovery of the germ theory of disease has failed to implicate pork ingestion as a vector for leprosy.
Dr. Samuel Collins supposedly observed that opium addiction had the ability to turn Caucasian women Chinese.[20] Goodwin and Chemerinsky quote from Collins: “‘when “Mrs. Jones,’ a . . . white woman, became an ‘opium eater’ her skin became yellow and her eyes assumed an ‘unearthly’ aspect.’”[21] His audience would automatically also equate “yellow” with Chinese-as-inferior, and not with jaundice. The supposed spreading of that ostensible “contagion” occurred by the intermixing of the “superior” Caucasian with “inferior” Chinese. Dr. Stout was a disciple of Johann F. Blumenbach. In 1795, the German arbitrarily separated humanity into 5 classes via a “scientific racial system.”[22] There would be the most superior, of course, the Caucasian white. Blumenbach claimed Caucasians originated near the landing of Noah’s Ark. Therefore, they were the archetype of God’s original creation.[23] Race category number two was Mongolian and olive “yellow.” Three was Ethiopian black. Four and five were represented by Malay, as tawny brown, and American “Indian,” as copper red, respectively. In concert with Blumenbach, Dr. Stout would go on to argue,
Among the causes which continue to exhaust and degrade a race, the intermixture of blood with inferior races is the most potent and the most deplorable. The primary law of nature teaches self preservation in protecting the purity of type in the race and perpetuating the endurance of the nation.[24]
Americans were given warnings about immigrants, warnings filtered through a prism of nascent eugenics. Stout, for instance, argued, “by commingling with the Eastern Asiatics . . . we are creating degenerate hybrids.”[25]
In 1882, a Chinese Exclusion Act was passed.[26] It was a Federal Law signed by then President Chester A. Arthur prohibiting any and all immigration of Chinese laborers. A prior law—the 1875 Page Act—already specifically banned all immigrant Chinese women. The Exclusion Act is infamous and remains the only law in U.S. history that prevented all members of a specific ethnic or national group from immigration into the United States. Physicians, through the pressure of illness metaphors, provided a justification for the Acts. Illness metaphors, naive science, and early adumbrations of eugenic theory became weapons of choice. The twentieth century would add questionable care by physicians to an already unfortunate and unethical mix.
In 1897 . . . supervising Surgeon General of the U.S Marine Hospital Service, Walter S. Wyman, designated trachoma a ‘dangerous, contagious disease’ that was ‘seldom seen except among recent immigrants from the Eastern end of the Mediterranean, Polish and Russian Jews, Armenians and others from that locality.’[27]
Throughout the mid- to late-nineteenth century, Asian immigration policy, especially directed at Chinese individuals, was more exclusionary than policy for prospective European immigrants. There were no European equivalents of the Page Law or Chinese Exclusion Act. However, World War I would change attitudes towards European immigrants for the worse as well. During the second decade of the twentieth century, America’s previously liberal immigration policies towards Non-Asians also came to a halt. U.S. entry into WWI led to the Espionage Act of 1917 and the Sedition Act of 1918. These acts led to repressive federal laws regarding European immigration. In addition, the 1920s were characterized by a “frenzied nativism leading to heightened anti-Semitism.”[28] Despite the formation of the Nuremberg Laws in the late 1930s, America was still described as stridently anti-Jewish, anti-refugee, and anti-foreign. An example of one of America’s many “anti-” sentiments occurred in 1939 involving Jewish refugees aboard the S.S. St. Louis. The ship left from Germany bound for Havana, Cuba with 907 Jewish passengers. They grasped Hitler’s goals. After approving landing permits for the passengers prior to travel, Cuban authorities invalidated them. Nonetheless, the ship departed with its passengers hoping for a change of heart upon arrival in Cuba. On May 27, the S.S. St. Louis docked in Havana, but passengers were denied permission to disembark. Despite the fact that Cuba had been already agreed upon as only a temporary destination prior to previously approved immigration to the United States—from three months to three years after arrival in Cuba—the U.S. government, under the aegis of Franklin D. Roosevelt, refused to accept them. The ship returned to Europe, and some passengers met their demise at the hands of the Nazis.[29]
At the same time, European Jewish immigration also exposed physician-supported antisemitism. A new disease would become an illness metaphor. That disease was trachoma, involving the eyes with the potential to cause blindness. The ostensible threat of trachoma in Jewish immigrants would be treated as sui generis. From 1897 through 1925, the annual average number of trachoma cases in immigrants entering the U.S. totaled 1,500 or less, consistent with 1% of subjects.[30] For Americans, however, the perceived threat of trachoma greatly eclipsed its overall prevalence. In American schools, outbreaks were immediately blamed on immigrants without a shred of proof. Americans viewed any immigrant person with trachoma as a problem. Since antisemitism was rearing its ugly head, one group eventually affected by a disease-animated prejudice was Eastern European Jews. There were no similar public health efforts aimed at any other group in America with trachoma. As the introductory quote to this section implies, trachoma was framed as a disease carried nearly exclusively by Eastern European Jews. Similar to immigration disease metaphors before and after, the claim was prejudicial. In the words of physician and historian Howard Markel, “trachoma briefly came to represent the embodiment of germs that travelled.”[31] The cultural stigma of the disease would be catalyzed by physicians.
