FRED DE SAM LAZARO: Eutaw, Alabama, is one of the poorest places in the United States, with a per capita income of just $15,000 a year, about half the US average. Its once-reliable cash crop, cotton, is long gone.
Despite a history of civil rights struggles, blacks and whites still lead very separate lives in the old days, the area could depend on homegrown talent, but the names on the shingles at the doctors office here say a lot about how the face and name of the country doctor has changed in America.
FRED DE SAM LAZARO: Doctors Adnan Seljuki, Mohammad Siddiqve, Salahuddin Faroooui, all from Pakistan, and Lourdes Ada, from the Philippines, now form the backbone of Eutaw's medical care they came to the rescue of a town that was at one point fearful of attracting enough doctors to keep its small hospital open.
Sandrall Hullett was a doctor in Eutaw for 30 years, now she just works part-time in the local nursing home. She knows how life can be in a small town with too few physicians.
DR. SANDRALL HULLETT, Physician: I've worked periods of time when I had no one but me seeing over 50 patients a day. That's very, very hard work if you're doing that and delivering babies at the same time.
FRED DE SAM LAZARO: It's hard to attract American doctors to rural areas like Eutaw because of the poverty and isolation. But compared to the state of medicine in his home country, Adnan Seljuki finds the situation in Eutaw satisfying.
DR. ADNAN SELJUKI, Greene County Physicians Clinic: One thing which I really liked about this system here, the healthcare, is that although the poverty is there, but the healthcare is almost first-class healthcare for all people here. Any patient who comes to the emergency room here gets everything, which is supposed to be given to them.
FRED DE SAM LAZARO: Foreign doctors used to be criticized for having inferior training, but these days, they wave to pass rigorous exams on a par with their US counterparts, according to Dr. Fitzhugh Mullan who practices in inner-city Washington.
DR. FITZHUGH MULLAN: In the last couple of years, the US Medical Licensure Exam has included a portion for international medical graduates where individuals are measured on their ability to interact appropriately in a clinical setting.
The effort is to make sure that people passing exams are not just paper whizzes, but in fact are clinically and interpersonally able as well.
FRED DE SAM LAZARO: However, Dr. Mullan, who headed the National Health Service Corps under President Carter, says cultural and language concern remain.
DR. FITZHUGH MULLAN: It is very, very important to be as knowledgeable about, and as comfortable with the culture of the folks that you're treating as a physician as possible. And front and center, of course, is language, but there's a lot else that comes with it in terms of cultural understanding as well.
FRED DE SAM LAZARO: The doctors in Eutaw have tried hard to get around the language barrier
FRED DE SAM LAZARO: Do you ever have difficulty understanding your patients?
DR. LOURDES ADA, Greene County Physicians Clinic: Yes, sometimes.
FRED DE SAM LAZARO: What do you do in those situations?
DR. LOURDES ADA: I ask somebody from the staff to help me listen closely what the patient means. You know, it takes a lot of patience, keep repeating what they just said; "may I hear it again?"
FRED DE SAM LAZARO: Muslims in a mostly Christian town, foreign born in the town where most people's families go back generations, the doctors also have tried hard to fit in to the town life.
FRED DE SAM LAZARO: Sandrall Hullett knows about the difficulty of fitting in. She was the town's first female and African American doctor.
DR. SANDRALL HULLETT : Learning to do the small talk, and that's what really... in small towns, that's what really helps a lot.
FRED DE SAM LAZARO: What sort of small talk?
DR. SANDRALL HULLETT: You know, we talk about the garden, kids, politics, big things football games, Alabama, you can't tell someone you don't know who is playing football; that you don't know whether Auburn or Alabama won the game or not.
FRED DE SAM LAZARO: But Dr. Hullett, who's recruited most of the foreign doctors to town, acknowledges problems with earlier hires, in what she calls cultural competency -- like the one physician who refused to examine pregnant patients unless a husband or male relative brought them in.
DR. SANDRALL HULLETT: His philosophy was that if a woman was pregnant, then the father of the child, thinking everybody was married, should be there every time this lady came for her visit. And so, we tried to explain to him that you don't do that. And he did not want to work with us, so we had to fire him. We actually fired him.
