In the United States, we continue to drive our efforts in managing the spread of infectious disease. Infection prevention and control in the hospital setting is a focus in keeping patients safe. But what about managing the influx of disease from beyond our borders? This question has prompted public debate on contemporary immigration practices.
The United States Public Health Service was formed in 1798, concerned primarily with the health of merchant seamen, eventually centrally organized under what we know as the Surgeon General. As immigration ballooned at the turn of the century, the Public Health Service began a mandatory health screening program at every port of entry. From 1892 to 1924, Ellis Island was the Nation’s busiest entry point. By 1924, more than 12 million immigrants had arrived at Ellis Island, each undergoing a health inspection before being allowed admittance into the country. Ellis Island had the nation’s largest Public Health Service hospital complex of its time, 22 buildings, designed to treat minor illnesses, quarantine and treat contagious diseases, handle maternity patients and even house those deemed mentally incompetent. This system sought to prevent the influx of pandemic and contagious disease. Most immigrants (an estimated 98%) were admitted to the U.S. following their examination, many often being treated at the Ellis Island hospital complex. A book written by Lorie Conway details the story of the Ellis Hospital complex, chronicling the experiences of the immigrant patients. Today the complex is hauntingly vacant, having suffered major damage from Hurricane Sandy and awaiting new purpose. One of the buildings is open to the public during specially scheduled tours, now home to an exhibit of historical photographs translated into art by artist, JR, which helps to bring the experience of those hospitalized at Ellis to life. (Parascandola, 1998 and N. Eng. J. Med, 2007)
How has healthcare and immigration evolved in contemporary times? Public health crises, ranging from HIV to SARS have served as a reminder that measures need to be in place to protect the American people, as well as an indication that there is a need for Americans to contribute to the understanding and treatment of these world-wide health needs. Only two years ago, the world, faced another major health crisis, Ebola. By 2015, more than 10,000 deaths from Ebola were reported. (Reuter, 2015 Mar.) The vast majority of these were from the West African nations of Guinea, Liberia and Sierra Leone. Three cases occurred in the United States, prompting new immigration and travel screening procedures. People traveling or seeking to migrate from these African Nations were required to fly into one of five U.S. International airports in Chicago, New York, New Jersey, Virginia or Atlanta. Harkening back to the public health screening at Ellis Island, medical screenings for Ebola were set up before admittance to the U.S. was allowed. This practice allowed the CDC to monitor any potential for the disease to spread in the U.S.
Zika is the most recent public health crisis, reigniting the debate about potential vulnerabilities in the immigration process. Travelers and individuals can freely enter the U.S. from known Zika-affected countries without passing through any kind of medical screening, leading to a fear that Zika will spread throughout the U.S. if gone unchecked. Zika is spread through infected mosquitoes and may be sexually transmitted or possibly through blood transfusion, with devastating impact particularly for women who are in their child reproductive years. The CDC reported that as of July 27, 2016 there have been 1,657 travel-associated cases reported, with an expanding number of cases also in the U.S. Territories. (CDC, July 27 2016) . Just this month, there have been 15 additional cases of locally-acquired cases of Zika in the greater Miami, FL area. (Visser, 2016, Aug. 2) While some experts debate the need for stricter travel and immigration regulations, particularly requiring medical screenings for Zika, others argue that controlling the mosquito population and not the immigrant population is where efforts should be focused. (Fischer, 2016). All agree that travel to areas where there is a Zika epidemic is not recommended and if travel must occur, protection is a must.
The Immigration and Nationality Act (INA) established health-related grounds for denying admission into the U.S. These include (Chishti et al, 2014):
- Those with a communicable disease of public health significance
- Those without documentation of a required set of immunizations
- Those with a physical or mental disorder associated with dangerous behavior
- Those who are drug addicts
Leprosy, plague, TB to modern-day Ebola, SARS, pandemic influenza and not too long ago HIV, have all qualified as “diseases of public health significance”. Zika is clearly a disease of public health significance, but it is not currently grounds for immigration exclusion.
In our hospitals, over the borders and across the globe, infection prevention remains a priority for public health officials and all healthcare practitioners. The spreading of Ebola to U.S. nurses who cared for Ebola patients sparked hospitals to reevaluate infection control practices in their organizations, ranging from renewed emphasis on hand hygiene, to the proper use of PPE. The infection control practices at Ellis Island were effective and innovative for their time, resulting in prevention of the spread of many highly contagious diseases. As health organizations continue to battle continuously evolving diseases, infection prevention must be a collaboration between healthcare providers and the general public who should follow guidelines for safe practices at home and abroad.
Get the Zika facts and prevention strategies here.
Parascandola, J. Doctors at the gate: PHS at Ellis Island. Public Health rep., 1998, Jan.-Feb. 113(1); 83-86.
The New England Journal of Medicine. Forgotten Ellis Island: The extraordinary Story of America’s Immigrant Hospital (Book Review). 2008, Mar. 13. 358:12-02-1203.
Chishti, M., Hipsman, F., and Pierce, S. Ebola outbreak rekindles debate on restricting admissions to the United States on health grounds. Migration Policy Institute, 2014, Oct. 23. Retrieved at http://www.migrationpolicy.org/article/ebola-outbreak-rekindles-debate-restricting-admissions-united-states-health-grounds
Death toll from West Africa’s Ebola outbreak passes 10,000: WHO. Reuter at http://www.reuters.com/article/us-health-ebola-toll-idUSKBN0M82CM20150312
Fischer, K. Zika’s immigration connection: Virus comes from places with open access to our borders. Healthzette, updated 2016, Apr. 18. Retrieved at http://www.lifezette.com/healthzette/zikas-immigration-connection
Centers for Disease Control and Prevention. Zika virus disease in the United States, 2015-2016. Updated 2016, July 27. Retrieved at http://www.cdc.gov/zika/geo/united-states.html
Visser, S. Zika in Miami: Mayor hopes spraying stops its spread. CNN, 2016, Aug. 2. Retrieved at http://www.cnn.com/2016/08/02/health/miami-florida-zika
Special thanks to John Piltzecker and Judy Giuriceo of Statue of Liberty National Monument and Ellis Island