Despite the fact that physicians of this era knew very little about trachoma, they used its presence in Eastern European Jews punitively. Public Health Service physicians decided all cases of trachoma were contagious, and as a result, 9 out of 10 immigrant individuals diagnosed with the disease were returned to their homes.[32] Physicians completely ignored the fact that indigenous American populations—poor Appalachian whites and Native Americans—already were a reservoir for the disease (65–95% of their demographic were infected).[33] In 1897, Dr. Walter S. Wyman described trachoma as a “dangerous, contagious disease” and then inaccurately said it was seldom found except in a limited number of immigrant races, primarily “Polish and Russian Jews.”[34] Jumping on the trachoma bandwagon, Dr. Taliaferro Clark accused “undesirable” Russian and Polish Jews of therefore threatening our shores.[35] Clark advanced from these untruths to planning the infamous “Tuskegee Study.”[36] Dr. Victor Safford correlated trachoma in immigrants to their “unacceptable quality,” further describing them, ad hominem, as “miserable and filthy as can be collected from Eastern Europe.”[37] At the same time in Germany, ophthalmologist Julius Boldt suggested the disease was uniquely Jewish. His National Socialist opinion was enthusiastically adopted by misdirected but vocal American medical colleagues.[38]
Human beings were being characterized as miserable and filthy by physicians ostensibly as a consequence of an eye disease. A disease and its metaphors were a less than subtle mask for antisemitism. The perception affected their quality of care. In this afflicted demographic, the egregiously unsterile physician technique utilized was even noticed by laypersons. President Theodore Roosevelt was stunned by physician examination technique for immigrants potentially infected with trachoma. He wrote:
I would like a report from Ellis Island as to some scheme for improving the examination of the eyes of immigrants to discover whether they had trachoma. When I was at Ellis Island myself I was struck by the way in which the doctors made the examinations with dirty hands and with no pretense to clean their instruments, so that it would seem to me that these examinations as conducted would themselves be a fruitful source of carrying infection from diseased to healthy people.[39]
In the specific case of one immigrant, Rabbi Chaim Goldenbaum, an Eastern European, after eversion of his eyelids for initial evaluation at Ellis Island, a diagnosis of trachoma was made. The physician used blue chalk to inscribe a “T” for trachoma on his overcoat just as the Star of David would become the anti-Semitic identifier of choice in Germany.[40]
Rabbi Goldenblum’s care after the diagnosis of trachoma has been described as “brutal” by today’s standard of care, even if as one recognizes that at that “point in history . . . there was still no definitive medications capable of vanquishing the infection.”[41] He underwent a procedure called “follicular expression” whereby his eyelids were everted and painted with a solution of cocaine as an anesthetic. His trachoma granules were then ruptured with forceps in an effort to squeeze out the contents. Hemorrhage was frequently the result. Scarification by way of tiny superficial incisions was done after the expressions. He was repeatedly treated once per week in this manner. He also endured the so-called “blue stone” therapy whereby copper sulfate was rubbed onto his eyelids followed by “grattage,” that is, the vigorous rubbing of the inner eyelids with a steel toothbrush-shaped instrument dipped in corrosive chemicals.[42]
One might be suspicious that blue stone therapy may have utilized instruments that were not sterilized between patient uses. Commentators noted a sharp decline in the quality of care for those who immigrated to America in third- or fourth-class accommodations versus better class travel.[43] In the novel, Off for America, Sholom Aleichem describes such practices through the words of a Jewish immigrant lamenting his daughter’s treatment for trachoma after he heard her saying, “‘The doctor . . . rubs my eyes with the same blue-stone he uses on the other patients.’”[44] Consistent with Machiavelli’s introductory quote, as well as the premise that unethical physician behavior in the context of immigration has been redundant throughout American history, the trachoma “template” became imbedded in America’s medical culture in the early to mid-twentieth century. A cycle of redundant medical behavior would not be far behind.
