United States immigration exclusions and the re-emergence of infectious diseases: The politics and science of protecting the public's health

Background. HIV and tuberculosis are deadly diseases that proliferate the developing world and are entering the US through immigrants, visitors and returning US residents. This study involves four diseases from the list of communicable diseases of public health significance in Section 212(a) of the US Immigration and Nationality Act during three major reforms from 1986 to 1996. SARS and other immediate disease threats are listed separately under US quarantine law. Infectious TB is the one disease that the two lists share.; Central question. Why are four disease conditions, HIV, infectious tuberculosis, syphilis and gonorrhea, listed equally under US immigration law but enforced differently in policy?; Proposed explanations. Cost containment, Medical nature of the disease, Epidemiology, and Racial restriction.; Methodology. An historical case study examining policy, medical, and legal literature supplemented with in-depth interviews of a snowball sample of key informants.; Findings. Data on diseases in aliens in the US is scarce. Reliable data for sexually transmitted disease prevalence in countries outside the US is unavailable. Few studies exist on the effectiveness of the alien medical examination, abroad or in the US. Congressional debate/action on communicable disease restrictions centered on HIV. Congress overlooked the shift to inspections of aliens from overseas to inside US during their debates. The Helms Amendment making HIV an excludable disease affected people who couldn't vote. The Nickels Amendment of 1993 codified the HIV exclusion into immigration law to prevent President Clinton from administratively removing it.; Conclusions. None of the proposed explanations fully explain the differing enforcement of these diseases. Cost, epidemiology and medical nature of the disease partially explain the varying enforcement. The disease exclusions keep so few people out of the US that race is probably not a factor. Politics explains much of the Congress' action. Little science or data were involved. Conflicting missions to protect and to facilitate commerce hamper the attempts to regulate entry of aliens. The US alien medical screening system needs a comprehensive review to determine which elements must be reformed to address the current epidemiology of infectious diseases and realities of immigration.