How foreign doctors save lives in rural America
Many rural areas in the US suffer from a shortage of doctors. Unable to attract Americans, they have turned to foreign-born physicians.
The city of Logan in West Virginia has just 1,779 citizens. The nearest large city, Charleston, is an hour away, via winding roads through the Appalachian mountains. Logan is surrounded by rural land, and is in an area which has lost half its population since the 1950s.
It's a far cry from just about anything that would attract an affluent doctor from overseas. And yet they come.
Just 232 doctors per 100,000 residents work in the state of West Virginia. One neighbouring state has more than 400.
The US Department of Health designates 51 out of 55 counties in the state as "medically under-served areas". Logan County is among them, and that is precisely why doctors from all parts of the world fill the hallways of Logan Regional Medical Center.
Path to green card
A visa waiver programme was set up in 1994 to address the shortage by offering foreign-born doctors on J-1 student visas an easy path to a permanent residency - if they agree to work in an under-served area for three years.
"I would never even have considered West Virginia when I was training back in New Jersey," says Dr Ziad Salem, who has been working in Logan for more than five years.
Born in Beirut, Dr Salem grew up in Paris and went to medical school in Los Angeles. A job in a rural area was the only chance to stay in the US, but Logan was not his only option.
Hospitals and state agencies have to compete to get the best foreign-born doctors to their part of the country.
Logan Regional recruits them through its corporate office in Tennessee, and by using professional recruiters scouring hospital residency programmes nationwide.
The specialist areas that most of the foreign-born physicians were trained in makes them an invaluable asset to hospital and community alike.
"We have a pulmonologist on a J-1 because we didn't find an American. That is life-saving treatment right there," says John Walker, CEO of Logan Regional.
Each state is allowed to fill 30 slots every year under the visa waiver programme. West Virginia was able to fill 19 of them in 2011.
"We try to speak to them and let them know that the state is beautiful and great to raise a family. It's economically safe and has a low crime rate," says Monique Witten Mahone, J-1 visa waiver co-ordinator for the Division of Rural Health and Recruitment.
It's a marketing campaign to a highly skilled and needed workforce that might have never heard about the area and feels slightly out of place.
"When I first decided to go to West Virginia there was a little bit of an anxiety," says Dr David Afram, who was born in Syria and did his residency in Washington, DC.
"I mean this is not New York, New Jersey, or Detroit. It's probably not an area that is used to foreign-born people or accents and even minorities like African-Americans or Hispanics are extremely rare in the state."
Only 1.3% of the population in West Virginia is foreign-born, one of the US's lowest levels, but a third of its doctors was born abroad, according to Census data. People have grown accustomed to hearing foreign accents in the doctor's office.
"This area... needed a gastroenterologist. [People] actually respect the fact that we are here," says Salem.
When Dr Abraham Verghese worked in rural Tennessee in the 1980s caring for Aids patients, he found that his foreign looks were a welcome sight in a small community where everyone knew each other.
"Many of my patients were very grateful that I didn't look like a hometown boy and that I had no reason to judge them," says Dr Verghese.
The physicians' visa very much depends on them staying employed at the hospital that sponsored them from the start, which in some instances has resulted in abuse.
Dr Salem and Dr Afram say they feel very appreciated at Logan Regional, but each know of colleagues in other states that did not get the same treatment.
"It was very obvious," says Dr Afram of his friends' experiences. "You are here because you have to be here, because you have nowhere to go. In terms of the hours, in terms of the respect, in terms of the call schedule - it was sort of like a slave labour."
But word-of-mouth reputation is important for Logan's hospital to satisfy the never-ending demand for more doctors.
Both doctors received their green card recently and with it the freedom to leave Logan and practise anywhere in the US.
"You see the huge need and what you would have to leave behind if you actually left here," says Dr Salem.
"I finished my waiver requirement, I even got my green card recently, and I still have signed a contract for another two years because I grew accustomed to the people and to the place. I'm still here."