Contemporary medical discourse in the context of immigration has copied the template provided by previous generations of physicians, utilizing both “old” and “new” illness metaphors. Two favorite diseases today in this regard are leprosy (old) and Ebola (new).
Cassandra White observed, “leprosy is popularly imagined to be a disease of the past, to be highly contagious, and to cause flesh to rot and limbs to fall off. Leprosy can be a powerful metaphor, carrying with it all the ills assumed to be caused by foreign populations entering the U.S.”[45] The lay press has picked up on the supposed resurgence of leprosy today, as one recent news article intimates in its title “Leprosy, a Synonym for Stigma, Returns.”[46] Dr. William Levis of the U.S Public Health Service has furnished some dubious statistics regarding the contemporary state of leprosy in the United States. Despite the fact that the number of new cases annually peaked at 456 in 1983 and since 1988 has remained stable, journalist Sharon Lerner in a 1999 piece that frequently quoted Levis has said “leprosy is emerging—burgeoning, even—as a modern problem.”[47] Four years later, she proceeded to say that more than 7,000 people have leprosy although the inflated number includes a majority of people who have successfully completed therapy and are no longer infectious. Her next step was predictable. The people afflicted in the U.S. “are immigrants from global leprosy hot spots.”[48] She then includes a statement from an interview with Levis, “the disease is now officially endemic to the Northeastern United States for the first time ever.”[49] Whitford, in using Lerner’s statistics, did not recognize that the year 2000 had the fewest number of leprosy cases in the U.S. since 1962![50] Also, Denis Daumerie of the World Health Organization countered Levis’ statistics and pronounced that there is absolutely no risk posed by immigrants coming to the U.S.[51]
Levis’ banner has been carried by other physicians. Dr. Jennifer Bingham said that “without cooperation, leprosy, which has no vaccine, and is transmitted through the air, will spread, and could become an epidemic.”[52] From an epidemiological perspective, this statement is absurd. Although person to person spread of leprosy may occur by respiratory droplets as Bingham contends, the CDC observes, “Prolonged, close contact with someone with untreated leprosy over many months is needed to catch the disease.[53] The number of new cases in the U.S. per year is approximately 100. In comparison, there are more than 200,000 new cases worldwide. Furthermore, most U.S. cases occur in American citizens who travel to endemic sites, rather than vice versa.[54]
In a similar vein of “nothing new under the sun,” Ebola evokes a disproportionate scare just as trachoma did generations ago—again a medical specter targeting immigrants. There have been only 2 cases of Ebola transmission inside the U.S. and both patients survived. However, in a November 2014 poll, the U.S. public ranked Ebola as the third most urgent health problem facing the country—higher than cancer or heart disease! Cancer and heart disease together are responsible for nearly half of all deaths in the U.S. per year. The repercussions of this unfounded and irrational fear are palpable. Robin Wright noted that it has increased racial profiling and resuscitated the metaphor of the “dark continent” so that children of African descent have been mocked as “Ebola kids.”[55]
In a reprise of the shoddy treatment rendered trachoma victims, Thomas Eric Duncan—a black immigrant person who acquired Ebola on a return trip to Africa and not in the United States—is a stark example. His medical records reveal that he presented to an emergency room in Texas with a temperature of 103 degrees. He reported severe pain, grading it on a level of 8/10. Despite the fact that he was unstable and undiagnosed with a severe life-threatening illness—and furthermore, that he made it clear that he had been in Liberia one week prior—he was discharged and told to take Tylenol and antibiotics. He died at home without medical care. Duncan, as a black African immigrant, received substandard care, and some argue the scenario would not have occurred had he been a Caucasian resident of the U.S. It has been said in response that “claims to protect the [U.S.] public’s health frequently have served as proxies for bias, discrimination, and nativism.”[56] Could the quality of Mr. Duncan’s care have been in any way affected by either his race or country of origin? It may have been under the influence of implicit bias.
