...on the West Coast, the Congress passed the Chinese Immigration Exclusion Act in 1882, which barred further immigration of Asians until it was repealed in 1952 and replaced by the McCarren-Walter Immigration and Naturalization Act. This permitted a second immigration wave of controlled numbers of Chinese from Taiwan and Hong Kong who could demonstrate their abikty to support themselves and among whom were numerous foreign-trained medical graduates. Filipino and, still later, Korean immigrants arrived in increasing numbers after World War II.
Length of residence in the United States is of critical importance in comprehending different levels of English-language acquisition, degree of acculturation, and the extent to which a racial group has been assimilated within this country. Of further ethnographic interest is the phenomenon of "ghettoization," which is the result of having sufficient and visible numbers of people who coalesce out of common interests, mutual protection, and fear or discomfort towards the majority group. Such ghettos provide convenience and comfort, opportunity to utilize a common native language, and access to customary dietary needs. Such a well-demarcated community may then be perceived as acceptable, even exotic, by the larger community. Small businesses, restaurants, and hotels in ghetto communities are not in direct competition with the larger community and are therefore not considered an economic threat.
Most metropolitan areas have supported self-contained Chinese communities that met their residents' social, psychologic, educational, cultural, economic, and dietary needs. The dialects spoken in these communities are predominantly Cantonese and Toi San. Mandarinspeaking Chinese (from Taiwan) tend to avoid such communities, as those who speak Mandarin cannot be understood by those who speak Cantonese and Toi San. For this reason, Mandarin-speaking Chinese have tended to settle in white neighborhoods.
Japanese Communities were largely ghettoized before World War II, but they were destroyed as a direct result of forced evacuation and internment in federally sponsored concentration camps between 1942 and 1946.2 Upon their release and return to the West Coast, the Japanese attempted to resettle in their former communities, only to find that this was not possible; other transitional racial groups had moved into the well-demarcated urban areas previously occupied by the Japanese. At best, the remnants of "Japan-town" are limited to business establishments, restaurants, and hotels. The Japanese are thus more geographically dispersed in the cities of the West Coast. Filipino and Korean communities tend to be geographically identifiable as residential neighborhoods, but they lack the clear demarcation implied in such descriptive terms as "Chinatown" and "Little Tokyo."
These differences within the Chinese, Filipino, Korean, and Japanese populations are clearly reflected among Asian psychiatrists in the United States. Language proficiency has been best achieved by psychiatrists of Japanese descent, as they represent a time-limited immigrational wave (1890-1920) with the gradual dilution of values and beliefs over three generations of acculturation. Chinese psychiatrists who are American-born and whose histories reflect long tenure in the United States tend to demonstrate comparable acculturative patterns. However, the effects of being reared in a Chinese ghetto tend to modify their Englishspeaking patterns despite several generations of residence in this country. The Filipino and Korean immigrants, who are the most recent, are least proficient in English and have had insufficient time to engage in acculturative processes.
We found that there are no established rosters of Asian psychiatrists in the United States. Primary source material was therefore restricted to the official 19683 and 19734 A. P. A. directories, which include 89 per cent of all psychiatrists within the United States.
Asian names, country of origin, and psychiatric training in Asian countries were descriptors utilized to identify 243 A. P.A. members potentially of Asian extraction. Female psychiatrists who married non-Asians and carry Caucasian last names, but who have Asian first or middle names, were also identified. Women of Asian extraction who have English first and middle names and who married non-Asians were not identifiable, and no estimate of this population can be made.
