The History of the Public Charge and Public Health

Russians Ali Gegiow and Sabas Zarikoew were two among many spilling onto the ports of Ellis Island during January of 1914. Shiving in the freezing weather and weary from their long journey, the two youths were nonetheless hopeful that they could find labor in the country so many before them had spoken rapturously about. With railroad tickets to friends and family in Portland in hand, along with a tidy sum of $65—in the realm of $750 today—Gegiow and Zarikoew seemed poised to begin their lives on the Western seaboard.

Immigration officers, however, had heard rumors that work was lacking in Portland, which made them doubtful that the two immigrants would find jobs. And without jobs, the officers reasoned, the two farm workers were likely to require aid from the government. America didn’t need more unemployed people siphoning resources, so authorities excluded Gegiow and Zarikoew from further entry on the basis that they were likely to become “public charges.” It would take over one year, myriad court appeals, and a final ruling from the Supreme Court for the two men to resume their lives, this time as legal immigrants in America’s borders.

This century-old story draws remarkable parallels to the present. Throughout 2020, courts have faced arguments from immigrants, states, and cities, elicited in response to the United States Department of Homeland Security’s August 2019 proposition to expand the list of benefits used to determine “public charge” status for noncitizens.

But what are the origins of the “public charge”—a term that has incited so much debate in our country? How is the concept of the “public charge” fundamentally rooted in our nation’s public health system? This article is the first installation of a two part series that will seek to provide some answers to these questions and more.

Broadly, the notion of the public charge finds its roots in immigration and identity. Despite its frequently political context, the history of immigration entails more than simply policy decisions. Immigration, after all, has long constituted an essential part of the quintessential American identity—an identity shaped by social, cultural, and economic landscapes spanning hundreds of years of American history, some of which is explored here.

Freedom, Felons, and the First “Public Charge”: 1600s to late 1800s

In early America, immigration primarily materialized through colonization. From the early seventeenth to the late eighteenth centuries, European migrants established communities along the eastern seaboard in search of adventure, religious freedom, and potential wealth. Ideologically, these migrants were guided by a number of principles that persist today, particularly in patriotic values. The metaphor of the “melting pot,” for example, has endured as a symbol of cultural diversity in America since its conception by a French aristocrat in the late eighteenth century. Immigration has been fundamental to the complex construction of America as an eclectic nation unconditionally open to all.

Early American policy contrasted with this unrestricted presentation. These policies carved boundaries to exclude—both socially and physically—sociocultural classes understood fundamentally inadequate to embody the American identity. On the one hand, colonial institutions of slavery subjugated Africans and their kin. While slaves were physically allowed into the country, practically, they were excluded from the rights and benefits of American citizens. They didn’t align with early Western notions of humanity, let alone American identity. One official put it plainly: in 1787, New Jersey governor William Paterson stated that he could regard slaves “in no light but as property. They are no free agents, have no personal liberty, [and] no faculty of acquiring property.” 

On the other hand, state immigration policy frequently excluded foreigners outside of slavery. Felons, often shipped from Britain to conveniently remove problematic subjects, were barred from many states, with Georgia threatening “on conviction, suffer death” to those caught repeatedly trying to enter the state. The Alien and Sedition Acts of 1798 gave America’s fledgling government the power to deport immigrants on ideological grounds—in effect, permitting the removal of those who spoke too critically of the government. And importantly, many sought to deport or socially remove Black freedpersons from their lives. For southern states, free Blacks constituted a visible threat to institutions of slavery underpinning not only their economic productivity, but also their way of life. For northern states, free Blacks constituted a potential liability—some were required to “give surety not to become a public charge and for good behavior.” Here existed one of the earliest iterations of the public charge: as an individual who relied upon their town or city to take care of them, and completely lacked the capacity to be self-sufficient. Notably, this iteration of the public charge was Black, hinting at other social and cultural factors that would later be merged into the notion of the public charge.

The spirit of the public charge was also used in other restrictions. In 1820, Massachusetts began requiring shipowners to insure passengers deemed likely to become “chargeable for their support to the Commonwealth,” codified as an attempt to “prevent the introduction of paupers.” Nearly twenty years later, another statute from Maschusetts specified that any “lunatic, idiot, maimed, aged, or infirm persons” were required to pay a bond of one thousand dollars upon entry, again justified to prevent  “city, town, or state charge[s].” The message was clear: America was interested in White, able-bodied, healthy, moral, honest, and normative immigrants; others were labeled as “public charges” who did not deserve to enter the country. Some of these qualities—morality, honesty—do not seem problematically discriminatory taken at face value, but they became problematic when factors like skin color were equated to qualities of character.

