AMERICAN JOURNAL OF
Public Editorial Health August 1978 Volume 68, Number 8
Established 1911
Foreign Physicians and Other Health Care Providers EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD, (1980)
Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1980) H. Jack Geiger, MD, SciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1980) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor CONTRIBUTING EDITORS William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley, MLS Book Section
AJPH August 1978, Vol. 68, No. 8
Health care delivery to underserved, often underprivileged, populations is not only a problem for the countries of the developing world; numerous segments of the world's most advanced countries also suffer from a quantitative and qualitative lack of health care for geographic, cultural, economic, racial, and other reasons. The paper by Zeighami, et al.,' in this issue of the Journal is therefore relevant not only to Iran and other developing countries; many of its lessons also apply to the problems of the affluent countries. These authors investigated the reasons why physicians from other countries, recruited to work in Iran, had emigrated from their home country. They also compared the acceptance of foreign physicians by the Iranian peasants they would serve, with the acceptance of Iranian auxiliaries who were not physicians. Not surprisingly-they found that the main reasons given for migration were higher salaries and the expectation of a higher standard of living, followed by a wish to improve skills and to exercise their profession under more favorable conditions. These same reasons undoubtedly would also be given by the many Foreign Medical Graduates (FMGs) in the United States.'3 Such aspirations, in the face of the value system under which we live, are perfectly acceptable, understandable, and even laudable. Thus we face a dilemma. The less developed countries (LDCs) desperately need skilled manpower-including physicians-and they cannot afford to lose the manpower they have trained, at a relatively high cost, in their own institutions. On the other hand, the income and standard of living for these skilled professionals often does not equal levels they might enjoy in more affluent countries, and the LDC technical and scientific infrastructure rarely can be compared with that of the industrially more advanced countries. This "push-factor", the economic and technical disadvantage of developing societies, cannot be remedied quickly; however, the richer and more advanced societies should be able to provide for their own health manpower needs and thereby minimize the "pull-factor", that is the scarcity of their own health manpower which opens up the opportunities for immigrants. On the other hand, we must note that the U.S. has traditionally supported the right of the individual to better his or her personal and professional condition, and we are in no position to chastise the ambitious and enterprising FMG for attempting to better himself or herself. Fortunately, the majority of ineividuals forego materialistic goals for idealistic and other reasons and remain in, or return to, their home country to contribute to its development. A comparable dilemma is found in the often voiced demand that skilled professionals, including physicians, from the minority groups in the U.S., should be singled out to dedicate themselves to the betterment of conditions of those populations from which they came, again foregoing individual personal and professional advantages. True integration is in fact the responsibility of all of us. In the field of international health, one can conclude that the richer countries should make resources available to the less advantaged countries, but cannot expect 733
EDITORIALS
a mass transfer of human resources, including physicians and other health workers; such a transfer in any case would be inappropriate for political, economic, social, and cultural reasons. What can be done is to focus on those resources that will enable the LDCs to educate and train their own cadre of appropriate health workers. This brings us to the other important finding of Zeighami and his co-workers.1 In Iran under the conditions investigated, which one could loosely describe as primary care practice, the population seemed to prefer Iranian auxiliaries to foreign physicians by a considerable margin. Circumstances made this simultaneous comparison of two variables necessary; the comparison does not indicate whether the Iranian auxiliaries were preferred because they were Iranians or because they were auxiliaries. A comparison between Iranian and foreign physicians and between Iranian physicians and Iranian auxiliaries would have helped to answer that
preferred family and self-help to the foreign physician; the inference is that these are other potentially important alternatives which, with educational input, could help ease manpower shortages and reduce health care costs. This important investigation, which should be repeated and expanded, demonstrates that many health care problems are international in scope. It emphasizes for us our need to produce enough manpower to meet our own needs so that we do not deliberately drain off LDC resources. It should also motivate us to re-examine the tasks and capabilities of different levels of health care providers as a promising way to remedy shortages and distribution problems without jeopardizing quality.
DIETER KOCH- WESER, MD, PHD
question. Language plays a very important role in preventing disease and in diagnosing and treating illness; sick people like the comfort of speaking their own language with the care providers; together with cultural, social, and other affinities, these are powerful incentives for people from ethnic minorities to seek health care from physicians of the same ethnic group.4 Regardless of ethnic differences, patients relate better to providers from the same, or at least a similar, cultural and socioeconomic level. Even in a highly specialized field, like psychiatry, a carefully conducted investigation in Columbia indicates that auxiliaries are as effective in diagnosis and treatment and often better accepted by patients than physicians.5 It is possible that the Iranian population investigated 1 would have chosen an Iranian auxiliary over an Iranian physician, and that might be the case in many settings in many countries. This study from Iran presents few data and almost no discussion on the "Indigenous Practitioner", "Family Help", or "Self-Help", all of which respondents were asked to compare with Iranian auxiliaries and foreign physicians. Indigenous practitioners did not fare too well, but females
Address reprint requests to Dr. Dieter Koch-Weser, Associate Dean for International Programs, and Chairman, Department of Preventive and Social Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.
