Growing up in a small, rural town in southern India, Anuradha Amara’s grandfather was the area’s only doctor — one who was practically self-taught.
He never turned people away, no matter how sick or poor. He refused cash payments, instead accepting only fruits, vegetables and grains.
Over meals prepared by these ingredients, he instilled in Amara and her cousins the important role physicians have in their community. He had dreams of them going to America, where opportunities were better. Especially for women.
Now a physician herself, Amara thinks about her grandfather’s lessons almost every day when caring for her Christiana Care Health System patients.
But these days, it’s followed by another thought.
“What if I have to go back?”
Amara is one of many physicians in Delaware and throughout the country who have made America their home — but fear they will never obtain permanent residence.
Because of current immigration quotas and a growing backlog, Indian immigrants who submit their paperwork today will likely have to wait more than 50 years to receive their green card, according to one estimate.
Under the Trump administration, physicians and immigration lawyers said the process to renew 3-year temporary visas has become more difficult. Doctors are concerned that these visas could be rejected, requiring them to return to their home country.
This comes at a time when states, including Delaware, are facing a primary care physician shortage that’s only expected to get worse. Many foreign-born physicians practice in primary care and in medically underserved areas, a requirement for some work visas.
It is why doctors throughout the country are advocating for legislation that would extend the number of visas given to foreign-born doctors, in order to entice them to continue to practice in underserved areas. The bill would also fast track their path to becoming a permanent resident.
Health officials say foreign-born doctors are essential to Delaware, where about 238,000 people live in a primary care health professional shortage area. These doctors, they say, will practice in areas others will not.
“It is crucial,” said Tom Brown, president of the Nanticoke Physician Network.
“Crucial.”
The 54-year-wait
When foreign-born doctors come to practice or train in the United States, they usually do so with two types of visas — J-1 or H-1B visas.
J-1 visas are for doctors coming to train in U.S. residency programs or receive a graduate medical education. Doctors with this visa are required to work in their home country for two years before they can apply for permanent residence.
Physicians can waive this requirement if they practice for three years in a health care professional shortage area or a medically underserved population. States can accept up to 30 J-1 visas every year.
H-1B visas are temporary work visas for people with advanced degrees, often those working in tech and health care. It requires foreigners to be sponsored by a company and needs to be renewed every three years.
Delaware does not track the number of practicing physicians with H-1B visas. Nationally, about one in six medical professionals in the United States are foreign-born, according to a 2018 study published in the Journal of the American Medical Association.
Up until 2017, it was “extraordinarily routine” for someone on an H-1B visa to get renewed, said William Stock, a Philadelphia immigration lawyer who works with Delaware hospitals.
But the Trump Administration has now said it will not defer its decision to a previous visa approval, Stock said. Meaning, people will have to show their “eligibility from scratch.”
According to the National Foundation for American Policy, denial rates for H-1B visas for continuing employment have increased from 3% in fiscal year 2015 to 18% in the first quarter of 2019.
“Physicians are definitely feeling nervous,” Stock said. “In my experience, physicians have the least to worry about, but that doesn’t mean they have nothing to worry about.”
Some, especially those from India, feel the likelihood of obtaining permanent residence is becoming more and more bleak.
Each year, the United States grants 140,000 employment-preference green cards and 226,000 family-preference green cards. The law limits the total number of green cards a single nationality can receive to 25,620 every year, or 7% of all green cards.
This means large countries like India and China receive the same number of green cards as small countries like Monaco and Barbados. And these quotas haven’t changed since they went into effect in 1991.
The thinking at the time was to create a “discrimination-free landscape,” said Shoba Sivaprasad Wadhia, an immigration lawyer and law professor at Penn State University.
It is now hindering the opportunity for those from larger countries to obtain a green card in a reasonable amount of time, she said. Immigration services are currently processing green card applications from 2009, according to its visa bulletin.
The Cato Institute, a libertarian think tank, published a report in June that found that Indian immigrants applying for a green card right now will likely have to wait 54 years for their application to be processed.
