The Shortage of Healthcare Professionals in Outlying Regions of Brazil and the COVID-19 Pandemic: Reflections on Immigrant Integration and the Realization of the Right to Health ()
1. Introduction
At the end of December 2019, a new virus broke out in Wuhan, China, and quickly spread worldwide, causing the greatest pandemic of the last 100 years, COVID-19. When we started writing this report, in the winter of 2020, Brazil had about two million infected and almost 100,000 deaths due to the coronavirus. In a scenario characterized by poorly implemented quarantines and a lack of political commitment to address the health crisis, a new issue arises: the shortage of qualified labor and healthcare professionals. Thus, we are faced with a rather challenging reality: on the one hand, the shortage of health professionals, and on the other, the large number of people who obtain medical degrees abroad (immigrant doctors and doctors who graduated abroad) who do not have authorization to practice the medical profession in Brazil.
These thousands of people in that situation encountered the obstacle of only being able to practice medicine in Brazil once they successfully passed the revalidation exam to validate their diplomas. The proficiency test responsible for validating the diplomas of these doctors who graduated abroad is called Revalida. It is administered by the National Institute for Studies and Research Anísio Teixeira (INEP, 2020) , resulting from a partnership between the Brazilian Ministries of Education and Health. However, this exam is not applied periodically having already gone three years without being applied. Without the revalidation of diplomas, professionals, despite being duly qualified in their country of origin, cannot exercise their profession in Brazil, even for exclusively emergency purposes, as in the case of the pandemic.
In light of this inconsistency, which raises questions about migration, ethics, public health, and class protectionism, we have undertaken to write this report to examine the rights of immigrants and their interactions with the host community. We affirm that our primary concern was not merely the act of receiving immigrants, especially in the medicine areas, but rather how to incorporate them into society, utilizing their valuable skills to benefit the receiving community. This approach aimed to maximize the overall societal benefit, particularly during the COVID-19 pandemic.
Based on the hypothetical-deductive method and the bibliographic and documentary procedures, our research will explore the following hypothesis: The relaxation of legal constraints, in exceptional circumstances, can generate rights and guarantees for both the immigrant and the Brazilian population. If our hypothesis is confirmed, we will argue for the flexibility of the Revalida exam, allowing foreign-trained doctors to be employed and practice their profession during extraordinary contexts.
Our research will first focus on analyzing the specific situation of immigrants who enter Brazil with professional qualifications in the health field but face barriers preventing them from practicing their profession and contributing to Brazilian society due to legal bureaucracy.
In the second phase, we will explore the role that immigrant doctors can play in situations of scarcity, taking into consideration the shortage of healthcare professionals in certain areas of the country. The central focus will be to examine the intersection of the migrant’s right to work with the population’s right to universal access to healthcare, as guaranteed by the Brazilian constitution. Building on this proposal, we will evaluate the feasibility of allowing doctors trained abroad who have migrated to Brazil to practice their professions not only as a right of the immigrant but as a duty of action towards society. In contrast, we intend to argue that class protectionism weakens the liberty, which the National Council of Medicine defends. Our point is that the arguments put forth by public administration and medical councils in opposition to the flexibility of the Revalida exam would go against the principle of equal access to healthcare that they themselves defend. To support our position, we will primarily draw on the arguments of distributive justice and individual freedom presented by Ronald Dworkin in The Sovereign Virtue.
Finally, in the third stage, we will investigate the legal situation of the Public Civil Action (Ação Civil Pública) promoted by the Public Defender’s Office of the State of São Paulo (Defensoria Pública da União do Estado de São Paulo) and its legal implications. In addition, we believe that the Brazilian case will be of interest because many countries might be faced with similar problems.
2. Migration Processes and the National Examination for the Revalidation of Medical Diplomas: The Importance of Immigrant Medical Professionals for the Realization of Public Health Policies in Brazil
Migration processes are historical and result from several factors. The development of Brazil in recent decades has made the country the destination chosen by many, given its growing visibility. In this sense, according to the United Nations (UN) report on the promotion and protection of the human rights of migrants in the context of large movements, it is necessary to observe the vulnerability surrounding some migrations.
