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The birth of the public health system as a part of border control & surveillance

Digital scan of an act passed at the first session of the fifth congress in Philadelphia from 1797 on worn beige paper.

The primary components of the public health system in the United States emerged from a healthcare system designed to support those involved in transatlantic trade. Created shortly after the United States was founded, the first act of “public health” was the creation of The Act for the Relief of Sick and Disabled Seamen in 1798. The Marine Hospitals Fund was then established as a part of this Act to provide hospital care for merchant seamen and to address health issues relating to maritime trade, including yellow fever, scurvy and health “threats” to the newly independent United States.

With the assertion of a new federal state came the establishment of borders and systems for protecting them. As a newly-created nation, the United States, looked to build both legitimacy and wealth. Nation-to-nation trade agreements establish legitimacy for new nations and are the primary vehicle for building wealth. For the new United States, nation-to-nation agreements happened both through treaties with tribal nations on North America (also known as Turtle Island) and by establishing agreements with nations on the other side of the Atlantic. There was no difference between these trade agreements: they were all seen as part of the same practice. The Act for the Relief of Sick and Disabled Seamen was designed to protect the strength of the Atlantic border and those who served to keep it safe and open for trade.

Painting of wharf with sailboats docked, men in a horse carriage, and other people.

Transatlantic trade at this time primarily referred to the North Atlantic Slave Trade, as well as the trade of wood, wheat, flour and other goods. Each of these trades contributed to the wealth of the newly developing nation and was therefore seen as vital to protect. During this time, the British Royal Navy patrolled the Atlantic waters off the coast of the United States, looking for sailors who were loyal to the British who could be conscripted into the British Army. The U.S. was also concerned with preventing the loss of these soldiers.

The establishment of the Marine Hospitals Fund was the first federal health law passed in the US. It operated as a kind of employment healthcare system; a tax was taken out of every seamen's paycheck to support hospital operations. The Marine Hospitals Fund focused on health initiatives that would protect the "commerce and health of America," including establishing quarantine guidelines.

In 1799, Castle Island in Boston Harbor was chosen as the temporary space for the first Marine Hospital, marking the shift from a fund that provided care for seamen to a brick-and-mortar hospital. The Marine Hospitals were the first publicly-established and funded hospitals. In 1808, the first permanent Marine Hospital was established in Boston.

Labeled black and white landscape photo of two buildings separated from the foreground by a fence. In the background, the ocean and ships.

Over the following decades, Marine hospitals continued to expand. In 1836, a high percentage of the budget of the health service went towards addressing syphilis and other forms of venereal disease. When a Boston hospital director was asked to cut his budget, he reflected that he could reduce it by half if he could keep out patients with either syphilis or tuberculosis. At the time, this was a well-understood code for keeping out poor white, Black, and Indigenous communities who experienced these illnesses at high rates.

What started as a strategy of establishing hospitals along the Atlantic coast expanded in 1853 with the first Marine Hospital built in San Francisco. Many of the physicians who worked in this hospital had originally come to California with the Gold Rush but when they did not strike it rich, they turned back to their original profession.

Germ theory

Germ theory was a new and emerging framework for understanding the origin and spread of disease. As this science emerged, funding was directed to the Marine Health Service to create new structures for study and dissemination of information, resulting in the establishment of “hygiene” protocols to prevent the spread of disease. Unfortunately, this understanding of hygiene usually focused on disappearing or controlling the bodies of specific groups of people who were perceived to be the problem. The shape of hygienic treatment was part of the instigation for later eugenic policies. Poor European immigrants, Black people, Native people and Asian people–along with sex workers and others perceived to be “unfit”–were largely targeted by these public hygiene strategies, entrenching stereotypes of who was seen as “clean” and who was seen as “dirty.”