REFERENCES 1. Zeighami B, Zeighami E, Mehrabanpour J, Jairdian I, and Ronaghy H: Physician importation-A solution to developing countries' rural health care problems. Am J Public Health 68:739-742,
1978. 2. Task Force on Foreign Medical Graduates. Association of American Medical Colleges: Graduates of foreign medical schools in the United States: A challenge to medical education. Journal of Medical Education 49:813, 1974. 3. Butter I, Wright G and Tasca D: FMG's in Michigan: A case of dependence. Inquiry XV: No. 1, p. 45, 1978. 4. Strasser S: The exile physicians. Journal of Intern. Physicians Vol. 1, No. 6:2, 1977. 5. Climent CE, de Arango MV, Plutchik R and Leon CA: Development of an alternative , efficient, low cost mental health delivery system in Cali, Colombia Part I: The auxiliary nurse. Social Psychiatry 13:29-35, 1978.
Achievement, Awards, and APHA While much may be said for the philosophic inner satisfaction that comes from knowing that one has done well in a particular endeavor, public recognition of high achievement is both heart-warming and stimulating, not only to the one recognized but to colleagues and friends. Recognized achievement assumes an even greater significance when it involves services to the public's interest and, in particular, to the people's health. Allen Pond's scholarly and comprehensive review of how, over the years, the American Public Health Association has recognized excellence, achievement, and public service covers an illuminating panorama.I From an essay 734
competition in the early days, directed at a single specified goal, the awards have moved on to a pattern of assessing and rewarding achievement, both generally and specifically, over the broad spectrum of public health. As the narrative unfolds, one can appreciate certain constant values-leadership, innovation and, above all, an example to be emulated-that appear over and over again in the assessments and citations, even though the immediate public health goals have continually changed and evolved. Indeed, those public health goals have become better known and better understood with each year's announcement of the awards. For those being honored, it is a humbling experienceAJPH August, 1978, Vol. 68, No. 8
Public Editorial Health August 1978 Volume 68, Number 8
Established 1911
Foreign Physicians and Other Health Care Providers EDITOR Alfred Yankauer, MD, MPH
EDITORIAL BOARD Michel A. Ibrahim, MD, PhD, (1980)
Chairperson Rashi Fein, PhD (1978) Ruth B. Galanter, MCP (1980) H. Jack Geiger, MD, SciHyg (1978) George E. Hardy, Jr., MD, MPH (1978) C. C. Johnson, Jr., MSCE (1980) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1978) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1978) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Deborah Watkins Production Editor CONTRIBUTING EDITORS William J. Curran, JD, SMHyg Public Health and the Law Jean Conelley, MLS Book Section
AJPH August 1978, Vol. 68, No. 8
Health care delivery to underserved, often underprivileged, populations is not only a problem for the countries of the developing world; numerous segments of the world's most advanced countries also suffer from a quantitative and qualitative lack of health care for geographic, cultural, economic, racial, and other reasons. The paper by Zeighami, et al.,' in this issue of the Journal is therefore relevant not only to Iran and other developing countries; many of its lessons also apply to the problems of the affluent countries. These authors investigated the reasons why physicians from other countries, recruited to work in Iran, had emigrated from their home country. They also compared the acceptance of foreign physicians by the Iranian peasants they would serve, with the acceptance of Iranian auxiliaries who were not physicians. Not surprisingly-they found that the main reasons given for migration were higher salaries and the expectation of a higher standard of living, followed by a wish to improve skills and to exercise their profession under more favorable conditions. These same reasons undoubtedly would also be given by the many Foreign Medical Graduates (FMGs) in the United States.'3 Such aspirations, in the face of the value system under which we live, are perfectly acceptable, understandable, and even laudable. Thus we face a dilemma. The less developed countries (LDCs) desperately need skilled manpower-including physicians-and they cannot afford to lose the manpower they have trained, at a relatively high cost, in their own institutions. On the other hand, the income and standard of living for these skilled professionals often does not equal levels they might enjoy in more affluent countries, and the LDC technical and scientific infrastructure rarely can be compared with that of the industrially more advanced countries. This "push-factor", the economic and technical disadvantage of developing societies, cannot be remedied quickly; however, the richer and more advanced societies should be able to provide for their own health manpower needs and thereby minimize the "pull-factor", that is the scarcity of their own health manpower which opens up the opportunities for immigrants. On the other hand, we must note that the U.S. has traditionally supported the right of the individual to better his or her personal and professional condition, and we are in no position to chastise the ambitious and enterprising FMG for attempting to better himself or herself. Fortunately, the majority of ineividuals forego materialistic goals for idealistic and other reasons and remain in, or return to, their home country to contribute to its development. A comparable dilemma is found in the often voiced demand that skilled professionals, including physicians, from the minority groups in the U.S., should be singled out to dedicate themselves to the betterment of conditions of those populations from which they came, again foregoing individual personal and professional advantages. True integration is in fact the responsibility of all of us. In the field of international health, one can conclude that the richer countries should make resources available to the less advantaged countries, but cannot expect 733