Furthermore, as shown in Figure 1, the Global Trends report on forced displacement (UNHCR, 2023) shows that by the end of 2022, 108.4 million people were forcibly displaced worldwide as a result of persecution, conflict, violence, human rights violations or events seriously disturbing public order. Of this number, 35.3 million were refugees, 62.5 million were displaced persons, and 5.4 million were asylum seekers. Therefore, it can be observed that in 2021, the total number of displacements was 89.3 million people and, compared to 2014, that represents an increase of approximately 54.88% (UNHCR, 2022) .
According to data from the General Coordination of Labor Immigration (Coordenação Geral de Imigração Laboral-CGIL), systematized by the Observatory of International Migrations (Observatório das Migrações Internacionais— OBMigra), it is possible to observe that Brazil is a destination for many migrants (Graf, 2021) . Between 2018 and 2022, 130,427 authorizations have been granted to immigrants by CNIg, which highlights the need for special attention to integration policies for these individuals (Cavalcanti, Oliveira, & Silva, 2021, 2022, 2023) .
Migration movements can be differentiated in various ways, including forced and spontaneous migration. In forced migration, there is the subjective element of coercion, which involves threats to life and subsistence, caused by either natural or human factors, with refugees being one example. On the other hand,
spontaneous migration results from dissatisfaction caused by negative factors in the country of origin and attractive factors in the destination country, which leads individuals to seek better prospects for life (IOM, 2006: p. 39) . In this sense, Márcia Gomes (Gomes, 2017) explains the various motivations for migration, including economic migration, which aims to send money back to family members who remained in the country of origin.
From this, it remains imperative to emphasize that the integration of immigrants goes through the process of recognition of their skills and training, not allowing qualified professionals to be prevented from exercising their profession due to the absence of application of a test, as in the case of immigrant doctors. It is at this point that the possibility or not of making the National Examination for Revalidation of Medical Diplomas (Exame Nacional de Revalidação de Diplomas Médicos - Revalida) more flexible.
The National Exam for Revalidation of Medical Diplomas has been applied by the National Institute of Educational Studies and Research Anísio Teixeira (INEP, 2020) since 2011, in collaboration with the Subcommittee for Revalidation of Medical Diplomas (Subcomissão de Revalidação de Diplomas Médicos).
The evaluation is divided into two stages: the first consists of a written test, and the second assesses the candidates’ clinical skills. According to the data available on the Inep platform, after a long time without the exam being administered, in the year 2022, 13,880 doctors took the exam, and the pass rate for the exam, which was held in the second half of 2022, was only 3.75% (INEP, 2022) . Therefore, the majority continue without the possibility of practicing their profession despite being qualified as doctors abroad. Furthermore, the reported problems are numerous: exorbitant exam registration fees, correction errors, unjustified increases in passing scores, and debatable content when compared to Brazil’s educational standards.
At the same time, according to the medical demography report of 2023, in spite of the increase in the number of doctors in Brazil, as shown in Figure 2 some regions continue to have a deficit of doctors, as medical graduates in Brazil are not interested in taking up these positions.
The poor distribution of newly graduated medical professionals in the country shows that while the national average is 2.41 doctors per thousand inhabitants, the interior regions of Amazonas and Roraima have, respectively, an average of 0.21 and 0.28 doctors per thousand inhabitants. Also, Pará and Sergipe stand out negatively with an average ratio of 0.43 and 0.35 doctors per thousand inhabitants, respectively, which astonishingly reveals a rate 83% lower than the national average.
The demand from society for better living conditions highlighted the need for the State to address social inequalities and exclusions. The role of the State in action, therefore, involves the implementation of public policies which, according to the concept by Celina Souza, start from the “perspective that the whole is more important than the sum of its parts, and that individuals, institutions, interactions, ideology and interests all matter, even if there are differences in the relative importance of these factors.” ( Souza, 2006: p. 25 , authors translate)
Additionally, Maria Bucci explains public policy as a government program or framework of action that “consists of a set of articulated measures, aimed at giving an impulse, that is, moving the government machinery towards achieving some public goal, or, from the perspective of jurists, realizing a right.” ( Bucci, 2006: p. 14 , authors translate)
The elucidation regarding the importance of public policies becomes necessary in the face of the need to address issues such as the role of immigrants in realizing the right to health, public policies, and the COVID-19 pandemic. In
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Figure 2. States with a deficit of doctors in the outlying region. Source: Developed by the authors based on the Medical Demography in Brazil (Scheffer, 2023) .