Public health interventions in the colonial era were primarily invoked in times of infectious disease, when select states mandated quarantines for ill immigrants. Others like New York and Massachusetts, went even further by removing non-citizens who showed signs of common illnesses, like smallpox or typhus. But beyond quarantine, public health had little reach. Tools like medical statistics (popularized in the 1850s) and scientific discoveries like the germ theory of disease (popularized in the late nineteenth century) had not yet been developed, leaving public health with little authority to be effective. Broadly, public health as a profession was still in its early stages.

However, close examination of developing public health interventions reveal some of its lesser-known ideological ties. In the Northern colonies, public health, as well as general theories of health and medicine, was closely intermeshed with religious Puritan values. For example, in the late 1600s, preacher Cotton Mather encouraged his fellow ministers to “let us look upon sin, as the cause of sickness,” attributing the cause of disease to morally improper behavior. As immigrants—including an influx of “Irish, English, and Huguenots of the lower social orders”—moved into the Northern colonies, Mather directed his ire toward the unwelcome visitors, writing in his diary that ministers and religious societies needed to “preserve the Morals of our people, from Corruption” by the incoming “Strangers to this Town.” In the Southern colonies, most non-citizens were slaves; here, public health was “less a matter of public responsibility than of the slaveowner’s self-interest.” Although it was widely known that slaves faced widespread health issues, both chronic and acute, due to their grueling labor, few in the South were interested in helping slaves. Some abolitionists tried to leverage slavery’s “dire health impact” to advocate for social and political change, but social and geographic barriers likely prevented them from obtaining detailed information on slave health.

A Nation of Undesirables: Late 1800s to 1965

In 1870, following the Civil War and decades of civil rights movements, Congress granted African immigrants and their descendants the ability to undergo the naturalization process. The move marked a large shift in the status of African-Americans: it legally granted them the right to represent America. Congress, however, was less generous to other non-citizens. During the legislative process, they intentionally denied Chinese immigrants access to the naturalization process due to their “undesirable qualities.”

The idea that large streams of such “undesirables” were seeking to enter the country guided policy for many decades thereafter. Immigration numbers rose from just over two million in 1850 to a momentary peak of over fourteen million in 1930. This increase constituted a threat to a nativist vision of a pure American nation. 

So, attacks against Chinese immigrants continued. Willing to work as cheap labor and viewed as culturally “immutable,” Chinese immigrants were the first targets of immigration policy. Laws passed in 1882 and 1924 excluded specifically Chinese immigrants, and were the first such laws targeted toward a particular ethnic class. Chinese immigrants were, in the words of Justice Harlan in his dissenting opinion in Plessy v. Ferguson, “a race so different from our own that we do not permit those belonging to it to become citizens of the United States.”

The Immigration Act of 1882, passed several months after the Chinese Exclusion Act of 1882, was the first act to regulate immigration at a federal level. This Act permitted the government to prevent any person “unable to take care of himself or herself without becoming a public charge” from entering the country. Nine years later, a revised version of the Act permitted the exclusion of any “paupers or persons likely to become a public charge,” and allowed the deportation of any who did become a public charge within a year. Neither law specifically defined how a public charge should be identified. But practically, the loose terminology of the law allowed officials to liberally determine who could enter the country and exclude all others as likely to become a public charge.

Officials made these determinations at immigration stations dispersed among America’s borders, such as the one founded in Ellis Island in 1892. At these stations, immigrants were screened prior to being admitted into the country. Some immigrants, largely those travelling on higher-end steamships, would be permitted to pass with minimal procedure. Others would be subject to a more rigorous examination. In their inspections, medical officers combined medical science, public health directives, and racial ideology to stem the flow of immigrants into the country. Immigrants that posed any potential concern were clinically divided into three classes. Class A included individuals with “loathsome or dangerous” diseases, such as trachoma or venereal disease, as well as mental disorders. Class B individuals had conditions that subjectively made them “likely to become a public charge.” The last, Class C, entailed individuals with conditions of minor concern. Members of these classes were then shuttled into physical and medical examination rooms for further inspection. Some would leave these rooms free to explore the American frontier; others were denied entry through the border and forced to return to their home country.

Racial ideology entered these examinations as medical officers sorted their subjects into different classes. Chinese women, on the one hand, “faced constant suspicion of prostitution and thereby lowering U.S. moral standards if allowed to enter.” On the other hand, “new immigrants from Russia, Poland, and Italy were perceived as racially different from Americans and incapable of assimilation.” And in other cases, disease and level of abledness were used as proxies for immoral behavior. Poor physique, for instance, was characterized as a quality of someone who “is physically degenerate, and as such not only unlikely to become a desirable citizen, but also very likely to transmit his undesirable qualities to his offspring.”