The principle of implicit bias—and its contributions to healthcare quality disparities—has received substantive recent attention. Implicit bias is comprised of thoughts and feelings outside of conscious control that can favor healthcare interventions for white versus non-white patients.[57] Cardiovascular care and coronary interventions may serve as an example.[58] Black patients at risk for cardiac arrest are less likely to receive automatic defibrillator placement that their white counterparts. This study was performed in Medicare recipients making reimbursement issues less likely to explain the disparate results observed in blacks versus whites. The same racial disparity has been identified in the utilization of cardiac resynchronization therapy, coronary reperfusion therapies, and the emergency department care of chest pain.
Therefore, one may inquire if the care rendered Mr. Duncan was merely an isolated event, or possibly a reflection of either his race or immigration from Africa. Was his care symptomatic of a ubiquitous bias in the contemporary medical care for immigrant persons identifiable by their darker skin?
At the outset of this discussion, Christian Hippocratism was mentioned in regard to American medicine’s ethical behavior towards immigrant persons, and contingently on detainees, without elaboration. On a fundamental level, what is Christian Hippocratism and exactly what role should it play in today’s immigration crisis?
Hippocratism and its Oath themselves were a revolutionary change in the praxis of medicine. As Margaret Mead opined,
For the first time in our tradition there was a complete separation between killing and curing [the Oath’s declaration on the separation between “witch doctor-shaman” and physician]. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure. . . . One profession . . . [was] to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect—the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child.[59]
No longer would the doctor also be shaman and therefore choose whether to heal or kill. And critical to the ethical question of physicians and immigrant humanity, the doctor would also protect and treat the marginalized, including the “foreign man,” woman, or child. The Hippocratic contribution to Western culture found a congruence with “the least of these” heralded by the earliest Christian tradition in medicine. That is why Hippocratism became Christian Hippocratism. The sanctity of each and every human life demanded and expected no less from Christian physicians.
In some degree, the legacy of Hippocratism can still be discerned in secular Western medicine. The American Medical Association’s Code of Ethics states, “A physician shall support access to medical care for all people” and “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”[60] Despite these statements however, there have been some recent disturbing data regarding care for immigrant people as well as undocumented and detainee humanity.
Undocumented immigrants in the U.S. experience lower-quality healthcare throughout their lives—from beginning to the end.[61] Complicating this spectrum is a higher incidence of asthma, diabetes, HIV, obesity, and tuberculosis.[62] Despite contributing $3 billion to Medicare, undocumented persons with end stage renal disease may be relegated to “emergency-only” dialysis, and as a consequence incur higher morbidity and mortality.[63] Although undocumented persons and immigrants donate organs for transplantation, as a group they receive fewer transplants in return.[64] Furthermore, the situation is worsening, and in doing so, should be raising more red flags for Christian-Hippocratic physicians. Two examples attest to the seriousness of the contemporary ethical situation in this regard.
A recent whistleblower alleged a potential serious medical-ethical breech in the context of detainee women.[65] The allegation was that these women were undergoing an excess of hysterectomies. Rather than an incidental aberration, might such behavior reflect an incipient genocide? After WWII, efforts directed at a group’s reproduction—through sterilization or abortion—were proscribed and identified as genocide.
California’s Proposition 187 has also raised critical ethical issues in a Christian Hippocratic context.[66] The proposition mandates that health facilities and physicians deny nonemergency medical treatment to undocumented individuals. The authors of an editorial, writing in a non-religious context, observed that such a proposition conflicts with the Hippocratic imperative to provide care for anyone who is ill and therefore calls for compassion. The proposition also mandates that physicians breech confidentiality requirements of Christian Hippocratism and report undocumented persons seeking medical care. The deaths of at least two undocumented persons have been attributed to delays in seeking medical care because of fears of deportation. The editorial authors, again in a non-religious context, accuse Proposition 187 of eroding medical professionalism. We find it hard to disagree.