protecting and ensuring the fundamental right to health, Article 196 of the Brazilian Federal Constitution (Brazil, 1988) is highlighted, which states that “health is a right of all and a duty of the State, guaranteed through social and economic policies.” Therefore, it is based on the need to promote universal, equal, free, and quality access for all. Hector Cury Soares emphasizes that “in the case of the right to health as a service, public policy, undoubtedly, is an instrument to make it effective when we perceive it as a way to coordinate public actions to fulfill the rights of citizens.” ( Soares, 2014: p. 55 , own translation) Coelho, Lolli e Bitencourt emphasizes the need to consider the challenges of legal and institutional dynamics from an approach of law and public policies (Coelho, Lolli, & Bitencourt, 2022: p. 45) .
One of the programs linked to primary health care is the Family Health Strategy (ESF), whose interdisciplinary approach provides preventive care and population monitoring through Basic Health Units (UBSs). Therefore, it is essential to have a prepared, humanitarian, and non-transient multidisciplinary team that remains engaged in following the families in each region. The Family Health Strategy democratizes access to healthcare, providing everyone with a comprehensive and multidisciplinary program of services, and takes a leading role in more vulnerable regions, by the fundamental principles of the Unified Health System (SUS).
However, despite promoting essential primary care attributes, there needs to be a better distribution of doctors in more vulnerable regions, where the passage of healthcare professionals in health units is transient or nonexistent. The integration of qualified healthcare professionals from other countries, specifically immigrant doctors who have not taken the National Examination for Medical Degree Validation (Revalida), emerges not only as a possibility but also as a way to ensure the rights to life and health provided for in Articles 5, 6, and 196 of the Federal Constitution.
After all, the integration of immigrants involves recognizing their skills and training, not allowing qualified professionals to be prevented from practicing their profession due to the absence of an exam, as in the case of immigrant doctors.
As previously stated, migration involves various aspects, including life in society, family groups, work, health, and public safety, among other peculiarities. In other words, considering that work is a primary source of income, depriving someone of freely practicing their profession is taking away the opportunity for reestablishment in the destination country.
Therefore, in the context of the COVID-19 pandemic, the debate arises about the possibility of flexibility in the examination process, even if exceptionally and temporarily, in order to allow these doctors from abroad to practice their profession and utilize their skills, considering the absence of the exam and the consequent underutilization of their expertise.
Therefore, it is reiterated that, in addition to the problem of the distribution of doctors in the country, there is a shortage of doctors in Basic Health Units that either 1) do not have a professional or 2) suffer from immense turnover that affects the care and knowledge about the population in the neighborhoods. Meanwhile, doctors trained abroad who have not validated their diplomas in Brazilian territory work in supermarkets and retail in general to ensure their survival.
3. Philosophical Perspectives and Developments
Having understood the Brazilian historical context, we move on to the second moment of this chapter: the understanding of the philosophical perspectives and developments. For this, first, we will present the philosophical principles that guide the recognition of equality and dignity of immigrants in Brazil, highlighting the importance of guaranteeing them the right to work like any other citizen. Then, analyzing the need for equal treatment along liberal lines as he claims to defend the current administrative model. For this, we will initially use the idea of Dworkinian justice.
Ronald Dworkin is a legal philosopher who defends liberalism associated with the criteria of justice. His idea of justice is based on the liberal egalitarian sphere, so he understands the perspective of distributive justice and individual freedoms. In this sense, more than establishing what justice is in a general way, the issue at hand is to know what is the just way to respond to injustice, that is, how to prevent inequality from eroding the social values that should be distributed to all, such as “freedom and opportunity, income and wealth, and the social bases of self-respect.” (Rawls, 2000: p. 245)
Álvaro de Vita expounds on social injustices, affirming that, “to determine what kind of events qualify as ‘injustices’, we are inevitably led to engage in counterfactual comparisons between the status quo and institutional structures that are possible alternatives.” ( Vita, 2007: p. 220 , own translation) The equality, for Dworkin, will be guaranteed only to the extent that resources are distributed equally. According to Dworkin’s egalitarian theory of justice, in the context of a Democratic State of Law, equality must always prevail over freedom since it is the cardinal virtue present in the political community. Given its importance, equality of resources and opportunities emerges as a facet for distributive justice compatible with a society based on a political principle of equal consideration for all its members.
