Work visas: foreign doctors in the US have more than covid-19 to fearBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3172 (Published 17 August 2020) Cite this as: BMJ 2020;370:m3172
Covid-19 has hit the city of Florence in South Carolina hard in the past few weeks, says Karthik Karanam, a nephrologist there. At times area physicians and hospitals have been “stretched to the limit,” he told The BMJ. “I have seen a lot of death. Some of them were my personal patients, so that takes a toll.”
That’s a burden Karanam shares with many other US doctors. But he carries some extra burdens. As a physician from India practicing under a temporary work visa he fears that, if he gets seriously ill from covid-19 and can’t work, he could lose his job, his visa, and the only country his children have ever known. If the worst happened and he died of covid-19 his wife would lose her spousal visa, he says, and “the next moment, my entire family [would] be deported.”
Karanam’s worries are shared by many foreign physicians living in the United States under work and study visas. These physicians lack the protections and job flexibility given to permanent residents and citizens. While many of their concerns predate the pandemic, the crisis has made the problems more acute.
Getting into the US is harder now
Meanwhile, US government responses to the pandemic have created new anxieties and logistical hurdles for medical workers trying to get in. The Committee of Interns and Residents, a 17 000 member union of doctors in training, says that it has assisted more than 250 international physicians who were stuck in their home countries after they were supposed to start working in US hospitals in late June or early July.
Many of the delays were caused by confusion over a late June change in US immigration policy that blocked most visas for temporary workers. The State Department clarified exemptions for doctors, but delays in consulate appointments and visa processing still persisted, says Linda Alvarez of the Committee of Interns and Residents: as of late July, 53 of those doctors were still stuck abroad. More recent numbers are not yet available, but any delay is worrisome because “these doctors are coming to work in some of the hospitals that are the hardest hit [by covid-19],” she says.
International students pursuing medical degrees, including those already in the US, have faced new worries too. In early July, US Immigration and Customs Enforcement announced that international students at US colleges and universities would have to leave if they took only online classes, which some institutions are resorting to because of virus fears. After legal challenges the agency partially walked back the policy,1 saying that current students could stay but that no new students could come in.
Azan Zahir Virji, a second year student at Harvard Medical School who comes from Tanzania, says, “This has left a really sour taste in the mouths of international students who were already here and students thinking about coming to the US to study. It’s really affected how we see our futures in this country.”
New challenges for “the best and brightest”
Nearly 30% of physicians living in the US in 2016 were born in other countries, says a study published in JAMA.2 The nation has long attracted physicians from around the world: they come both to fill gaps in the physician workforce and to pursue their own dreams. “America still recruits the best and brightest,” says Thomas Ricketts, a professor of health policy, management, and social medicine at the University of North Carolina at Chapel Hill.
While most are citizens or have “green cards” that confer permanent residence, others work under temporary visas tied to their employment. The most common temporary visa program for practicing physicians is H1-B, which allows US employers to hire foreign nationals for positions unlikely to be filled by Americans. As of 2016, US employers were authorized to fill 10 500 physician jobs under the program, another study in JAMA found.3 In addition, thousands of hospital residents and fellows practice under J-1 educational exchange visas. While those visas require recipients to return to their home countries for at least two years after training, waivers that send new graduates to underserved communities allow some to stay on.
“These physicians are working in some of the neediest communities,” says Mahsa Khanbabai, an immigration lawyer in Easton, Massachusetts. Because their visas are tied to their jobs, the fears of being deported if they get covid-19 are valid, she says. But, she adds, many also are frustrated that they can’t do more to fight the virus. The problem: their visas permit them to work only for their sponsoring employer. Changing from one employer to another is a complex, often time consuming process.
Varun Malayala, a hospitalist in Delaware, a few hours’ drive from New York, says that he and several of his colleagues felt the same frustration in early April, when New York was hard hit and asking for help. “We were sitting at home, not doing much, and could have gone and helped in the hotspots,” he says.
By late April and early May outbreaks at chicken processing facilities had brought the full brunt of covid-19 to rural Delaware, and Malayala found himself working extra shifts at his hospital. Soon after that, he heard from a recruiter looking for a “covid experienced” physician in Alaska. Malayala, who is 35, single, and willing to move, was interested—but he says that, “after the whole H1-B discussion came up, it didn’t go anywhere.”
By early August Malayala had lined up a new job in Pennsylvania, not far from Delaware, and was awaiting approval of a new H1-B visa for that job. While he’s pleased to have the Pennsylvania job, he says, he wants the security of a green card—something he’s been waiting for since 2014.
A long backlog, especially for Indian physicians
Malayala is one of about 15 000 foreign born physicians caught in green card backlogs, says the advocacy group Physicians for American Health Care Access. It adds that most of them, like Malayala, are from India.
Indians are disproportionately affected because the US apportions green cards by country of origin. Indian physicians must wait alongside much larger numbers of professionals in technology, finance, and other fields. As of 2018, new Indian applicants could expect to wait nearly 50 years, according to one estimate by the Cato Institute, a libertarian think tank.4 But Khanbabai says that wait times constantly fluctuate: Indians who applied in 2009 are getting green cards now, she says.
Physicians for American Health Care Access is lobbying for federal legislation that would award unused green cards from other countries to physicians and nurses currently in the backlog. The group would like to get that provision included in a covid-19 relief package under debate in Congress right now, says Ram Sanjeev Alur, the organization’s president. Alur, an internist who works at a veterans’ hospital in Marion, Illinois, says that the legislation is a natural fit at a time when the US is calling healthcare workers heroes. “If, while we fight this pandemic, we get sick and die, our dependents have no leg to stand on,” he explains.
Karanam says that he worked extra hours in July because one of the six other kidney specialists covering his five county area was sick with covid-19. Karanam spent a recent Saturday morning trying to admit two dialysis patients with the virus to a hospital with no available beds.
“With this covid pandemic going on, there’s a lot of pressure on physicians,” he says. Losing his family’s right to stay in the US is “one thing I don’t want to constantly have on my mind when I care for these patients.”
I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
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