Medical exclusion of immigrants

The current communicable diseases of public health significance include the following: Tuberculosis, Syphilis, Chancroid, Gonorrhea, Granuloma Inguinale, Lymphogranuloma Venereum, Hansen's Disease (Leprosy) and “quarantinable diseases designated by any Presidential Executive Order”.[3] International public health emergencies, as determined by the International Health Regulations (IHR) are also included.[3] An applicant with one of these diseases can still be admitted if it is under the “national interest” or if they are the “spouse, unmarried son, unmarried daughter, minor unmarried lawfully adopted child, father, or mother of a U.S. citizen, alien lawfully admitted for permanent residence, or an alien issued an immigrant visa, or is a VAWA self-petitioner”.[4] In 2009, 482 of the 993 potential LPRS that were originally denied for communicable disease were accepted.[4]

The vaccination requirement includes the following vaccinations: Mumps, Measles, Rubella, Tetanus, diphtheria, Meningococcal disease, Pneumococcal disease, Haemophilus influenzae type B, Rotavirus, Varicella, Influenza, Hepatitis A and B, Pertussis, and Polio.[3] These requirements are established by the Advisory Committee on Immunization Practices (ACIP).[3]

The examination “consists of a physical examination, an evaluation (skin test/chest x-ray examination) for tuberculosis, and blood test for syphilis”.[3] All immigrants are required to have this examination conducted by a panel physician overseas before they come to America.[3] Foreign nationals pay for their own exam but the cost is covered by the US government for refugees.[4] I-693, the Report of Medical Examination and Vaccination Record, is used to report the medical examination to officials. There is no filing fee for the I-693 form.

Medical inspections fall under the authority of Customs and Border Protection (CBP) division the Department of Homeland Security (DHS), as it is responsible for the inspection of all people who enter the country. The medical exam guidelines are created by the Center for Disease Control’s Division of Global Migration and Quarantine.[3] The Department of Health and Human Services is responsible for “promulgating” the regulations.[3]

Statutory health exclusion began with the Immigration Act of 1891, which barred “‘persons suffering from a loathsome or a dangerous contagious disease’”.[4] This required an inspection of all aliens at port of entry.[4] The law also placed responsibility on the steamship companies to “vaccinate, disinfect, and medically examine emigrants to certify their health prior to departure.”.[5] In 1893, Congressional action required emigrants to “answer a long list of questions prior to departure, their answers practically constituting a medical history of each individual."[5] Ten years later, the 1903 Immigration Act excluded the insane and epileptics.[5] Insanity was described “as a deranged condition, characterized by delusions, depression, or homicidal tendencies”.[6] In 1907, the premise of exclusion based on mental health was expanded with the addition of “imbeciles, the feebleminded, and the physically or mentally defective."[5] The defects were excludable if they were “of a nature which may affect the ability of such alien to earn a living’”.[7]

The Immigration Act of 1917 added the “classification of constitutional psychopathic inferiority” and lowered the criteria to be classified as insane to one previous attack of insanity (compared to previous two or more in 1907).[7] This also included disabilities and diseases such as: “arthritis, asthma, bunions, deafness, deformities, flat feet, heart disease, hernia, hysteria, poor eyesight, poor physical development, spinal curvature, vascular disease of the heart, and varicose veins.” [7] The early legislation created a “list of medical and psychiatric conditions that grew longer each year”.[8] This led to an increase in the percentage of rejected immigrants that were rejected based on medical criteria from two percent in 1898 to 57 percent in 1913 and finally to 69 percent in 1915.[8] The increasing regulation was tied to the rise of bacteriology, the use of eugenics to protect against “racial degeneracy,” and the expansion of the federal government’s involvement in immigration.[8] Eugenics was publicly adopted by the Surgeon General and Public Health Service “to help stem the flood of "inferior stock".[9] The inferior stock mentality was adopted in the quota system of the Immigration Act of 1924, which marked the beginning of examination of immigrants in their home countries.

In the Immigration and Nationality Act of 1952 (INA), seven of the 31 grounds for exclusion were health-related.[4] A few decades later, under the Immigration Act of 1990, the health related grounds were “streamlined and modernized all of the grounds for inadmissibility into nine broad categories”.[4] Under the act, “Congress recodified the health-related ground for inadmissibility to include any alien “who is determined (in accordance with regulations prescribed by the Secretary of Health and Human Services) to have a communicable disease of public health significance”.[4]

In 1993, the National Institutes of Health Revitalization Act added HIV as excludable.[8] This was done by a Congressional amendment that added exclusion based on “’infection with the etiological agent for acquired immune deficiency syndrome’”.[4] HIV was later removed from the exclusions in 2009 and effective by law on January 4, 2010.[3] The vaccination requirement was added with the Illegal Immigration Reform and Immigrant Responsibility Act of 1996.[4] Vaccinations were required for “nine ‘vaccine-preventable diseases’” including: “mumps, measles, rubella, polio, tetanus and diphtheria toxoids, pertussis, influenza type B and hepatitis B”.[4]