1970 U.S. Census data were used to ascertain the distribution of Asian populations within tiie United States.5 Although census data on Chinese, Filipino, and Japanese populations reflect the numbers in these three groupings with reasonable accuracy, the 1970 Korean data are believed to be grossly underestimated. The 1970 census listed 70,000 Koreans in the United States; this number has been questioned by Korean investigators, who say that the figure is probably closer to 200,000.6
Two hundred forty-three psychiatrists of Asian origin - 73 Chinese, 72 Filipino, 66 Korean, and 32 Japanese - were identified from the 1973 A.P.A. directory. This number constituted 1.2 per cent of the 20,184 A.P.A. members, slightly higher than the percentage composition of Asian populations within the United States. There were 1,439,412 persons of Asian origin among 203,211,926 people reported in the 1970 U.S. Census, comprising 0.7 per cent of the total population. Since the number of Asian psychiatrists has increased substantially since the relaxation of immigration quotas in 1952, the present survey includes both foreign-born and American-born Asian psychiatrists.
Table 2 lists the Asian population of each state and the numbers of Asian psychiatrists by national origin. It highlights a striking distribution problem: high concentrations of Asian psychiatrists occur in states with relatively low Asian populations; conversely, there are scanty resources in states with significant Asian populations. The added issue of urban/rural distribution occurs, since some urban areas with large Asian populations have relatively low access to Asian psychiatric resources, while other rural areas that have an almost nonexistent racial population base are rich in Asian psychiatric resources.
Dr. Sata is director of psychiatric services, Harborview Medical Center, Seattle, and Associate Professor of Psychiatry. University of Washington.
The unusual distribution of psychiatrists by state appears to be a combination of factors, including acceptability into psychiatric training programs, licensure restrictions, employment opportunities, and an informal communication system among foreign medical graduates on the climate of acceptance in a given region or state.
The states with notable Asian populations (here defined, somewhat arbitrarily, as 30,000 Chinese, Japanese, or Filipinos) include California (522,270), Hawaii (363,261), New York (116,008), Illinois (44,427), and Washington (40,998).
New York State has 44 Asian psychiatrists (Chinese, Filipino, Japanese), with a population base of 116,008. Korean population data are available only for New York City (9,484), though there are known to be 22 Korean psychiatrists in the state. The psychiatristpopulation ratios are impressive at first glance; across the four racial groupings they would be 1:1,964 collectively or 1:6,784 for Japanese, 1:4,069 for Chinese, 1:680 for Filipinos, and 1:431 for Koreans. But upon closer examination, there are only two Chinese, three Filipino, two Japanese, and four Korean psychiatrists who actually reside and work in New York City. The bulk of Asian psychiatric resources (55 psychiatrists of 66 identified) appear to be cloistered in state institutions and nonmetropolitan community mental health centers. In short, most Asian psychiatric resources are not available to Asian populations, which tend to concentrate in urban centers. The Asian psychiatrist-population ratio for New York City is 1:11,400, which more accurately identifies available resources.
ASIAN POPULATION AND ASIAN PSYCHIATRISTS, BY STATE
ASIAN POPULATION AND ASIAN PSYCHIATRISTS, BY STATE
Illinois has one psychiatrist in each of the four racial groups, with a population base of 17,299 Japanese, 14,474 Chinese, 12,654 Filipinos, and an unknown number of Koreans. Washington State has three Asian psychiatrists (one Japanese, one Filipino, one Chinese) for a population base of 20,335 Japanese, 11,462 Filipinos, and 9,201 Chinese. California and Hawaii are notable for having both large Asian populations and a peculiar distribution of psychiatrists (Table 3). The unusually low numbers of Korean and Filipino psychiatrists reflect the late arrival of these two groups to the United States, as mentioned above, as well as the requirements for licensure of foreign medical graduates in these states.
Table 2 reveals that 34 states lack Japanese psychiatrists, 31 states lack Chinese psychiatrists, and 26 states lack Filipino psychiatrists. No assessment is possible for Korean psychiatrists, since state-by-state population data are not available. In most instances a small Asian population correlates with slight or absent Asian psychiatric resources, but exceptions to this are found in Hawaii, California, and Michigan. California has one Filipino psychiatrist in a population of 138,859 and one Korean psychiatrist for an estimated population of approximately 70,000. Hawaii has no Filipino psychiatrists but a Filipino population of 93,915. On the other hand, Michigan has only 15,285 Asians collectively but 22 Asian psychiatrists living and working in the state.