Elder man with receded grey hair and mustache in suit stands with his arm bent at one language, the other holding a microscope

In 1887, Joseph Kinyoun, head of the Marine Health Service, established the Hygienic Laboratory to study the trajectory of epidemics. This laboratory was the foundation for what eventually became the National Institutes of Health. The lab focused on identifying bacteria that caused epidemics, developing disinfectants to kill bacteria, and researching treatment strategies for the resulting diseases. As the timeline illustrates, research at this time was often code for nonconsensual experiments on Black, immigrant, and poor white bodies, and anyone else who was seen as expendable.

The second wave of social change that shaped the Marine Health Service was the growing industrial revolution in the Eastern U.S. and the agricultural expansion in the West. To meet these growing economic sectors–as well as to respond to immigrants fleeing war and economic depression–the United States opened its doors to large waves of immigrants who entered the country on both the Atlantic and the Pacific coasts. Finally, with the growth of industrialization came the growth of cities and with urbanization came the increase of environmental conditions that created epidemics.

One of the cultural impacts of the popularization of germ theory was a shift away from an understanding of environmental and social conditions that shaped diseases, towards a focus on how individuals got sick and passed along that sickness. This meant that as epidemics rose and fell, the locus of blame was placed on people’s bodies rather than the conditions they were living in. The mix of new understandings of germs as causes of disease, crowded living and working conditions, and large numbers of immigrants crossing American borders–combined with strategies of hygiene, community and border control–shaped how the Marine Health Service developed the system of care that eventually became the U.S. public health system.

Because these systems represented large and new public contracts with significant money attached, the likelihood of political corruption or the perception of corruption increased. During the Civil War, the Marine Hospital System was heavily criticized as operating for political reasons rather than for the care and support of seamen. One critic called out the misuse of funds, claiming that health dollars were disseminated to make politicians and businessmen rich. Every decision within the Marine Health Service was political or responsive to public opinion and pressure.

In 1870, after complaints about the misuse of funds, the Reorganization Act identified new ways to make Marine Hospitals fundable and accountable. The Act increased the overall tax contribution paid by seamen and developed new tax and funding strategies to cover the rest of the costs. Congress established the office of the Supervising Surgeon as the head of the Marine Hospital Service to hold the whole system accountable. The role was later renamed the Surgeon General. As a result of this Act, the Marine Hospital System was centralized and reorganized with a militarized structure, requiring entrance exams, military discipline and uniforms. Doctors were no longer called physicians but were now called medical officers. While the Marine Health Service was established to provide care and support for seamen, it had mostly been separate from the military. This new Act firmly established the Marine Health Service as a branch that operated alongside the military and that was informed by military strategy.

Color etching of exaggerated comic-like man who holds a skull in one hand and points with the other while talking to an audience.

At this point in the development of medicine in the United States, physicians and researchers were still looking to western European systems for new research and understanding. Within western European medicine, systems of racial categorization were being developed through the study of skulls (known as phrenology), body types, and more in an attempt to predict individual health responses and broader epidemics. Scientific racism grew out of early conversations about evolution as a way to declare racial difference as the basis for social problems. As a result of this, an increase in ethnic “cleansing” as a perceived form of “cultural hygiene” expanded across Europe, from the expulsion of the Roma from multi-generational communities, of Muslims from Southeast Europe, and of Jews, Catholics, Latvians and more from the Russian Republic. This campaign of ethnic cleansing as a function of racial science and the development of concepts of “racial hygiene” influenced the development of medicine in the United States.

Before 1872, the scope and practices of the health system varied from state to state in the U.S., including the establishment of quarantines and the tracking of infectious diseases. In 1872, under its new centralized system, the Marine Hospital Service began to develop a broader vision for public health. The first role of the new Surgeon General was to establish a consistent national health service. Ironically, consistency was not the hallmark of medicine during this period. In 1874, the American Medical Association stated that since racial segregation was legal, each state had the right to determine its own policies around race. This directly impacted how the Marine Health Service responded to later outbreaks in California.