Doctors Pellegrino and Thomasma have reminded our profession “no order can be carried out, no policy observed, and no regulation imposed without the physician’s assent . . . the physician is therefore de facto a moral accomplice in whatever is done for good or ill to patients.”[67] The AMA Code of Ethics reminds us as well, “A Physician shall . . . recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”[68] There is a clarion call to Christian physicians regarding our practice in this contentious arena. Each of us needs to address our own implicit bias. We have to confront and remediate the higher morbidity-mortality of immigrants. Proposition 187 is anathema to the practice of humane medicine. If an allegation of increased hysterectomies in detainees is true, they portend a heinous evil from the twentieth century. It is our shared Hippocratic calling to change unjust practice and law.
Historically, as well as in our present times, the Christian-Hippocratic healthcare community has explicitly engaged the unethical practices of abortion and euthanasia. There is another anti-Hippocratic elephant in our room—attitudes and care for undocumented humanity. The forces arrayed against us have waged a centuries-long battle utilizing some of history’s most inhumane weapons such as prejudice, genocide, and eugenics. Our voices have been muted for far too long. We as Christian-Hippocratic physicians must remain moral accomplices solely for the good of humanity, addressing every facet of Hippocratism for every person who comprises the “Least of These.”
[1] Niccolò Machiavelli, The Prince (New York: Race Point Publishing, 2017), 222.
[2] Mark G. Kuczewski, “How Medicine May Save the Life of U.S. Immigration Policy: From Clinical and Educational Encounters to Ethical Public Policy,” AMA Journal of Ethics 19, no. 3 (2017): 221, https://www.doi.org/10.1001/journalofethics.2017.19.3.peer1-1703.
[3] Markel H. Stern, “The Foreignness of Germs: The Persistent Association of Immigrants and Disease in American Society,” The Milbank Quarterly 80, no. 4 (2002): 757.
[4] Susan Sontag, Illness as Metaphor (New York: Picador, 1977).
[5] Kimberly Aparicio, “Asking for Care, Not Favors: Experience of Immigrants in the U.S. Medical System,” Virtual Mentor 10, no. 4 (2008):242–244, https://www.doi.org/10.1001/virtualmentor.2008.10.4.mnar1-0804; Sónia Dias, Ana Gama, Helena Calgaleiro, and Maria O. Martins, “Health Workers’ Attitudes toward Immigrant Patients: A Cross-Sectional Survey in Primary Health Care Services,” Human Resources for Health 10, no. 14 (2012): https://doi.org/10.1186/1478-4491-10-14.
[6] Quoted in Christine Barbour and Gerald C. Wright, Keeping the Republic: Power and Citizenship in American Politics, 8th ed. (Thousand Oaks, CA: SAGE, 2020), ebook ed (emphasis added).
[7] Correspondence from Benjamin Franklin to Peter Collinson, 9 May 1753, Founders Online, National Archives, https://founders.archives.gov/documents/Franklin/01-04-02-0173.
[8] Diana L. Ahmad, “Opium Smoking, Anti-Chinese Attitudes, and the American Medical Community, 1850–1890,” American Nineteenth Century History 1, no. 2 (2000):53–54, https://doi.org/10.1080/14664650008567016.
[9] Guenter B. Risse, “Grotesque Appearances: ‘The Chinese Must Go!’ Perceptions of Race and Revulsion in San Francisco’s Chinatown, 1849–1908,” (unpublished lecture, January 6, 2017), https://www.researchgate.net/publication/312121818_Grotesque_Appearances_'The_Chinese_Must_Go'_Perception_of_Race_and_Revulsion_in_San_Francisco's_Chinatown_1849-1908.
[10] Risse, “Grotesque Appearances”; and Yong Chen, Chinese San Francisco, 1850–1943: A Trans-Pacific Community (San Francisco: Stanford University Press, 2000), 7, 9, 15, 86.
[11] Arthur B. Stout, Chinese Immigration and the Physiological Causes of the Decay of a Nation (Agnew & Deffenbach, 1862), https://collections.nlm.nih.gov/catalog/nlm:nlmuid-8412061-bk. His prejudice was not limited to Chinese immigrants. Indeed, he once opined, “If the world mourns the presence of a negro race in the Eastern and Southern States, what tear may be shed when . . . the great West is overwhelmed.” Arthur B. Stout, quoted in Chen, Chinese San Francisco, 1850–1943, 86.