This survey represents a first effort to identify Asian psychiatric resources within the United States. The attempt is preliminary, and there are inherent problems in accurately identifying the populations to be examined. As a preliminary endeavor, it does suggest some potential areas of inquiry that would add to the sociocultural base of American psychiatry.
Given the unusual distribution patterns emerging from this study, several issues merit continued investigation. To what extent are Asian psychiatrists treating Asian patients? To what extent are Asian populations receiving psychiatric treatment? Do Asian psychiatrists have free access and mobility, or are there factors (such as lack of citizenship, limited employment opportunities, licensing problems, etc.) that inhibit bringing professional resources to available populations? Is it possible to develop improved profiles on Asian psychiatrists with regard to place of origin, facility with English, years of training, caliber of training, principal areas of professional activity, degree of acculturation and ability to relate with Americans, and success in specialty board certification?
We should not view such questions as academic, since there is growing national interest in the striking increase of foreign medical graduates immigrating from Asia. In 1972 alone, 2,523 physicians were admitted to the United States from the Philippines (831), Korea (810), Taiwan (333), Thailand (275), and China (274);7 these figures suggest that if psychiatry attracts 5 to 6 per cent of foreign medical graduates, the total number of Asian psychiatrists will double within the next few years. As the numbers of Asian psychiatrists and psychiatric trainees increase, we will need to readdress psychiatric training to make it culturally relevant and accommodative for the foreign medical graduates who have special requirements in order to benefit maximally from their training.
Our current level of commitment to foreign medical graduates is considerably less than optimal. We have used them as cost-effective substitutes in many state mental institutions, with an emphasis on service and insufficient attention to training. Little interest has been shown in providing a culturally sensitive training relationship with the foreign medical graduate of the quality described by McDermott and Maretzki,7 Brody et al.,8 and Miller et al.9 or an approach that would enable the trainee to effectively treat Asian Americans as well as nonAsian Americans. Lastly, the issue of language acquisition is left in the hands of the trainee, with little regard to the overwhelming psychologic and acculturative stresses thus imposed.
U.S. CENSUS DATA AND PSYCHIATRIC RESOURCES COMPARED
It may ultimately prove desirable to develop several international psychiatric residency programs, specializing in training foreign medical graduates who aspire to careers in psychiatry. Such programs could selectively recruit a multiracial faculty who are knowledgeable and responsive to these issues in psychiatric training of Asians and other foreign medical graduates. They could foster cross-cultural research, support international investigators, and provide quality training to develop professionals with unique resources and bicultural clinicians, researchers, and teachers. Such an approach has the potential for facilitating the integration and understanding of Asians, who constitute 57 per cent of the world population.
1. Census of Population: Subject Reports. Final Report PC (2)-IG Japanese, Chinese and Filipinos in the United States. Washington, D.C.: U.S. Department of Commerce, Bureau of the Census, 1970.
2. Daniels, R. Concentration Camps U.S.A.: Japanese Americans and World War II. New York: Holt. Rinehart and Winston. 1971.
3. Biographical Directory of the American Psychiatric Association. New York: R. R. Bowker Company, 1968.
4. Biographical Directory of the American Psychiatric Association. New York: R. R. Bowker Company, 1973.
5. Census of Population: Table 60, Race of the Population for Regions, Divisions and States. Washington, D.C.: U.S. Department of Commerce, Bureau of the Census, 1970.
6. Sil Dong Kim (director. Demonstration Project for Asian Americans, Seattle). Personal communications.
7. McDermott. J., Jr., and Maretzki, T. Some guidelines for training foreign medical graduates. Am. J. Psychiatry 132 (1975), 658-661 .
8. Brody, E. B., et al. Intellectual and emotional problems of foreign residents learning psychiatric theory and practice. Psychiatry 34 (1971). 238-247.
9. Miller, M. H., et al. Foreign medical graduates: A symposium. Presented at the annual meeting of the American Psychiatric Association, Dallas, May 2, 1972.