“Altogether, about 675,000 would-be legal immigrants — 14% of those waiting in 2018 — will die without seeing a green card,” the report said.
Because of this backlog, Wadhia believes the United States is at risk of losing “so much talent.”
“People are going to give up,” she said. “These are doctors who may think about going to New Zealand or Canada where things are easier. When they first came . they were not imagining they would have to wait 10,15, 20 years before they would ever have a green card.”
‘I could not take the chance’
Dr. Ashish Gupta says it matter-of-factly, almost pragmatically.
“I’m going to die before I get a green card,” explains the neonatologist, who practices at Saint Francis, Nanticoke and Nemours/A.I. duPont Hospital for Children.
He left India in 2007 on a J-1 visa, but could not submit paperwork for permanent residency until he finished his training in 2015.
Gupta said he sees the necessity of foreign doctors every day when walks the halls of a Delaware hospital. Gupta joked that, at times, he feels like he’s working in Delhi.
“We got a chance to work here and we are thankful,” he said. “We are highly dedicated, motivated. We serve the community. The problem is, we are staying in rural areas and spending our lives there waiting for permanent residency.”
Physicians often move to rural communities where there aren’t many people of color. Many are reluctant to change jobs, potentially limiting mobility, because it means applying for a new visa.
And they also can not legally open their own practice, instead they rely on hospitals or practices to sponsor them.
Dr. Anuradha Amara, a physician at Christiana Care Health System holds a picture of her grandfather who was a self-taught doctor back in her native Southern India. He encouraged all his children to become doctors and to go to America.Buy Photo
Gupta used to commute four hours every day, just so he was not separated from his wife. She was living and working in eastern Maryland at the time.
Dr. Amara, the Christiana Care hospitalist, lived apart from her husband for more than a year because the couple had a difficult time finding hospitals in the same city to sponsor them. She had a newborn child at the time.
Some physicians are forced to switch specialties in order to find hospitals to sponsor them. Gupta has seen trained cardiologists work as primary care doctors.
Those years of training have gone to waste, he said.
Dr. Srikrishna Malayala, chair of internal medicine at Bayhealth Hospital, said he went into primary care because he knew it would lead to more opportunities.
“I could not take the chance experimenting,” he said.
All three physicians also know of Delaware colleagues who are either considering moving to Canada or back to India — or have already done so. These doctors don’t want to leave the country or their patients but feel frustrated with the lack of options.
Amara wonders if the only way she will be able to get a green card is when her American children turn 21 and are eligible to sponsor her. They are currently ages 10 and 7.
If it weren’t for foreign doctors, rural hospitals like Nanticoke would not have enough job candidates to fill open positions, said Tom Brown, president of the Nanticoke Physician Network.
He believes hiring foreign doctors can help address the growing physician shortage, which could hit 122,000 physicians by 2032, according to the Association of Medical Colleges.
“They make personal sacrifices that take my breath away,” Brown said.
Delaware health
Last year, the American Medical Association wrote a letter to U.S. Citizenship and Immigration Services “imploring them to clear the backlog” for doctors with H-1B visas who are seeking to obtain permanent resident status.
The group Physicians for American health care Access, formed in 2018 by doctors across the country, is advocating for legislation that extends the number of foreign born doctors in the Conrad 30 program, which allows J-1 visa doctors to serve in the United States instead of returning to their home country.
The legislation also looks to allow physicians’ spouses to work and streamline the green card process for physicians who have spent more than five years practicing in an underserved area. The bill is currently waiting to be voted on in the U.S. Senate
Dr. Amara said she doesn’t regret coming to America — she loves this country. She and her husband live in Hockessin with their two children, in a home that has a pool and a hilly backyard perfect for sledding.
The people she has met here have been warm and opening. She feels valued by her patients.
Amara just wants the country’s immigration system to do the same.
“If we are considered essential,” she said, “how come we’re not considered essential here?”
Meredith Newman is a former reporter for Capital Gazette. Her story appeared first in The News Journal of Wilmington, Del., http://www.delawareonline.com