After yellow fever along the Mississippi River Valley claimed over 100,000 lives, demand for a nationally regulated quarantine system arose. The Quarantine Act of 1878 was established to form a national approach to quarantine. This Act gave the Marine Hospital Service full authority over state quarantines, dictating that, “no vessel or vehicle coming from any foreign port or country where any contagious or infectious disease may exist, and no vessel or vehicle conveying and person or persons, merchandise or animals, affected with any infectious or contagious disease, shall enter any port of the United States.” The new legislation created protocols for quarantine in cases of national emergency, a National Board of Health, and monitored the implementation of state laws, which led to a climate of political uncertainty regarding public health.

1950s postcard of large 7 story beige brick building with a gated entrance. Yellow text in the left top corner says: Marine Hospital

During this time, the Marine Hospital Service began tracking morbidity rates related to illnesses such as smallpox, cholera, yellow fever, and the plague. The Marine Hospital Service was authorized by Congress to collect morbidity reports from U.S. consuls overseas, to determine how to prevent diseases from entering the United States and spreading. This recorded data was also used to monitor and surveil communities under suspicion. The surveillance particularly focused on marginalized communities - including Black, Indigenous and migrant communities - which were perceived to be dangerous carriers of disease. This led to the entrenchment of the idea that some people are dirty and “impure,” more likely to carry germs, and therefore more in need of cleansing and treatment.

In 1887, the Marine Hospital System got involved with some of the first bacteriological research to take place in the United States. As shared earlier, the understanding that illness can arise from germs (aka viruses and bacteria), was still a new medical theory. In 1887, Joseph Kinyoun, head of the Marine Health Services, established one of the first bacteriological laboratories in the Marine Health Service Hospital in New York. During the same year, the Marine Hospital Service established the Hygienic Laboratory to study epidemics in general. This laboratory was the foundation for what eventually became the National Institutes of Health Researchers, a laboratory focused on identifying bacteria that caused epidemics as well as developing disinfectants to kill bacteria and establishing research to find treatment strategies.

Black and white photo portrait: three older men sit, with white text stating their name, while three younger men stand behind them.

In 1889, the Public Health Service Commissioned Corps was established to create a mobile force of health professionals that could be directed to different regions of the country to meet health crises and threats. At this time Marine Health began to develop medical testing for new immigrants to determine their right to enter the United States. In the beginning, the Corps hired only physicians but as the years passed, it evolved to include veterinarians, dentists, medical researchers, environmental health specialists, dietitians, engineers and more. In 1892, The Marine Hospital Service was renamed the Public Health and Marine Hospital Service. The name change marked the Service's shift towards the federal coordination of public health.

Three men dressed in uniforms stand in front of lines of people, their arms extended and examining someone's eyeballs.

By the time Ellis Island opened in 1892, there was a centralized national tracking system for the surveillance of epidemics and the spread of illness, a process for establishing quarantine protocols, and a militarized approach to deploying healthcare workers to meet identified needs. These emerged alongside and were embedded with biases and beliefs about what health looked like, who was essentially “clean” or “dangerous” and “guilty” versus “innocent.” The Immigration Act of 1891 expanded the Marine Health Services’ powers by designating what made an immigrant “fit” to enter society. The government sought to keep out immigrants who could potentially become a “public charge,” defined as someone not contributing to American society or able to earn their keep. If an immigrant was defined by a health or immigration official as sick or unfit, they were sent back to their port of origin at the cost of the steamship company. In order to ensure that only the able-bodied could pass into the United States, the Federal Government required inspections of immigrants at both their port of departure and upon arrival. Steamships were required to provide certificates from medical officers to the Marine Hospital Service after inspecting the bodies of immigrants and documenting what they found.

The National Quarantine Act of 1893 outlined federal responsibility for quarantines more closely. The act created a national system for quarantine, while still permitting state-run quarantines. It established standards for medically inspecting immigrants, ships, and cargoes through the federal Marine Hospital Service. These standards often assigned responsibility for disease to certain groups of people and then looked to separate or prevent those people from entering the country.