EDITORIALS
a mass transfer of human resources, including physicians and other health workers; such a transfer in any case would be inappropriate for political, economic, social, and cultural reasons. What can be done is to focus on those resources that will enable the LDCs to educate and train their own cadre of appropriate health workers. This brings us to the other important finding of Zeighami and his co-workers.1 In Iran under the conditions investigated, which one could loosely describe as primary care practice, the population seemed to prefer Iranian auxiliaries to foreign physicians by a considerable margin. Circumstances made this simultaneous comparison of two variables necessary; the comparison does not indicate whether the Iranian auxiliaries were preferred because they were Iranians or because they were auxiliaries. A comparison between Iranian and foreign physicians and between Iranian physicians and Iranian auxiliaries would have helped to answer that
preferred family and self-help to the foreign physician; the inference is that these are other potentially important alternatives which, with educational input, could help ease manpower shortages and reduce health care costs. This important investigation, which should be repeated and expanded, demonstrates that many health care problems are international in scope. It emphasizes for us our need to produce enough manpower to meet our own needs so that we do not deliberately drain off LDC resources. It should also motivate us to re-examine the tasks and capabilities of different levels of health care providers as a promising way to remedy shortages and distribution problems without jeopardizing quality.
DIETER KOCH- WESER, MD, PHD
question. Language plays a very important role in preventing disease and in diagnosing and treating illness; sick people like the comfort of speaking their own language with the care providers; together with cultural, social, and other affinities, these are powerful incentives for people from ethnic minorities to seek health care from physicians of the same ethnic group.4 Regardless of ethnic differences, patients relate better to providers from the same, or at least a similar, cultural and socioeconomic level. Even in a highly specialized field, like psychiatry, a carefully conducted investigation in Columbia indicates that auxiliaries are as effective in diagnosis and treatment and often better accepted by patients than physicians.5 It is possible that the Iranian population investigated 1 would have chosen an Iranian auxiliary over an Iranian physician, and that might be the case in many settings in many countries. This study from Iran presents few data and almost no discussion on the "Indigenous Practitioner", "Family Help", or "Self-Help", all of which respondents were asked to compare with Iranian auxiliaries and foreign physicians. Indigenous practitioners did not fare too well, but females
Address reprint requests to Dr. Dieter Koch-Weser, Associate Dean for International Programs, and Chairman, Department of Preventive and Social Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.
REFERENCES 1. Zeighami B, Zeighami E, Mehrabanpour J, Jairdian I, and Ronaghy H: Physician importation-A solution to developing countries' rural health care problems. Am J Public Health 68:739-742,
1978. 2. Task Force on Foreign Medical Graduates. Association of American Medical Colleges: Graduates of foreign medical schools in the United States: A challenge to medical education. Journal of Medical Education 49:813, 1974. 3. Butter I, Wright G and Tasca D: FMG's in Michigan: A case of dependence. Inquiry XV: No. 1, p. 45, 1978. 4. Strasser S: The exile physicians. Journal of Intern. Physicians Vol. 1, No. 6:2, 1977. 5. Climent CE, de Arango MV, Plutchik R and Leon CA: Development of an alternative , efficient, low cost mental health delivery system in Cali, Colombia Part I: The auxiliary nurse. Social Psychiatry 13:29-35, 1978.
Achievement, Awards, and APHA While much may be said for the philosophic inner satisfaction that comes from knowing that one has done well in a particular endeavor, public recognition of high achievement is both heart-warming and stimulating, not only to the one recognized but to colleagues and friends. Recognized achievement assumes an even greater significance when it involves services to the public's interest and, in particular, to the people's health. Allen Pond's scholarly and comprehensive review of how, over the years, the American Public Health Association has recognized excellence, achievement, and public service covers an illuminating panorama.I From an essay 734
competition in the early days, directed at a single specified goal, the awards have moved on to a pattern of assessing and rewarding achievement, both generally and specifically, over the broad spectrum of public health. As the narrative unfolds, one can appreciate certain constant values-leadership, innovation and, above all, an example to be emulated-that appear over and over again in the assessments and citations, even though the immediate public health goals have continually changed and evolved. Indeed, those public health goals have become better known and better understood with each year's announcement of the awards. For those being honored, it is a humbling experienceAJPH August, 1978, Vol. 68, No. 8