[12] Arthur B. Stout, quoted in Ahmad, “Opium Smoking, Anti-Chinese Attitudes, and the American Medical Community,” 61.
[13] Risse, “Grotesque Appearances.”
[14] David E. McMahon and Gregory W. Rutecki, “In Anticipation of the Germ Theory of Disease: Middleton Goldsmith and the History of Bromine,” The Pharos (Spring 2011): 9, http://alphaomegaalpha.org/pharos/PDFs/2011/2/McMahon-Rutecki.pdf.
[15] Chen, Chinese San Francisco, 1850–1943, 86.
[16] Chen, Chinese San Francisco, 1850–1943, 86.
[17] Risse, “Grotesque Appearances.”
[18] Risse, “Grotesque Appearances.”
[19] Risse, “Grotesque Appearances.”
[20] Michele Goodwin and Erwin Chemerinsky, “No Immunity: Race, Class, and Civil Liberties in Times of Health Crisis,” Harvard Law Review 129, no. 4 (2016): https://harvardlawreview.org/2016/02/no-immunity-race-class-and-civil-liberties-in-times-of-health-crisis/.
[21] Goodwin and Chemerinsky, “No Immunity,” 978.
[22] Risse, “Grotesque Appearances.”
[23] Risse, “Grotesque Appearances.”
[24] Arthur B. Stout, quoted in Risse, “Grotesque Appearances.”
[25] Arthur B. Stout, quoted in Goodwin and Chemerinsky, “No Immunity,” 972.
[26] Chen, Chinese San Francisco, 1850–1943, 333, 382.
[27] Howard Markel, “The Eyes Have It”: Trachoma, the Perception of Disease, the United States Public Health Service, and the American Jewish Immigration Experience, 1897-1924,” Bulletin of the History of Medicine 74, no. 2 (2000): 533, https://www.doi.org/10.1353/bhm.2000.0137 (emphasis added).
[28] Diana L. Linden, “Ben Shahn, the Four Freedoms, and the S.S. St. Louis,” American Jewish History 86, no. 4 (1998): 422.
[29] Linden, “Ben Shahn, the Four Freedoms, and the SS St. Louis,” 430–431.
[30] Markel, “‘The Eyes Have It,’” 526.
[31] Markel, “‘The Eyes Have It,’” 528.
[32] Markel, “‘The Eyes Have It,’” 531.
[33] Markel, “‘The Eyes Have It,’” 532.
[34] Markel, “‘The Eyes Have It,’” 533.
[35] Markel, “‘The Eyes Have It,’” 534.
[36] James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment (New York: Free Press, 1993), 54.
[37] Markel, “‘The Eyes Have It,’” 536.
[38] Markel, “‘The Eyes Have It,’” 539.
[39] Elting Elmore Morison, ed., Letters of Theodore Roosevelt, vol. 5 (Cambridge, MA: Harvard University Press, 1952), 162–163, cited in Markel, “‘The Eyes Have It,’” 550.
[40] Markel, “‘The Eyes Have It,’” 551.
[41] Markel, “‘The Eyes Have It,’” 554.
[42] Markel, “‘The Eyes Have It,’” 555.
[43] Alison Bateman-House and Amy Fairchild, “Medical Examination of Immigrants at Ellis Island,” AMA Journal of Ethics 10, no. 4 (2008): 236, https://www.doi.org/10.1001/virtualmentor.2008.10.4.mhst1-0804.
[44] Quoted in Markel, “‘The Eyes Have It,’” 553.
[45] Cassandra White, “Déjà Vu: Leprosy and Immigration Discourse in the Twenty-First Century United States,” Leprosy Review 81, no. 1 (2010): 17, https://www.lepra.org.uk/platforms/lepra/files/lr/Mar10/Lep17-26.pdf (emphasis added).
[46] Sharon Lerner, “Leprosy, a Synonym for Stigma, Returns,” New York Times, February 18, 2003, https://www.nytimes.com/2003/02/18/health/leprosy-a-synonym-for-a-stigma-returns.html.
[47] White, “Déjà Vu,” 19.
[48] White, “Déjà Vu,” 19, quoting Lerner, “Leprosy, a Synonym for Stigma Returns.”