When Ellis Island opened on the Atlantic Coast, it became the primary immigration station in the United States, accepting over 12 million immigrants by the time it closed almost sixty years later. Each immigrant was inspected at Ellis Island by a worker with the Marine Health Service and approved to enter the city, sent to a quarantine island to recover, or sent back to their port of origin. Public health officers boarded each ship to inspect all persons and cargo. This quarantine process included thorough inspection and categorization of all passengers, crew, and cargo to ensure that no infectious diseases were carried into the country, which included anything that could potentially lead to the immigrant becoming a “public charge” in need of care. While the inspection was mandatory, it was often cursory at best. Thousands of passengers walked past a small window where two doctors sat, looking at their tongues, their “color” and their overall health. The officers were supposedly trained to look for signs of typhus, smallpox, yellow fever and other diseases believed to be caused by germs. Public criticism decried many of these physicians for making determinations based on biases or political persuasion rather than actual health considerations.

A black and white photo of a crowded chip deck full of people being questioned by men in uniforms with paperwork.

From bodily inspections to cargo and food inspections, the Marine Health Service used a military-run factory approach to their inspections, working to move as many people through in the shortest amount of time. Many of the passengers arriving at Ellis Island did not speak English and the Marine Health Service did not employ interpreters. This meant that often, people who did not speak English and could not respond to orders, were deemed “unfit” on the basis of being “imbeciles.”

The Marine Health Service had the right to deem an entire ship as infected and call for the disinfection of the ship, which had to be paid for by the shipping company. While the medical officers were physicians, they were also political appointees, and many made decisions related to the importation of goods rather than the health of the passengers. Additionally, the actions of the Marine Health Service officers were directly tied to the political will around immigration. President Benjamin Harrison, elected from 1889-1993, wanted to eradicate immigration to the United States entirely. He established a series of immigration quotas related to people’s national origin and ethnicity. This quota system combined with the supposed health inspections to define the Marine Health Service's approach.

Harper's Weekly newspaper front page, including an illustration of a crowded room of people. In the background, people exit a boat in file.

The work of the Marine Health Service to track immigration and epidemics was not limited to the Atlantic coast. Anti-Chinese immigration was already prevalent on the West Coast and across the United States. Linking Asian people with disease was already prevalent in American mainstream thought and action. In 1875, the Paige Act restricted Chinese immigration and in 1882, the Chinese Exclusion Act worked to completely stop any new Chinese immigrants from entering the United States. Xenophobia was woven through U.S. policies of immigration; in 1900, when the first cases of bubonic plague were found on U.S. soil in California, a state response was primed to determine blame. Business leaders, led by the Governor of California, blamed the Chinese community for the plague, saying that Chinese immigrants brought it with them when they arrived. In addition, they protested any public health measures that the government tried to take, demanding a full quarantine, a total block off of Chinatown as the only method for addressing the potential epidemic. The irony was that, by the time the plague showed up, Chinese immigration had been restricted for 18 years.

U.S. Surgeon General Walter Wyman, responding to this political pressure, ordered all Chinese people in San Francisco to be inoculated against the plague. Three days later, he ordered all Japanese people to be inoculated as well, and declared that any Chinese or Japanese person without a health certificate would not be permitted to leave San Francisco. Even though many people were becoming sick with the plague, Wyman focused his vaccine strategy only on Chinese and Japanese people.

Health officials were charged with tracking the movements of Chinese and Japanese immigrants, recording any travel by demanding health status checks before and after arrival. All Asian immigrants were required to carry health certificates stating they had been inoculated against the bubonic plague. The City Board of Health in San Francisco decided to conduct weekly inspections of all premises occupied by Chinese and Japanese people. Reports emerged of medical examinations that were sexually and physically abusive. Eventually these reports showed up in both the Atlantic and Pacific testing sites.

