Although they are not the targets of bombs, planes, or anthrax, thousands of patients with mental illness in underserved areas may suffer because of a decision in late February by the U.S. Department of Agriculture (USDA) to drop its participation in the Department of State’s Waiver of Recommendations for Foreign Physicians Program. The department’s decision arose out of growing security concerns sparked by the September 11 attacks on New York and Washington, D.C.
Patients in these areas are often treated by foreign-born physicians who, until recently, could receive a J-1 visa waiver with the USDA’s help. Doctors with a J-1 visa are required by law to return to their home country for at least two years after graduating from a U.S. residency program before applying for another form of immigrant visa.
J-category visas are not reserved expressly for doctors—the Immigration and Naturalization Service (INS) grants them to all international visitors to America participating in education and cultural exchange programs. Schoolteachers, professors, au pairs, professional trainees, and researchers are just some of the groups that come to the United States on a J-1 visa.
With the J-1 visa waiver, doctors can remain in this country if they agree to practice for at least three years in a medically underserved community.
Clinics and hospitals in these communities often have trouble attracting U.S. medical graduates because the institutions are located in what some consider to be undesirable areas—rural locations many miles from the nearest town or poverty-stricken sections of American cities. The waiver program has made it much easier for foreign physicians who did their residency training in the U.S. to practice in these underserved areas since the program began in the mid-1990s. Since 1994, in fact, the USDA has recommended about 3,000 physicians to receive J-1 visa waivers. In some small-town hospitals, these physicians are the only clinicians.
In the USDA’s role as an "interested government agency" in the J-1 visa waiver program, it provided recommendation letters on behalf of foreign doctors and their prospective employers to the Department of State, which must ensure that the applications comply with federal guidelines. The application is then sent to the INS, which grants the physician a J-1 visa waiver.
Just two weeks after the terrorist attacks, however, the USDA suspended the processing of J-1 visa waiver applications after its Office of Inspector General recommended that the agency review its participation in the waiver program. As part of this review, according to a USDA fact sheet, the USDA forwarded seven pending applications to the U.S. Department of Justice for security screening, and three of those applicants were considered to be security risks.
The fact sheet also stated that the USDA lacks authority to conduct appropriate background checks on doctors who apply for the waivers.
When the USDA announced its decision to withdraw from the waiver program, there were 86 waiver requests pending from physicians in 23 states. However, on April 16, the USDA decided to process the pending applications with the help of the Department of Justice, Department of State, and Department of Health and Human Services.
According to the USDA Press Secretary and Deputy Director of Communications Alisa Harrison, concern expressed by certain members of Congress prompted the USDA to process the pending waivers. She specifically credited Sen. Pat Roberts (R-Kan.), a longtime advocate of rural health care, and Rep. Jerry Moran (R-Kan.), cochair of the National Coalition of Rural Healthcare, a 180-member organization dedicated to rural health care needs, in the USDA’s decision to process the pending waivers.
To a lesser extent, Harrison said, letter-writing campaigns to USDA Secretary Ann Veneman by a number of health care associations, including APA, played a role in the USDA’s decision to process the pending waivers.
In an April 9 letter to Veneman, APA and seven other organizations, including the National Rural Health Association and the American Hospital Association, voiced concern over the USDA’s decision. In addition, the organizations together stated a willingness to work with the USDA and the Bush administration to ensure that the health needs of rural America are met.
Such a collaboration is not outside the realm of possibility, according to the USDA. The April 16 fact sheet stated that "the Bush administration remains committed to ensuring that, to the maximum extent possible, physicians are available to provide service to medically underserved areas" and thus had formed an interagency task force to review the J-1 visa program for foreign physicians.
In some states such as Oregon, where entire hospitals are kept afloat by physicians who have acquired J-1 visa waivers, the news of the USDA’s suspension of the program stunned the medical community.
"We were quite shaken by this news," said Satya Chandragiri, M.D., chief medical officer of Eastern Oregon Psychiatric Center in Pendleton, which serves people with psychiatric disorders in 16 rural counties. "Because of this decision, we have no way to hire another psychiatrist," he told Psychiatric News.
Chandragiri, a recipient of an APA/Bristol-Myers Squibb Fellowship in Public Psychiatry in 1998, runs a facility that houses 60 adult patients with serious and persistent mental illness in one building and 50 adult developmentally disabled patients in a separate building. These 110 patients are under the care of four physicians. Three of the physicians, including Chandragiri, are working at the facility with a J-1 visa waiver.
Occasionally, locum tenens psychiatrists rotate through the facility for four to six weeks, but this is not ideal, in Chandragiri’s view. "You cannot have a patient who is recovering from a severe mental illness change doctors four times during his or her stay. This is a big frustration I am facing," said Chandragiri.
He noted that some patients have to wait anywhere from four to six weeks to see a psychiatrist or psychiatric nurse practitioner after being discharged from the hospital. He knows of one suicidal patient who had to wait three months to receive follow-up care after he was stabilized in the hospital. "It is a nightmare," he said, "that some county mental health centers only have a psychiatrist visiting once every three months."
Efforts to ease his colleagues’ huge caseloads and provide more care to patients by recruiting new physicians to the hospital have been expensive but largely unsuccessful, he said.
Once Chandragiri became aware of the USDA’s decision to stop participating in the visa waiver program, he alerted leadership at both APA and the American Association of Community Psychiatrists of the potential crisis that could arise. He also initiated talks between his supervisors and the Oregon state government about finding another route by which physicians could obtain J-1 visa waivers.
The USDA is not the only agency through which foreign physicians can obtain a visa waiver. Some state governments sponsor foreign physicians to practice in medically underserved areas after residency through what is called the Conrad State 20 program. Under this program, about 40 state governments that participate can recommend up to 20 J-1 visa waivers per state, per year. In addition, the Appalachian Regional Commission can request a J-1 visa waiver for foreign physicians in 13 states, and the Department of Veterans Affairs can, in some cases, also make an appeal for a J-1 visa waiver on behalf of a foreign physician who wishes to practice in a Veterans Affairs hospital.
But Oregon is one of four states—the others are Oklahoma, Kansas, and South Dakota—that rely solely on the USDA to acquire visa waivers for physicians, so Chandragiri’s hopes for avoiding a psychiatric-care crisis are now pinned on his state joining the Conrad State 20 program.
Information about the USDA’s decision to withdraw from the Department of State’s Waiver of Recommendations for Foreign Physicians Program is posted on the Web at www.usda.gov/news/releases/2002/03/fsj1visa.htm. ▪