Dworkin will thus start from the assumption that any resource must be equal. It will be up to the State, then, the function of equality in treating its national or foreign citizens, and there are two ways of understanding the right to equality, namely, 1) the right to equal treatment or 2) the right to equal treatment. Equal treatment 1) consists of the right to an equal distribution of opportunities, resources, and burdens (e.g., the right to vote or basic education), while the second 2) is configured by the right of all citizens to be treated with equal consideration and attention, this being an inalienable and fundamental right.
Equal consideration and respect must be demanded from the political community, equality being the true sovereign virtue of the community for Dworkin. According to Dworkin, every government must demonstrate “equal concern for the fate of all […]. Equal consideration is the sovereign virtue of the political community—without it, the government amounts to nothing but tyranny.” (Dworkin, 2002: p. 9) . Through the theory of equality of resources, he defends the practice of an egalitarian model, intending to promote equal conditions for all people, regardless of being national or foreign. In this sense, the right to health is a right that belongs to the sphere of equality, as highlighted by Sueli Dallari and Paulo Fortes (Dallari & Fortes, 1997) .
In addition, the poor distribution within the regions themselves should be highlighted, where cities in the interior are the most affected by the shortage of professionals. Consequently, the shortage of doctors—intensified during the COVID-19 pandemic—violates constitutionally guaranteed equal access to healthcare.
The problem lies in the fact that exclusions from access to health are “intolerable injustices,” according to Amartya Sen. For him, the government must necessarily avoid the injustice that is closely linked to the lack of public services and social assistance, such as, for example, the absence of epidemiological programs, of a well-planned system of medical assistance, because for human development the agent it needs to be well nourished and free from epidemics (Sen, 2000) . To reinforce his argument, Sen takes up the thinking of Adam Smith, the father of economic liberalism, to endorse the need for concern for human development even in liberal societies like ours.
Contrary to commonplace claims that liberal principles should prevail in society to the detriment of possible state intervention, Adam Smith argued that state non-intervention in commerce does not apply to social issues. On the contrary, for Smith “the State must intervene to guarantee, to all, equal conditions to prosper” (Costa, 2018: p. 165) . However, Adam Smith demonstrates concern about improving living conditions as a whole and the need to eradicate poverty, recognizing that the market order could produce perverse effects on the poorest population (Smith, 1776) . In such a situation, the government is responsible for caring for the most vulnerable, using certain public institutions to deal with the problems that eventually arise and not simply letting the market follow the free flow.
Nevertheless, the philosopher Stephen Darwall claims that theories such as the Smithian support a notion of human dignity (Darwall, 1999) . This notion would be based on the need to renounce our egocentric feelings and assume the interests and feelings of others without prejudice, defended by Smith. In turn, the recognition and appreciation of the other would reside in self-sacrifice, given that, against the deformation of injustice; we have to renounce our greatest private interests in favor of the even greater interests of others (Smith, 1759) . With this, the physical and psychological ills caused by scarcity, such as the pandemic, would be avoided.
The concern of classical liberalism as a solution to subsistence problems, quality of life, and the possibility of human development, avoiding intolerable injustices. Therefore, if we take this classic theory and associate it with a pandemic scenario, where the health of society is at stake, we perceive the need to defend that, based on liberal policies, we must be concerned about the poorest, necessarily demonstrating that even within liberal frameworks, there are social concerns. When we specifically enter into conditions of scarcity, such as the current health crisis we are observing, the need to be concerned about the population becomes even more evident.
Thus, processes that impede the health and survival of the population must be avoided at all costs to guarantee the population’s life. Furthermore, during the pandemic we are experiencing, this guarantee involves making Revalida more flexible to benefit the community. Therefore, in addition to the immigrant’s right to equal treatment at work, there is a moral duty to contribute and care for civil society. These qualified professionals can add knowledge, experience, and care for the well-being and survival of the Brazilian population when national health professionals are overloaded and outnumbered.
In addition to those discussions, the shortage of healthcare professionals in outlying regions of Brazil is a chronic issue that the COVID-19 pandemic has exacerbated. The lack of doctors, nurses, and other healthcare professionals in these areas was already a challenge before the health crisis. However, the pandemic has brought to light the urgent need to address this issue. The migration of healthcare professionals to metropolitan and coastal areas is a common phenomenon due to better working conditions, higher salaries, and more developed infrastructure in these areas. This leaves the interior of the country with a significant shortage of medical resources and inadequate healthcare infrastructure to meet the needs of the local population.