FRED DE SAM LAZARO: But she gives high marks to Eutaw's current crop of doctors. Most, like Dr Siddique, say they adjust to new cultural norms, on teen pregnancy, for example.
DR. MOHAMMAD SIDDIQUE, Greene County Physicians Clinic: It gives me lot of pain when I see young girls getting pregnant, and then they are out of their way for their future. And their path has so many problems. Really, it gives me a lot of pain.
FRED DE SAM LAZARO: Rural areas are not the only places, which have become dependent on foreign doctors. They are also prominent as residents in large urban hospitals, where they fill a void in the doctor supply pipeline, according to DR Mullah.
DR. FITZHUGH MULLAN: We graduate 16,000 or 17,000 students as physicians each year, and yet we offer about 22,000 first-year residency positions, internship positions. So there's a mismatch of 5,000 or 6,000 people and there's no place to go, essentially, but abroad. And that's become a very stable part of our system.
FRED DE SAM LAZARO: About half of those foreign students are actually US citizens who have studied abroad. The rest are foreign nationals, most from developing countries.
At Tomasson Hospital in El Paso, Texas, Dr. Abraham Verghese says he had a much easier time when he came to America two decades ago, than his foreign students do now. Verghese, who has written two best selling books about his experiences as a doctor, came from Ethiopia and India.
DR. ABRAHAM VERGHESE: There's a whole new set of hurdles which, 20 years ago, were relatively simple. You could most likely stay on if you wanted to. These days, the kind of visa that many of us came on simply doesn't exist.
FRED DE SAM LAZARO: Today, foreign medical graduates enter the US on J-1 visas, which require return that they return home after completing their residency, generally three to four years
DR. ABRAHAM VERGHESE: I think that most people who take the trouble to go through all the different hurdles you have to go through to come to America are under no illusions that they're going to go back after just three years of training.
I think they're very determined to stay, they're just as determined as they were when they were trying to get here. They remain just as determined to stay.
FRED DE SAM LAZARO: One of the few options for extending or waiving J-1 visas is to agree to serve in a federally designated physician shortage area, such as Eutaw, typically for two to four years. The doctors then get permanent work visas, and at that point, Dr. Mullan says, their aspirations are no different from American colleagues.
DR. FITZHUGH MULLAN: You have people starting their practice in areas that are less sought-after by American graduates. When you look, however, at the overall distribution of international graduates, many, if not most, return to practice settings in suburban or urban areas that are indistinguishable from US graduates. And the data shows that many migrate back to more middle-class kinds of settings.
FRED DE SAM LAZARO: In fact, the biggest complaint in Eutaw is that foreign doctors usually leave almost as soon as their obligation is completed.
SUZETTE QUINNIE: You get a lot of them that come. They don't stay. They do their training or whatever. By the time you get used to them and they're a real good doctor, they move on to somewhere else.
FRED DE SAM LAZARO: Three of Eutaw's four doctors who decided to remain did so even though they are now past their visa obligations, and they hope this brings new patients. Even though a clinic from a town 30 miles away opened a satellite facility in Utah, the immigrant doctors say they have the hometown affection. For the Pakistani families, devout Muslims, that's meant a lot post September 11.
MRS. KHOWLA SELJUKI: Right after September 11, initially, I was a little scared to go out because of my scarf and my Muslim outlook. But when I went out, people were more friendly to me here in Eutaw. In the grocery stores and everywhere, they were more friendly, and the people whom I barely knew, they were coming to me and they were, like, talking to me and asking me that, "if you need any help, if somebody gives you any trouble just call us and tell us," but nobody gave us any trouble.
FRED DE SAM LAZARO: But there may be other trouble on the horizon for rural communities now looking for doctors. Citing security concerns, the federal government recently announced it will no longer issue the waivers that extend the temporary stays of international medical graduates. Past attempts to limit foreign doctors have failed, and that's because they fulfill a need, according to Dr. Verghese.
DR. ABRAHAM VERGHESE: I think America is really in denial about the degree to which residents, particularly foreign medical graduates, man the county hospitals of this country and but for their services, I'm not sure how exactly we could manage.
FRED DE SAM LAZARO: Citing a desperate need for doctors in their home states, many members of Congress are hoping to overturn the anti- J-1 waiver decision, either through persuasion or legislation.