Medical examination, however, proved insufficient to temper mass immigration in the early twentieth century. Exclusionary policies continued, most prominently in the Literacy Act of 1917. Seeking to codify and unify all prior enacted immigration statutes, the Act simultaneously expanded the scope of existing law, mandating literacy tests and barring immigrants from the Asian-Pacific Zone. Public support for this act was so strong that both houses of the Legislature overrode a presidential veto, demonstrating bipartisan support for restricting immigration. Exclusion of immigrants at ports of entry on the basis of public charge peaked during this period, reaching nearly 100,000 exclusions from 1911-1920.

But despite the success of literacy tests, exclusion of immigrants on public charge grounds decreased from the 1930s onward. This decrease reflected a change in immigration logistics rather than the number of immigrants seeking to enter the country. A national origins quota system passed in 1924 set immigration quotas to a small fraction of immigrant populations counted in the 1890 U.S. Census—a number that did not accurately reflect the true abundance of immigrants present in the United States. It also introduced a new layer of inspection: prospective immigrants had to receive a visa from consular officials in embassy offices world wide, then pass inspection by border authorities upon reaching the United States. Now, rather than being excluded on public charge grounds at ports of entry, immigrants had visas denied about consular officials.

Similar policy persisted throughout the mid-twentieth century. An act passed in 1952 lifted bans on Asian immigration, but replaced them with quotas of two thousand people from countries in the “Asiatic Barred Zone,” letting only a small trickle of Eastern immigrants into the country. The move, once again, mirrored anxieties that had been thrusted into the public sphere by war: one writer aptly describes the cold war period as an era “when life on the planet literally hung in the balance over the issue of how government and economy were related.” The country was concerned about immigrants bringing virulent communism (and other forms of governance) into the country, and public discourse reflected the same sentiments that policy presented. Early in the century, one Representative argued that “it has become necessary that the United States cease to become an asylum,” articulating popular fears that the U.S. would become overrun with sick, racially inferior immigrants.

Opening Borders and Closing Minds: 1965 to 1996

In the 1960s, such harsh policy started to become problematic for a couple of reasons. It conflicted with civil rights movements flaring across the states, movements that were dismantling racist policies and segregationist structures. Activists were raising questions about the nature of American identity for minority groups who were constantly supplanted by their native-born counterparts. Similar questions were being raised about policies that excluded foreigners from integrating into the American identity. One Representative sharply pointed out that “apparently we are willing to risk a major war for the right of the Vietnamese people to live in freedom at the same time our quota system makes it clear that we do not want very great numbers of them to live with us.”

These contradictions led America to open borders with the Hart-Celler Act in 1965. The act eliminated the national origins formula, instead regulating visa distribution with the intent of reunifying immigrant families, permitting immigrants with desired skills, and sheltering refugees. Immigration numbers gradually increased, reaching the over one million immigrants annually seen today.

Three more key pieces of historical legislation, however, shaped the landscape of modern immigration. High demand for Latino labor in the sixties did not correlate with the limitations of the Hart-Celler Act, leading to increases in undocumented immigration. In 1986, president Ronald Reagan responded by criminalizing employment of illegal immigrants while giving amnesty to those who had entered prior to 1982. 

Recent studies have now shown that Reagan’s policy was effective in curbing illegal immigration, but the American public of the 1980s proved harder to convince. One columnist documented fears that the “overflow” of immigrants would lead the United States to become a “Third Worldized country,” while another accused illegal Mexican immigrants of bringing “disease, crime, and many other problems.” Problematically, these opinions were endorsed by political leaders and the law. President Reagan called for AIDS being added as another condition on which immigrants could be denied entry or permanent resident status, reinforcing stereotypes that homosexuality was not only a mental illness, but a moral sin. Existing law reflected his sentiments. A clause added in the 1960s permitted exclusion of “sexually deviant” individuals, referring primarily to the LGBTQ+ community, and remained in the law until its repeal in 1990.

In accordance with the return of opposition to immigration, President Clinton signed two acts in 1996 that reshaped the field of immigration policy. The first, known as the Illegal Immigrant Reform and Immigrant Responsibility Act (IIRIRA) increased local, state, and federal powers to locate and deport undocumented or problematic immigrants. The second, known as the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), sought to reduce immigrant access to public benefits. Drawing on fears that America was becoming a welfare state, it banned undocument and legal immigrants from receiving certain benefits, like Supplemental Security Income (SSI) and Medicaid. And importantly, it established a more concrete relationship between public benefit usage and exclusion on public charge grounds: in the following years, the Immigration and Naturalization Service would clarify that public charge status was contingent on either (a) public benefit usage, or (b) long-term medical institutionalization (which primarily occurs due to significant disease or injury).