[49] White, “Déjà Vu,” 19, quoting Lerner, “Leprosy, a Synonym for Stigma Returns.”
[50] White, “Déjà Vu,” 20.
[51] White, “Déjà Vu,” 20.
[52] Quoted in White, “Déjà Vu,” 22.
[53] CDC, “Hansen’s Disease (Leprosy),” CDC.gov, February 10, 2017, https://www.cdc.gov/leprosy/transmission/index.html.
[54] Steven Reinberg, “Leprosy Still Occurs in U.S. CDC Reports: Experts Estimate about 100 Cases a Year Occur in Ameridca,” Healthday, October 30, 2014, https://consumer.healthday.com/diseases-and-conditions-information-37/misc-diseases-and-conditions-news-203/leprosy-still-occurs-in-u-s-cdc-reports-693260.html.
[55] Robin Wright, “The Implicit Racism in Ebola Tragedy,” CNN, October 9, 2014, https://www.cnn.com/2014/10/09/opinion/wright-ebola-racism/index.html.
[56] Gillian K. Steelfisher, Robert J. Blendon, and Narayani Lasala-Blanco, “Ebola in the United States—Public Reactions and Implications,” New England Journal of Medicine 373, no. 9 (2015): 789, https://www.doi.org/10.1056/NEJMp1506290.
[57] Chloë FitzGerald and Samia Hurst, “Implicit Bias in Healthcare Professionals: A Systematic Review,” BMC Medical Ethics 18 (2017): 1-18, https://dx.doi.org/10.1186%2Fs12910-017-0179-8.
[58] Quin Capers IV and Zarina Sharalaya, “Racial Disparities in Cardiovascular Care: A Review of Culprits and Potential Solutions,” Journal of Racial and Ethnic Health Disparities 1, no. 3 (2014): https://doi.org/10.1007/s40615-014-0021-7.
[59] Mourice Levine, Psychiatry and Ethics (New York, 1972), quoting a personal communication, in Nigel M. de S. Cameron, The New Medicine: The Revolution in Technology and Ethics (London: Hodder and Stoughton, 1991), 9.
[60] American Medical Association, “AMA Principles of Medical Ethics,” AMA-ASSN.org, June 2001, https://www.ama-assn.org/about/publications-newsletters/ama-principles-medical-ethics.
[61] Ashwini R. Sehgal, “Dialysis without Borders,” Annals of Internal Medicine 169, no. 2 (2018): 122–123, https://www.doi.org/10.7326/M18-1267.
[62] Sehgal, “Dialysis without Borders”; 122-23.
[63] Nina Roberts, “Undocumented Immigrants Quietly Pay Billions into Social Security and Receive No Benefits,” Marketplace, January 28, 2019, https://www.marketplace.org/2019/01/28/undocumented-immigrants-quietly-pay-billions-social-security-and-receive-no/; Lilia Cervantes et al., “Association of Emergency-Only vs Standard Hemodialysis with Mortality and Health Care Use among Undocumented Immigrants with End-Stage Renal Disease,” JAMA Internal Medicine 178, no. 2 (2018): 188–195, https://www.doi.org/10.1001/jamainternmed.2017.7039.
[64] Gregory W. Rutecki, “Commentary: Disparities of Immigration Status and Insurance Coverage among Solid Organ Transplant Donors and Recipients,” Dignitas 24, no. 1 (2017): 9–11, https://cbhd.org/content/commentary-disparities-immigration-status-and-insurance-coverage-among-solid-organ.
[65] Gregory Rutecki, “Reawakening Medicine’s Twentieth Century Demons?” Intersections, October 30, 2020, https://everydaybioethics.org/intersections/reawakening-medicines-demons.
[66] Tal Ann Ziv and Bernard Lo, “Denial of Care to Illegal Immigrants—Proposition 187 in California,” New England Journal of Medicine 332, no. 16 (1995): 1095–1098, https://www.doi.org/10.1056/NEJM199504203321612.
[67] Edmund Pellegrino, The Virtues in Medical Practice (New York: Oxford University Press, 1993), 44.
[68] American Medical Association, “AMA Principles of Medical Ethics.”
Gregory W. Rutecki, and Joshua Niforatos, “Nothing New Under the Sun: Immigration and Physicians Present and Past,” Dignitas 26, no. 1–2 (2019): 14–21.