In summary, the shortage of healthcare professionals in outlying regions of Brazil is a significant challenge that has been exacerbated by the COVID-19 pandemic. Addressing this issue requires a multidisciplinary approach that includes attracting professionals, local training, telemedicine, education, immigrant integration, and investment in healthcare infrastructure. Ensuring the right to health for all communities, regardless of their location or origin, should be a national priority.
4. The Free Exercise of the Profession and the Integration of the Immigrant
The World Health Organization (WHO, 2020) , through its director-general Tedros Adhanom, declared the coronavirus outbreak as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, and emphasized that “the only way to defeat this outbreak is for all countries to work together in a spirit of solidarity and cooperation” (WHO, 2020) . On March 11, WHO raised the state of contamination to the COVID-19 pandemic, a disease caused by Sars-Cov-2. Observing the emergency that Brazil would have to fight, Law 13,979 of February 6, 2020, was enacted, providing measures to face the public health emergency of international importance resulting from the coronavirus (Brazil, 2020b) .
On March 20, 2020, the Ministry of Health recognized community transmission of the coronavirus (COVID-19) throughout the national territory, determining the adoption of measures by national managers “to promote social distancing and avoid gatherings, known as non-pharmacological measures, meaning they do not involve the use of drugs or vaccines,” recognized the state of public calamity in Brazil, related to the public health emergency of international concern related to the coronavirus (Brazil, 2020c) .
The integration of qualified health professionals from other countries during the pandemic, more specifically immigrant doctors who did not take the National Examination for the Revalidation of Medical Diplomas (Revalida), appears not only as a possibility but as a way to ensure the rights to life and health provided for in Articles 5, 6 and 196 of the Brazilian Federal Constitution (Brazil, 1988) .
According to Article 5 of the Brazilian Federal Constitution (Brazil, 1988) , “all are equal before the law, without distinction of any nature, guaranteeing to Brazilians and foreign residents in the country the inviolability of the right to life, freedom, equality, security, and property” (Brazil, 1988) . Therefore, the integration of immigrants through the possibility of practicing their profession aims to guarantee the right to health for the population, considering the shortage of healthcare professionals, as well as to reduce social inequalities for those seeking a dignified life in a different country.
In this regard, observing some important aspects of immigrants’ rights under the Migration Law (Brazil, 2017) is necessary. These include principles and guidelines by which migration policy should be guided, such as social, labor, and productive inclusion of migrants through public policies, promotion of academic recognition, and professional practice in Brazil.
The free exercise of the profession by immigrants trained in medicine abroad, a fundamental right provided for in Article 5, XIII, of the Brazilian Federal Constitution of 1988, is hindered as they are unable to meet one of the requirements imposed by infra-constitutional legislation, which is the validation examination for foreign diplomas.
As a result, the regular exercise of the profession faces obstacles under Article 17 of Law No. 3268/57 (Brazil, 1957) , which stipulates that doctors can only legally practice medicine, in any of its branches or specialties, after the prior registration of their titles, diplomas, certificates, or letters with the Ministry of Education and Culture (Ministério da Educação e Cultura) and their registration with the Regional Medical Council (Conselho Regional de Medicina) under whose jurisdiction their activity falls. Regarding the prior registration of the diploma with the Ministry of Education, the Law on Guidelines and Bases of National Education, Law No. 9394/96, established in Article 48, §2, that “undergraduate diplomas issued by foreign universities shall be revalidated by public universities that offer courses at the same level and in the same field or equivalent, respecting international agreements of reciprocity or equivalence” (Brazil, 1996) .
However, given the shortage of human resources in the health area during the pandemic, as well as the lack of application of the Revalida exam since 2017, the Federal Public Defender’s Office filed Public Civil Action (Brazil, 2020a) , to hire Brazilian and foreign physicians trained abroad, even if they have not validated the diploma in the national territory, on an exceptional and temporary basis, especially in health units and public hospitals until it occurs overcoming the COVID-19 pandemic.
