Open Letter To President Carter
Editor's note: This op-ed is in response to op-eds written by Immigration Attorney Greg Siskind and the response from President Carter.
I was disappointed to read your USA Today
editorial on international health care recruitment, especially because I am
such a big fan of yours. I began following your policy initiatives
closely when I was an intern for Senator Bayh in 1978, and your embracement of
human rights inspired me to seek a career in immigration law. I am
sending this letter because I know you as a uniquely dedicated, compassionate,
and principled former leader of the free world. No one doubts that the
statistics you cite are true, and reflect the horrible conditions in
Africa. I share your concern for the
millions of sick and dying people in Africa
and other impoverished areas around the world.
I hope your assistant who is reading this
for you will pass this letter on to you.
You mentioned international nurses in
your article. I am not an expert on international doctors. I have much more
experience with international nurses. I have helped many nurses come to
the US, I speak with them every day,
and I recently finished editing a comprehensive book on Nurse Immigration and
Migration. This book contains articles on all aspects of international
nursing, including technical immigration issues, international trends, nurse
perspectives, and several articles on the economic issues of health care
worker migration, written by leading international experts in the field.
Working with these authors I came to learn that the old "brain drain" paradigm
simply does not reflect reality and promotes a distorted oversimplification of
what is happening with health care migration. Brain-gain,
brain-circulation and related issues are continually debated by international
economists, with no clear consensus. But there is a very strong argument
that nurse mobility is a win-win strategy.
Your article reminds me of a front-page
New York Times article on Philippine nurses by Celia Dugger (Plan to Lure
Nurses May Harm Their Homelands, May 24, 2006). The vast majority of
foreign nurses come from the Philippines. With what I am
sure were the best of intentions, Ms. Dugger painted a completely inaccurate
portrait of nursing and nurse migration, leaving the impression that Americans
were plotting to steal "their" nurses, leaving poor people to suffer and die.
It all looked like a quite dramatic exposé, but it was
just wrong. The idea that there is a shortage of nurses in the
Philippines is plainly
absurd. All those nursing schools were created for the express
purpose of training nurses to work abroad. Filipino nurse migration is
an enthusiastically embraced national policy. The Philippine Overseas
Employment Authority and the Office of Workers Welfare Administration were
designed to facilitate the deployment of its workers abroad. The country
trains many more nurses than the country could afford to hire, specifically
for the purpose of emigration. The Philippines has hundreds of nursing schools,
most subsidized by the government, and the vast majority of graduates, 85%,
leave to seek employment elsewhere, especially in the US, Europe, Australia, and the Middle
East. They gain their training by volunteering their
services, because there are no jobs. There is a shortage of nursing jobs, not
nurses. The only reason these bright young men and women go into nursing
in the first place is because of the global opportunities that await
them. The Philippines has too many nurses, on
purpose. Nurse emigration is one of the best things that ever happened to the
Philippines, and to young Filipinos
A similar educational phenomenon is occurring in
India, where hundreds of new
nursing schools have opened in the past two decades. Yet more than 50%
of their nurses are unemployed. As we saw with IT workers from India, many are training
specifically to travel abroad. Anyone with even a passing interest in
global economics can see that India has not suffered from this
professional mobility. Most of these traveling professionals send
desperately needed money home, and many return home to raise families after
several years abroad.
Remittances to developing nations,
briefly mentioned in the Times article, total $200 billion to $300 billion per
year. Because of their informal nature, remittances are impossible to
measure with complete accuracy, but the Institute for Labor Studies (Manila)
estimates that the Philippines alone receives over eight billon dollars a
year, over 10% of its GDP.
In the Times article, Ms. Dugger’s
biggest fault was laziness. She did not take the time to learn about the
subject. She got some great quotes from what seemed like respectable
sources (one of whom has since been arrested for nurse credentials fraud), but
she did not have the knowledge to put the information in perspective.
The Times editorial page later issued a vague half-hearted regret, citing the
importance of nurse migration and the human rights issues involved, but the
damage had been done.
For the past several decades, registered
nurses have entered the U.S. (after thorough credential
reviews, language reviews and background checks) to fill work shortages.
Until recently typical RN visa processing time was about a year, but now visas
have become unavailable. There is now a five-year backlog and only a few
nurses are trickling in.
Congress has not moved to eliminate all
immigration restraints on foreign nurses. Temporary, limited, visa
availability has been discussed in some committees. All of the long,
difficult, credentials evaluations, training and experience reviews, spoken
and written English tests, security checks, and other restraints would
remain. Even the most modest considerations are being blocked by Senator
Richard Durbin. Senator Durbin has stated that foreign nurses are
causing the nurse shortage. He has even suggested that hospitals hiring
foreign nurses should pay at penalty of $20,000 per nurse, because that is
what it costs to train a nurse. I have no doubt that Senator Durbin has the
best of motives, and actually believes this, but is a bit troubling that such
a powerful man is so misinformed on this issue.
