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Visa Cut Threatens Rural Clinics


WATERFORD, Calif. — This little town is lucky. When Dr. K. Krishnamoorthi arrived last year, he became the first full-time doctor in a decade at its worn brick clinic. Now, walk-ins are welcome. Krishnamoorthi gamely explains every ailment from toenail fungus to heart disease in his South Indian lilt, and even telephones patients at night to check on their progress.

"What I'm happy about is just feeling good about the doctors here and not having to go to Modesto," said Carol Harrison, 53, who raises Holstein cows nearby and was recently treated for a throat infection and, yes, toenail fungus. A convenience for her, the shorter medical trips are a significant comfort to her mother-in-law, who is under Krishnamoorthi's follow-up care for heart surgery and a collapsed lung.

For many agricultural workers with no access to transportation, the proximity of a physician is a vital necessity.

The baby-faced Krishnamoorthi is part of a federal program that has addressed a critical shortage of medical care across rural America. Thanks to visa waivers sponsored by the U.S. Department of Agriculture, more than 3,000 foreign doctors have been assigned since 1994 to small towns.

But the program that brought Krishnamoorthi to this Central Valley farm town has fallen victim to the war on terrorism. Citing post-Sept. 11 security jitters, the department announced earlier this year that it would no longer sponsor the visa waivers.

The decision has caused panic among rural health advocates, who have come to depend on foreign medical graduates to hold together the country's fragile rural health system. In some areas, the foreigners make up more than 40% of all doctors. In California, the program has supplied towns with 232 doctors.

"If a federal agency is looking for a way to generate any greater vulnerability in an already under-resourced rural health system, this is a great way to do it," said Nancy Oliva, a public health consultant and board member for the Oak Valley Hospital District, which includes Waterford. "We rely on an international manpower pool."

Krishnamoorthi works in Waterford because a two-year search by the clinic's owner yielded not a single American-trained doctor. Six of the last eight doctors recruited to Waterford and the surrounding towns of Oakdale, Riverbank and Escalon have been foreign medical graduates granted special visa waivers. Among them were a pediatrician from Peru, doctors from the Philippines, one doctor from Syria and another from Iraq.

So-called J-1 visas require doctors to return to their home countries after they have completed their residencies, but thousands have received waivers allowing them to stay if they hang their shingles in underserved areas for three years. U.S. graduates tend to shun small towns because of long hours, antiquated hospital technology and a dearth of cultural activities.

But doctors from poorer, more unstable parts of the world have a different take on rural America. It is, after all, America. And the stints in the country significantly increase their chances of permanent residency here.

To Krishnamoorthi, 35, the Central Valley's hot weather and seasonal harvests are reminiscent of Mangalore, the southern coastal town of fruits and flowers where he grew up. He and his wife, Soma, who is a doctor at a sister clinic in the nearby town of Escalon, are eager to stay. Three-year-old Mahima--born in the Bronx while the Krishnamoorthis completed medical residencies at Lincoln Hospital--plays in a rambling park across the street from the family's ample Modesto home. Another baby is on the way.

"It's beneficial for everyone," said Krishnamoorthi. "I can have the American Dream. At the same time, I can serve a small community. We are thankful for life."

A Bush administration task force is reviewing the program in response to an outcry from rural health advocates. The USDA decision has set off a discussion on how to balance national security concerns with the needs of rural Americans who are typically poorer, older and sicker than the population as a whole.

"For certain rural communities, the only physician available for hundreds of miles will be a J-1 visa waiver doctor," said Alan Morgan, vice president of governmental affairs for the National Rural Health Assn., which is lobbying for the U.S. Department of Health and Human Services to take over sponsorship of the waivers or, barring that, for the USDA to reconsider. "It's had a tremendous impact."

Any federal agency can sponsor an unlimited number of the waivers, but since 1994 the USDA had taken the lead, accommodating doctors mostly from India, Pakistan, the Philippines and the Middle East.

A separate waiver program, sponsored by the states, has brought 2,000 additional doctors into underserved rural and urban areas since 1998. But, coincidentally, that program expired on June 1 and must be reauthorized by Congress. Pending bills that would extend and expand the states' program have bipartisan support and are expected to pass.

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