It is important to mention that granting permanent registration for the practice of the profession is only feasible with a legislative amendment capable of supporting such a decision. This is due to the need to respect the tripartite structure of powers, as the judiciary cannot go beyond its role under penalty of violating the constitutional text, which establishes in Article 60, §4, III, the separation of powers as an entrenched clause.
On the other hand, it is possible to grant temporary registration to these professionals with the Medical Council in times of a pandemic, as well as to initiate a plan to review this impediment, which lacks any plausible justification, especially considering that the quality of medical education in some of these countries is even better. Contrary to this notion, the Union argued for the possibility of the exceptional hiring of doctors during the pandemic, asserting that “waiving the revalidation of foreign diplomas for the emergency recruitment of doctors to combat the COVID-19 pandemic is a risky practice, susceptible to jeopardizing the safety of patients and users of the Unified Health System (SUS) whom these professionals may serve.” (Brazil, 2020a)
However, such registration is possible to the extent that the practice of medicine by foreign doctors in Brazil, without the approval of the Revalida exam, has already been made possible through exchanges carried out by the More Doctors Program (PMMB), established by Law No. 12,871/2013 (Brazil, 2013) . That indicates that foreign-trained doctors are qualified to practice their profession in Brazilian territory except for the requirement of the diploma validation exam mandated by law.
In this way, it becomes necessary to study the motivations behind migrations whether due to natural causes or caused by human actions and their impacts on receiving countries or internally. Moreover, it is crucial to propose solutions for supporting and integrating these groups, enabling the free exercise of the profession during a pandemic scenario and in general. After all, migration calls for implementing quality public policies that offer others their rights, such as a dignified life, through structural and social changes.
5. Conclusion
Returning to the fundamental question presented in the introduction and paraphrasing the philosopher Peter Singer (Singer, 2018) , the flexibility of Revalida for hiring these migrants is the greatest good we can do for all. In this sense, there appears to be an inconsistency when we observe the actions that hinder the hiring of immigrant doctors to address the pandemic in Brazil, given that the practice of the medical profession is a right of immigrants, guaranteed by the principles of equality enshrined in the Federal Constitution of 1988. It is also important to note that the flexibility of the Revalida exam would provide an opportunity for doctors trained abroad, willing to work and just in need of a chance, to contribute to the government and assist the population in extreme circumstances like the pandemic.
Furthermore, it is inconsistent to argue that the flexibility of Revalida violates the principles of liberalism, considering that liberals like Ronald Dworkin and Adam Smith emphasized the importance of egalitarian models that promote human progress. In this regard, we advocate that human dignity should take precedence over any bureaucratic or legal issues that hinder humanitarian efforts. Our position is to support the idea that the flexibility of Revalida is beneficial and safeguards our most valuable asset: life. In this sense, utilitarian arguments that support maintaining Revalida and deny the opportunity for these professionals to save lives in times of scarcity represent a violation of autonomy, dignity, and respect for alterity.
We emphasize again that when this work was written in the middle of 2020, the impending catastrophe was still a “prophecy.” At that time, the World Health Organization (WHO, 2020) had just announced that South America would be the new epicenter of COVID-19, with Brazil being the most affected country. Our original conclusion pointed to the risk of facing an even greater public calamity than what was already being experienced due to the shortage of healthcare professionals. Unfortunately, this prediction has become a reality, and today, approximately three years since the start of this report, we mourn the loss of over 700,000 lives in the country. However, it is crucial to emphasize that many things have changed since then, such as the development and distribution of vaccines and attempts to restore a reality that will never be the same.
For all these reasons, people’s right to health and medical care goes beyond the claims of professional classes, being a matter of humanitarian necessity in times of scarcity. After all, there needs to be a better distribution of doctors in more vulnerable regions, where the presence of healthcare professionals in health units is transient or nonexistent. In this regard, the remaining questions are to how many medical consultations could have been conducted in outlying regions with doctor shortages and how many lives could have been spared during the pandemic if the Revalida had been made more flexible when we were writing this text. Many factors contributed to this foreseen tragedy; however, a substantial factor is the lack of access to healthcare associated with the shortage of doctors in some regions. After all, recent experiences through service-education demonstrate that the flexibility of the Revalida test is a viable alternative to expand healthcare access and integrate immigrant doctors, leveraging their best skills for the benefit of Brazilian society and enabling a dignified recovery through the practice of their profession. Still, there is no plan to review this hindrance that lacks any plausible justification.