Foreign nurses didn’t cause the nurse
shortage – it is a product of demographics, and lack of long-term planning in
nurse education, and to some extent working conditions. The RN schools are
full. There are many thousands of qualified applicants turned away every
year. Everyone agrees that we should be opening more nursing schools and
training more nursing teachers, as quickly as possible. This is where
our domestic efforts should be focused. The problem is that there are not
enough trained and educated nurse teachers available to open new nursing
schools, and it will take many years to get new schools accredited and opened,
no matter how much money is spent now. In the mean time the current
U.S. shortage of nurses, with real,
high-salaried jobs available now, will grow from 200,000 to twice that, or
more, in the coming years.
Highly skilled, qualified, and dedicated
foreign nurses (perhaps 10,000 to 20,000 per year, based on past levels) are
obviously not a cure-all to such a huge problem, but offer some partial
amelioration for needy patients, especially in the hard-to-fill positions in
sub-acute and long-term care.
There is absolutely no evidence that any
health care facility is hiring foreign nurses rather than contributing to
homegrown nurses. The nurse shortage is so severe that hospitals are
trying everything they can, including bigger bonuses, better compensation,
improved work conditions, training programs, and other retention strategies.
Unfortunately, the biggest result is re-circulation of the same nurses from
one facility to another. Until the nursing school capacities increase,
there are not many options available to hospitals.
Americans are literally dying every day because of the
shortage of nurses, and we should do whatever we can to
Clearly conditions are horrible in the countries you
mentioned. The health care crisis in Africa is tragic, but overwhelmingly a result of poverty
and corruption, not nurse mobility. Most nurses in sub-Saharan
Africa are either unemployed or paid a
pittance. In Nairobi alone, there are over 8000 idle,
unemployed nurses. Many are driven from their countries by war, famine,
and disease. As you know, in several countries, the death rate from
infectious disease for these health care workers is very high. Based on
census records of the largest nine receiving nations, there are approximately
70,000 nurses who have migrated from Africa to wealthy countries in the past
two decades, compared to approximately 760,000 nurses in Africa now. Even assuming that all these nurses
were trained in Africa and left to pursue RN jobs abroad, we are looking at an
aggregate of approximately 8%, a significant figure, but similar to migration
patterns in Europe and Asia.
One of the key sources of confusion is in defining
what a "shortage" is. There are two very different types of
shortages. In the US, we have a classic market
shortage of RNs, which means there are at least 200,000 high-salaried
positions open today, just waiting for qualified candidates. In the
developing world, there is no such shortage. There we see a "moral"
shortage of health care, and just about everything else. There we see
people dying by the thousands from lack of care, not because there are no
health care workers to fill vacant positions, but because these countries lack
the resources to build the needed medical infrastructure and offer real
careers to health care workers. It is horrible. We wish it wasn’t true, and we
want to find people to blame.
Most people do not make that important distinction,
and I often hear people in the field succumb to the zero-sum perspective,
saying such things as "well, there are only so many nurses in the
Health care conditions in Africa are tragic, but health care worker migration is
not. And hiring unemployed or miserable nurses is not selfish. These
nurses are not chattels; they are intelligent, thoughtful people, with an
inherent right to seek a better life. Talk to them. Learn about them.
This opportunity, that most of us take for granted, has given these nurses and
their families previously unimaginable independence and empowerment
(especially for women). The rights of these people should not be a
peripheral side issue, to be mentioned in passing as a "perhaps."
People listen to you. Political and social
leaders take you very seriously. You are greatly respected, not only for
your knowledge of the world, but more importantly for your
integrity. I would like for you to consider the potential harm of
migration restrictions. Should we tell Indian and Filipino nursing
students to quit school? To give up hope?
Approximately 20,000 people in the U.S.
die every year because of unavailable nursing care. No one in the
India dies because a nurse
migrates to the U.S. Not one. In fact
they have many more nurses available because of the overseas employment
incentive. And, because of this global mobility, our planet now has many, many
thousands more dedicated professional nurses.
A couple of months ago, one of my clients, a nurse
from Manila, was working the 11-7 overnight
shift in a sub-acute ward near Boston. This is a shift that is perpetually
understaffed – there are no U.S. nurses available. In her
rounds she noticed a door that would not open. She was able to pry the door
open and found the patient, recovering from difficult and painful surgery, had
blocked the door and cut his wrists. The foreign nurse, who was
unemployed in the Philippines, was able to stop the
bleeding enough to keep him alive. This patient would have died if she had not
been there, but he has since recovered and is home with his family. No
one keeps tracks of stories like these, or of the grimmer stories when help is
The "obvious solution" is indeed to increase the
number of healthcare workers throughout the globe. The best American
policy is not based on restrictions and reprimands, but on opportunity and
hope. The best way to do that is to follow the examples of the
Philippines and India
and give dedicated young men and women around the world the opportunity to
become working nurses.
I hope you can help to correct some of these serious
inaccuracies about these critical issues. But even if you won’t, please
keep up your good work around the world. You are truly an
Reprinted with permission from Joseph Curran.
About The Author
Joseph Curran is a partner in Curran & Berger Law Firm. He has been exclusively involved in the practice of immigration and nationality law since 1985, with experience representing clients in all aspects of this area of law.
The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.
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