On March 6, 1900, the body of a working man was found in a basement
in San Francisco's Chinese quarter, apparently dead of plague. The San Francisco
Board of Health took prompt action, quarantining the entire Chinatown area.
A house-to-house search, led by uniformed police officers, was made for other
victims and for various unsanitary conditions. Within hours, the Chinatown
community was alarmed and the sick and dead were hidden, while fears were
voiced that the entire quarter would be razed, as had happened in Honolulu's
Chinatown. Despite pathological confirmation of plague, the strong public
response forced the quarantine to be lifted after 3 days. Over the next 2
months, while San Franciscans debated the scientific, public health, and commercial
aspects of the discovery, more plague cases were identified. Unable to organize
an effective response, concerned about the spread of the disease to other
cities, and convinced by the notion that Asians were particularly susceptible
to plague because of their dietary reliance on rice rather than animal protein,
President McKinley ordered a quarantine of all Chinese and Japanese persons
in San Francisco. Railroads and other means of public transportation were
forbidden from carrying Asians and other members of what McKinley called "races
liable to the plague" out of the city unless they held health certificates
from the Marine Hospital Service, the predecessor of the US Public Health
Service.1 The presidential order was challenged
in federal court, which held that it was a clear violation of the equal protection
guarantees of the Fourteenth Amendment to the Constitution, and the quarantine
was overturned.2 But the combination of
scientific and medical uncertainty, commercial concerns, and the vulnerability
of marginalized groups would recur repeatedly over the succeeding century,
leading to unjust and often ineffective control of infectious outbreaks.
Even in situations of less urgency than plague, social inequities have
intruded into apparently scientific infection control measures. At the turn
of the 20th century, when communicable diseases like diphtheria and typhoid
were thought of as major public health threats, quarantine regulations were
enforced differently for the rich and for the poor. While well-to-do families
were permitted to quarantine their sick in their own homes or were entirely
shielded from the issue by private physicians who simply chose not to report
their cases to the city, the poor were more often carried off to municipal
isolation wards, while their homes were placarded with signs warning that
a case of "scarlet fever" or "measles" had occurred there.3 Similar
disparities occurred among persons traveling to the United States from Europe.
While steerage and third-class passengers were taken off the incoming ships
in the harbor and landed at quarantine stations like Ellis Island in New York
City to be examined for signs of contagion, cabin-class passengers were examined
only briefly in their cabins and then landed directly in Manhattan to continue
their journeys without further interruption.4 Public
health concerns were defined by many public health officials as issues of
race and economic status. In fact, so closely were the signs and symptoms
of infection linked to ethnicity in the minds of public health officials that
when physicians diagnosed typhus in the Devlin sisters, 2 native-born New
York school girls, the health department simply rejected the diagnosis, and
the girls were not quarantined.3 Although
some conditions of life for the poorer classes may have made them more vulnerable
to infection, in many cases the targets for quarantine were populations with
low rates of morbidity and mortality due to infectious diseases.3
Maintaining public health is a police function of the state5; the government may impose restrictions on private
rights to promote the health and welfare of the general public. At the turn
of the 20th century, the New York City Board of Health included the police
commissioner. Police officers can be used to enforce quarantine orders, as
they were in San Francisco in 1900. However, government coercion conflicts
with US traditions of antiauthoritarianism and personal liberty, requiring
careful thought if quarantine is to be considered for control of infectious
disease.6 A strategy of cooperation, though,
depends on trust in the public health system and in the authorities responsible
for it. Traditional methods of quarantine and isolation, such as those used
in San Francisco in 1900, those applied to immigrants in the early 20th century,
and those used to detain persons with tuberculosis in more recent times,7 have frequently fallen short of these standards.
Isolation strategies have often dealt differently with persons of different
social and economic status, and the burdens of infection control policies
have fallen more heavily on those least able to bear them—the poor,
immigrants, and marginalized ethnic groups.
Funding/Support: This work was supported in
part by the US Public Health Service Centers for Disease Control and Prevention
Cooperative Agreement for Academic Centers for Public Health Preparedness.
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