As the Marine Health Service continued to act as border control workers on each coast, the overall Service continued to build its medical research capacity. In 1902, the Biologics Control Act authorized the U.S. Public Health and Marine Hospital Service's Hygienic Laboratory "to inspect firms producing vaccines, and grant licenses to those that met rigorous standards of cleanliness and product purity." In particular, the act mandated that the production and sale of vaccines, serums, antitoxins, and more must meet annual licensing requirements. This mandate was put into place after contaminated whooping cough vaccines were distributed without any scrutiny or oversight.

In 1906, funding for all Marine Hospitals shifted to a completely federally-funded system. This was the last move towards centralizing the system and moving away from differences in local control and practice. As part of that centralization, the Marine Health Service assessed gaps in health care across the United States and in 1910, rural health surveys led to the establishment of local county health boards and departments for managing rural health care.

In 1912, Marine Health Service was removed from the Public Health Service name and the agency became known only as the U.S. Public Health Service. During this period of transition, the Public Health Service was called on to address cases of bubonic plague reported in San Juan, Puerto Rico. Puerto Rico had just become an occupied territory in 1898. When bubonic plague was reported, there was not yet an established U.S.-connected healthcare system on the island. The Marine Health Service came in, established a U.S.-health system in Puerto Rico, and enforced strict hygiene protocols. A sanitation protocol went into effect; health officers entered homes and businesses to throw away what they perceived to be garbage. Those who were the poorest were strongly impacted by this, as many times, the “garbage” that health officials destroyed were personal artifacts, furniture and clothing that was all the residents had. Health status stations were sent up around neighborhoods and no one could leave or enter without being checked for signs of illness. Because Puerto Rico was a colony, the U.S. health authorities were resistant to paying for more than what would end the spread of the plague. Some of their actions, and inactions, contributed to a linking of sickness with poverty on the island, the idea that poor people were unclean and a danger to collective health. This continued to support the framework that disease is the fault of bodies-that-are-sick rather than the result of layered environmental and social contexts and conditions which impact people’s health.

The U.S. Marine Health Service established the elements of public healthcare and health surveillance: research, tracking, and testing combined with treatment. These elements were primed to build the medical research strategies used as part of building a eugenics framework for healthcare.

In 1915, tests were performed on incarcerated men at the Rankin Prison Farm in Mississippi to determine the cause of pellagra, a disease also known as “the red flame.” Dr. Joseph Goldberger, working for the US Public Health Office (formerly the US Marine Hospital Service), performed tests on twelve incarcerated men who were offered pardons in exchange for their participation. Goldberger determined that the condition of pellagra was caused by poverty and malnutrition rather than infectious disease. He hosted "filth parties" where he and guests consumed skin scrapings and excrement in capsules to prove that pellagra was not infectious. In order to prove that poverty and diet can cause a disease state, he exploited the social position of the people in his experiments and violated their autonomy. Forced medical research and forced sterilizations would become the core of eugenics practices for many years to come.

In 1944, Marine hospitals across the United States began to close. The Hill-Burton Act passed in 1946, a federal act which dedicated funding to the opening of new hospitals that would operate as nonprofit entities with a commitment to providing “charity care.” In 1981, the Marine Hospital System was abolished. The last hospitals were transferred to other organizations and their administration was handed to the Bureau of Primary Health Care within the Health Resources and Services Administration.

While some social conditions have shifted – segregated healthcare is no longer legal, although it still exists, and forced medical experimentation and sterilization are no longer widely seen as acceptable, although they also still exist – the underlying patterns that shaped and created the Marine Health Service are still here. When the Chinese government first identified COVID-19, generations-old assumptions of who is dangerous and diseased came into play. Being the first to identify a new disease does not necessarily mean being the origin of a new disease, but the same xenophobic response still shaped both the state and, in some places, the community response. Higher incidents of anti-Asian violence combined with immigration bans were among the first responses. As the COVID timeline shows – from inequities in nursing home care, to internal vaccine apartheid, to the treatment (and lack thereof) of people incarcerated in prisons and detention centers – the same ideologies of who deserves dignified care and who does not carry forward into the present.