GREENWOOD, Miss. – A national shortage of doctors is hitting poor places the hardest, and efforts to bring in foreign physicians to fill the gap are running into a knot of restrictions from the war on terror and the immigration debate.
Doctors recruited from places such as India, the Philippines and sub-Saharan Africa to work in underserved areas like the Mississippi Delta and the lonesome West already face an arduous and expensive gauntlet of agencies, professional tests and background checks to secure work papers and permanent residency.
Those restrictions have only tightened in the years since 9-11, and now many believe the process will become more difficult after the attempted terrorist bombings in Britain that have been linked to foreign doctors.
"The consensus seems to be that if you have a first name like Mohammed, you can forget it," Dr. Sanjay Chaube, a much-needed internist in Hurricane Katrina-ravaged Bay St. Louis, Miss., and one of more than 40,000 Indian doctors in the U.S. He is working in this country under what is known as a J-1 visa waiver.
The government estimates that more than 35 million Americans live in underserved areas, and it would take 16,000 doctors to immediately fill that need, according to the American Medical Association. And the gap is expected to widen dramatically over the next several years, reaching 24,000 in 2020 by one government estimate. A 2005 study in the journal Health Affairs said it could hit an astonishing 200,000 by then, based on a rising population and an aging work force.
"And that will mostly be felt in rural America," said Sen. Kent Conrad, D-N.D. He added: "We're facing a real crisis."
America's rural and inner-city poor already are suffering the most. For example, there are 280 doctors for every 100,000 people in the U.S. But there are only 103 for every 100,000 in the 18-county area of the Mississippi Delta, according to the Mississippi State University Social Science Research Center. And the Delta has some of the nation's highest rates of infant mortality, heart disease and other serious illnesses.
Steps are slowly being taken by individual states and universities to enroll more students in medical school. But it takes years to educate a doctor. And even then, many professionals are unconvinced those steps alone will make much difference.
To help relieve the misery in the Delta, Appalachia and other parts of the country in dire need of physicians, the government lets foreign doctors into the country under J-1 visa waivers, dispensed through a variety of state and federal programs.
J-1 visa waivers allow foreign doctors to work in underserved areas for three to five years, with a shot at eventually obtaining permanent residency.
Over each of the past three years, about 1,000 practicing physicians have come to the U.S. on J-1 visa waivers. Many of them are from unstable or undeveloped countries and come here in search of better training, working conditions and pay.
Yet, since 9-11, the federal government has made it more difficult to qualify for the special visas and to obtain permanent residency. The tests are harder, the legal fees are higher, and the rules have been changed by the Department of Health and Human Services in such a way that fewer counties and clinics are designated "underserved" and thus eligible to obtain J-1 doctors.
As a result, some foreigners are choosing to leave after their commitment is up, or are not applying to come to the U.S. at all.
The number of physicians in training with J-1 visa waivers has fallen by almost half over the past decade, from 11,600 in academic year 1996-97 to fewer than 6,200 in 2004-05, according to the Government Accountability Office. And federal and state requests for J-1s for doctors dropped from 1,374 in 1995 to 1,012 in 2005.
Medical professionals and others have put much of the blame on HHS.
Before 9-11, the Department of Agriculture operated a program that brought more than 1,000 doctors a year to the United States, but it was shut down after 9-11. HHS then took charge of a new program in 2003 with tighter rules, and has approved just 61 J-1 visas since.
But the HHS said the numbers dropped because of a lack of interest among doctors.
"We just aren't getting that many applications because the pool is smaller and the tendency is to go to the states because the rules about what they can do are much broader," said Stephen R. Smith, senior adviser to the Health Resources and Services Administration's administrator at HHS.
The vast majority of J-1s are being issued instead under a 13-year-old program sponsored by Conrad. The Conrad State 30, as it is now called, authorizes 30 J-1s per state per year. But the program will expire unless reauthorized by Congress in 2008.
Some foreign doctors are giving up on the American dream.
Husband-and-wife Drs. Rohit Panchal and Vaishali Shah were heralded on a billboard in Greenwood when they arrived. As a pulmonologist with critical care training and an internist, they treat a patient population with some of the highest rates of lung cancer, diabetes and other grave illnesses.
They find the work rewarding, but when their commitment ends they are considering returning to India instead of trying to obtain permanent residency.
"It's too long and tedious a process. It's too tiring," Panchal said during a break from rounds in the Greenwood Leflore Hospital.
The federal government cannot be blamed for everything, said Dr. Sampatkumar Shivangi, an obstetrician and gynecologist in Jackson, Miss., who is president-elect of the American Association of Physicians of Indian Origin.
He once tried unsuccessfully to help a J-1 physician find a position with a rural Mississippi clinic.
"Some of the physicians in that community didn't want a physician to come and practice there because it would take away patients," Shivangi said.