Despite decreased access to mainstream health care, throughout the twentieth century, immigrants were able to turn to alternative sources of health services. Some modes of health care leaned toward naturopathic and “alternative” medicine. For example, many Asian Americans frequently used herbal therapies such as 甘草—more commonly known as licorice root—to improve their energy, relieve arthritic pain, and eliminates toxins from the body. Other modes of health care mobilized immigrant community clinics and worker health centers to provide immigrant communities health services run by their peers, people who understand the unique health traditions of their cultures. The Mount Sinai Hospital in New York, for instance, was established by and for Jewish communities in the mid-nineteenth century, with the goal of providing “free medical care for indigent Jews.” And on the other side of the country, the Tiburcio Vasquez Health Center, located in southern Alameda County, has served Latino and minority populations for over forty years, beginning as a small set of trailers providing health services to migrant and minority workers with poor access to healthcare.

Foreign Bodies, Foreign Lives

This article briefly chronicles the history of the public charge. The notion of the public charge was instantiated to refer to those who literally could not support themselves without complete intervention by the locality they lived under. As centuries passed, the public charge has been pressured to adopt additional meaning. It has been colored by racial logic that purports that certain foreign races and skin colors are both visibly and invisibly sick, diseased, and demented. It has been shaded by scientific methods that seek to find microbes and pathogens and conclude that foreign bodies produce these foreign entities. More recently, the public charge has been forced to assume a calculated relationship with usage of specific public benefits, deviating from the historical usage of the term.

Characterized as “undesirables,” noncitizen populations have often led lives constrained by fear. This fear, explained UC Davis dean of Law Kevin Johnson, comes in many forms. “Part of it is a cultural and linguistic fear. A lot of noncitizens come from countries where trust in the government is not something you do. […] Filing petitions with the government and accessing the government for health is something very culturally different from anything they’re used to.” 

But others parts of this fear are rooted in more current events. “The fear in immigrant communities now is as great as it has ever been about possible removal from the country,” continued Johnson. “One of those concerns is the tightened public charge rule put into place President Trump that is now in effect. […] In terms of the coronavirus, there is a concern that accessing any kind of health serves might render an immigrant subject to deportation from the country, or result in denial of their naturalization, or lead to general trouble with the administration.” Johnson finished with a word of caution moving forward. “Advocates are concerned now that non-citizens—both documented and undocumented—will be afraid of accessing public services: going to the doctor, going to the hospital, getting tested, and the like. This is a concern that doesn’t just affect the public health of immigrants and noncitizens. It could affect the public health of all of us.”

Time and time again, we seem to conflate foreign bodies with diseased bodies, particularly in cases where they are victims of disease, rather than the cause of its spread. In order to exclude foreigners, we claim they are sick, and threaten to deport them. This sickness is impossibly yet simultaneously physical, mental, and moral; it penetrates human bodies to discursively produce the “undesirable” adjacent to, yet under the similarly impossible “ideal immigrant.” 

This production obscures the actual lives of immigrants, homogenizing immigrants who are from a multitude of geographic localities and generations. It has caused us to forget about the actual health of immigrant populations and to blame observed negative health outcomes among immigrants on immigrants themselves, rather than take responsibility for the poor support structures they live under. These problems are not easily solved, but recognition that we are committing them is always the first step.

But in order to recognize these problems, we need to look at the history underlying the health of immigrant populations. What events, policies, and decisions, historically, have contributed to the modern era of healthcare and health practice? It is, for instance, relatively well-known that redlining policies in the 1930s have had myriad detrimental effects on the health of African-American populations that persist even in the modern era. Less is known, however, about the effects of the Great Depression on Eastern Asian populations, apart from popularly-studied Chinatown communities. Even less is known historically about the health status of minorities within Asian-American populations, such as of frequently-underrepresented Southeast-Asian individuals (e.g., Malaysia, Thailand, Indonesia). 

This type of historical work does not only help inform the work of the present. It serves as a cogent acknowledgement that the history of public health has been overrepresented by mainstream biomedicine and its advocates. It sheds light [finish this thought]. And perhaps most importantly, it promises to begin correcting our historical injustices by writing inclusive history that represents a multiplicity of diverse voices.