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Immigrants to the United States in the late 1800s and early 1900s were warned by steamship companies and immigrant aid guides that they would have to pass medical exams to enter the country. Failure on the exam could result in being sent back to the old country. But surprisingly few were sent back because relatively few were sick.

Although the medical exam kept out people with communicable diseases like turberculosis and trachoma, Dr. Amy Fairchild says in "Science at the Borders: Immigrant Medical Inspection and the Shaping of the Modern Industrial Labor Force," (Johns Hopkins University Press, 2003), its larger impact was to give immigrants a fast lesson about factory work rules. The book is based on the doctoral dissertation of Dr. Fairchild, who is now an assistant professor of sociomedical sciences at the Mailman School of Public Health.

Mass processing of immigrants began around the turn of the century, when Congress realized the country quickly needed some 25 million unskilled laborers to keep the pace of commerce moving. "It didn't matter where they came from as long as they didn't disrupt the industrial order," Dr. Fairchild says.

Entry centers such as Ellis Island mimicked the factory floor system, where immigrants were put in groups to wait their turn and had to follow orders to get their medical exam, which was quick and relatively superficial. Part of the power of Ellis Island in particular was that immigrants could see before them what was happening in the processing center's great hall. The few people who were turned back were an example to the prospective immigrants.

"The immigrants, who were anxious, watched the others in front of them and stood up straight — they saw the need to be healthy," Dr. Fairchild says. "It was an indoctrinating moment."

In the 1920s, the approach to immigration changed as the government began excluding certain races and groups of people seen as undesirable. The 1924 Immigration Act started a quota system where immigration from certain countries was restricted. For example, the U.S. government allowed only small numbers of southern and eastern Europeans into the country because they were considered genetically and culturally inferior to northern and western Europeans, according to the prejudiced views of the American eugenics movement at the time. There was a push to institute literacy tests as a way to keep "inferior" European immigrants out of the country.

This theme of racial exclusion is what drew Dr. Fairchild to the topic of immigration. She could see parallels between the past and the work she did for the New York State Department of Health's AIDS Institute in the early 1990s. She analyzed data and advocated for the release of Haitian refugees detained at Guantanamo Bay, Cuba, who were denied entry to the United States in part because they had HIV. Since 1987, the United States has banned noncitizens with HIV from entering the country without a special waiver.

Dr. Fairchild has focused her research on how history can inform public health policy. Next she plans to write a book on the history of American leprosy (or Hansen's disease) hospitals in Louisiana and Hawaii, which are still open today. She was surprised to hear a National Public Radio story that said that when the U.S. Public Health Service tried to close them a few years ago, the two dozen or so people living in them protested successfully to keep them open.

"I thought people would resist living under quarantine but these people were demanding access to it," she says. "It's another case of contemporary public health policy getting me interested in the past and the lessons we can learn from history."

–Matthew Dougherty