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"The visa medical examination said she was normal!"
"If hepatitis B is a contagious disease, why doesn't the US Embassy require a test for it before they give visa approval?"
"My child doesn't need any tests now that he has arrived home because he already was checked for his visa."
All of these statements show common misconceptions about one of the most poorly understood aspects of international adoption. For parents who travel, the visa examination is just the last hurdle of the obstacle course that will finally allow them to leave with their new child. For children who are escorted, parents may not be aware that a medical examination was ever a part of the visa process since no paperwork must be done for it in the US.
Why a medical examination for a visa at all? The visa exam has only two purposes: to protect the public health of the citizens of the US and to exclude mentally or morally defective persons from the US who might become public charges.In other words, the Public Health Service wants to protect the people who already live in the US from two threats: exposure to a contagious disease and the burden of supporting persons who might never become law-abiding self-supporting members of our society. If you think about these guidelines, you will realize that the concern is not for the health of the immigrant, it is for the health of the people already in the US. The US Government has no particular interest in assuring the well-being of people who are not citizens of this country. Thus, it does not undertake to determine that all persons applying for a permanent residency visa are healthy or well. It only cares that those persons are not threats to the safety and well-being of its own citizens. Thus, a visa medical examination does not assure an adoptive parent that his child is physically, emotionally or developmentally normal [but only that the child] has no infectious or contagious disease.
What does the law require in a visa medical examination? Any person applying for a permanent residency visa (students, tourists and other temporary visitors are exempt) must undergo a physical examination by a medical officer approved by the US Embassy or consulate. The examination must look for these excludable conditions: Sexually transmitted diseases including chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum and syphilis. Active leprosy. HIV infection. Active tuberculosis. Mental retardation, insanity, narcotic or alcohol addiction or sexual deviation. Serious or permanent physical defects, diseases or disabilities.In addition, persons 15 years and over must have blood tests for syphilis and HIV infection and a chest x-ray looking for signs of tuberculosis. Children under 15 are not required to have these tests unless the examining physician feels the history or physical examination indicates a possibility of exposure. Notice that many contagious diseases such as hepatitis B, chicken pox, measles, intestinal parasites and malaria are not on this list. They are missing because: the conditions are already very common in the US, they are not spread by casual physical contact or the conditions needed to spread the diseases are not found or are rare in the US. (So why is HIV on the list? For purely political reasons, of course.)
What do these regulations mean for the internationally adopted child? Most children will have a brief physical examination including a medical history (if there is any information to be obtained). If the child does not have any obvious abnormalities and there is no reason to particularly suspect one of the listed infectious diseases, no other tests or examinations will be required. The officer will fill out the medical form which is then sealed into an envelope to be delivered to the US Embassy. There, after all other documents have been approved, the medical examination is reviewed and the visa usually granted. The actual medical report goes into a sealed packet which is left with the Immigration Officer at the point of entry into the US. Thus, if the parents are not present at the visa examination, they are likely never to receive the results of that examination and may not realize that it ever took place.
What if the examining physician feels there is a problem? He may order any tests that he wishes to rule out any of the conditions on the above list. Although these are usually as simple as a syphilis blood test, he may request psychological or IQ testing if he thinks it is necessary. In some areas of the world, certain tests are done routinely, regardless of the condition of the child. Thus, you will almost always find that the officer will require syphilis testing in infants in Latin America or HIV testing in children in Haiti or Uganda. The parents can not protest the request for the test. The officer will just give an unfavorable medical report and the visa will be denied. The parents can request extra testing themselves; they are paying for the examination. Such testing may not be readily available, may not be accurate and almost certainly will delay the granting of the visa. However, in some circumstances, it is the only reasonable approach, as in HIV testing in Romania. Obvious conditions such as a missing limb, a cleft palate or a known disability such as epilepsy, thalassemia or cerebral palsy will often merely be noted on the examination report without any further evaluation as to the severity or reparability of the condition. The quality of these kinds of notes is extremely variable. In Seoul, which grants more orphan visas than any other office in the world, even simple birth marks or hernias will be listed. In other offices which see few children or which frequently process children in very poor nutritional or developmental condition, only severely disabling conditions will be noted. Thus, a parent cannot rely on the visa examination as an absolute assurance that the child does not have anything on the list of excludable conditions. The quality of the exam depends almost entirely on the experience and thoroughness of the person performing it.
What if the examining officer issues an unfavorable report, that is, he finds a condition on the excludable list? Parents can appeal almost any decision, following certain courses of action. If the child has active tuberculosis or another untreated infectious disease, the condition can be reclassified after the child has begun treatment. If the condition is a mental or physical disability, the orphan visa officer may interview the parents, if they are present, to assure himself that they realize the extent of the condition and that they are capable of caring for the child. However, for most severe disabling conditions and for HIV infection, the parents will have to undertake a "waiver process." To obtain a waiver, the embassy or consulate forwards the visa medical report and any supporting evaluations or tests to the Centers for Disease Control (CDC) in Atlanta. There, the Office of Quarantine contacts the family who must then provide:
This information is forwarded back to the CDC where a panel of physicians reviews the material and makes a determination that the child will not likely not be a threat to the health of others or become a public charge. This determination is then sent back to the embassy or consulate. Only then, the material is again reviewed and, if all appears appropriate, an orphan visa granted.The waiver process typically takes 3 to 6 months to complete; however, it can be accomplished in as short a time as a week if the medical condition is life-threatening or there is some other compelling reason to move quickly. Most waivers applied for by adoptive parents are approved, probably because the parents have already had plenty of opportunity to review the child's condition and their own financial resources.General questions about the medical visa examination can be answered by any INS office or the CDC. Specific questions about a particular child or about local requirements are best answered by the embassy or consulate where the visa will be obtained.
The best advice to keep in mind is: The visa exam is just another bureaucratic step in the immigration process. Parents should not depend on it for any medically valuable information. If there are concerns about a particular child, ask questions of the agency or lawyer or get a second medical opinion. Visa approval provides no guarantees to the health of your child.