June 29, 2006 -- Many recent articles have addressed the flow of nurses from developing nations to the United States, in the context of the proposed easing of entry restrictions in the immigration bill that passed the Senate in May. On May 24, The New York Times ran Celia Dugger's "U.S. Plan to Lure Nurses May Hurt Poor Nations." This piece is a very strong, front-page examination of the state of nurse immigration to the United States, and the likely effects of eliminating the current restrictions. Dugger carefully presents different sides of the debate, citing the remittances the immigrating nurses send back home and the devastating blow to the home nations' health resources, including a weakened ability to fight diseases like AIDS. The Times followed up with a half-baked May 27 editorial, "For Want of a Nurse." For all its flaws--the most glaring being the suggestion that the generation of nurses now nearing retirement chose the profession solely because they did not want to teach--the editorial does urge the nation to start solving its nursing shortage "on its own," particularly by spending more on nursing education. Coverage of nurse emigration after the Senate bill's passage suggests that it would likely increase if the bill became law. Nida Mariam's June 18 piece in Daily News & Analysis (Mumbai, India), "City wakes up to nurse exodus," suggests that easing the U.S. restrictions would contribute to an already severe nursing shortage in India. There, many new nursing school graduates head abroad and hospitals suffer from extreme short staffing. Today the CNN site posted a fairly good unsigned Associated Press piece, "Nurses lead Kenyan brain drain." It highlights the immigration to the U.S. of Kenyan nurses who are desperate to support their families. And it suggests that easing the restrictions would have a real impact in Africa, not just in the Asian nations from which most nurse immigrants have traditionally come.
Nurses "largely overlooked"
Dugger's May 24 "U.S. Plan to Lure Nurses May Hurt Poor Nations" reports that the Senate bill's removal of the limit on the number of nurses who can immigrate has been "largely overlooked in the emotional debate over illegal immigration." However, some fear it would "drain [nurses] from the world's developing countries" to the U.S., which "sits at the pinnacle of the global labor market for nurses." Dugger notes that many African nations have begun to ask for compensation for the "training and loss of nurses and doctors who move away," compensation the new bill does not provide. Indeed, as the piece notes, the United States has trouble training those of its own citizens who wish to become nurses. It notes that the National League of Nursing says U.S. nursing schools rejected almost 150,000 "qualified" applicants in 2005, and that a key reason is the shortage of faculty, who "earn less than practicing nurses."
The piece quotes bill supporter Senator Sam Brownback (R-Kan.) as saying that the bill would help ease the U.S. shortage, and that while it might affect the Philippines and India, which send thousands of nurses to the U.S. each year, it would be unlikely to have a big impact on Africa, which has not traditionally sent as many. Brownback also argues that the Philippines would benefit from remittances and (in Dugger's words) "the nurses' voluntary efforts to improve health care in their home countries." The nature of those efforts is not explained. The piece does report that remittances have provided the Philippines with "a huge boost to a weak economy," and some government agencies there have even encouraged nurses to go. The American Hospital Association also strongly supports easing the U.S. restrictions, and AHA representative Bruce Morrison contends that there's no need for a cap "when there's a nationwide shortage." Morrison does allow that "the longer the United States puts off investing in training nurses, the more pressure there will be to find nurses abroad."
Dugger describes opposition to the measure in some detail. The American Nurses Association's Erin McKeon suggests that Congress is "outsourcing the education of nurses" rather than supporting domestic nursing programs. The ANA reportedly fears the bill would damage the nurses' home nations and the U.S. work force. The piece does not explain how it could hurt U.S. nurses, but it seems pretty clear that foreign nurses new to the U.S. would find it much more difficult to advocate for themselves and their patients. And Holly Burkhalter of Physicians for Human Rights argues that the proposal could harm efforts to combat diseases like AIDS and malaria in the developing world by worsening shortages of health workers.
Dugger also reports that "public health experts" in poor nations "reacted with dismay and outrage" to the proposal. The piece suggests that it could have an especially strong impact on the Philippines, where "[t]housands of ill-paid doctors have even abandoned their own profession to become migrant-ready nurses themselves." Dr. Jaime Galvez Tan, a "medical professor" at the University of the Philippines and former head of the nation's National Institutes of Health, is later quoted as saying that 80% of the nation's government physicians have either become nurses "or are enrolled in nursing programs." This makes clear, at least to the careful reader, that physicians cannot automatically become nurses. Galvez Tan told Dugger: "I plead for justice. There has to be give and take, not just take, take, take by the United States." Philippine Nurse Association president George Cordero says that the "Filipino people will suffer because the U.S. will get all our trained nurses. But what can we do?" And Eric Buch, a health policy professor at the University of Pretoria and the top health advisor to the New Partnership for Africa's Development, predicts that recruiting agencies will target African nations where nurses were trained in English, and that "the U.S. could become a place where we bleed our health care workers."
Taking nurses for granted
On May 27, the Times ran the editorial "For Want of a Nurse." It argues that the U.S. has long taken nurses for granted, and that it should pay them better, but it oversimplifies the problem and potential solutions. The piece rightly notes that the nation traditionally relied on the limited career options for women to provide "highly qualified people working for extremely low wages." But "women's liberation" has produced a "drastic shortage of teachers and nurses." It says the problem is especially acute now that the aging U.S. population faces "the coming retirement of the last generation of women who chose nursing simply because they didn't want to teach." This statement suggests that any rational career seeker would consider teaching first, and that there would be no specific reason for women to choose nursing other than the generalized desire to work outside the home--you know, a reason like saving lives. The idea that expanding job opportunities for women is solely responsible for the nursing shortage is also a huge oversimplification. That has of course been a factor for decades, but the most immediate reason for the current shortage is the managed care-driven short-staffing that has driven nurses from the bedside. A more basic one is the gross undervaluation of the profession--like suggesting its most senior members chose it solely because they didn't want to teach--that has led to a lack of adequate clinical and educational resources.
The editorial mentions Dugger's piece and the plight of the poor nations losing the "scant cream" of their health workers. But it declines to suggest that any limits should be placed on the recruitment of nurses from those nations, apparently because it thinks that would be inconsistent with its position that "unskilled illegal immigrants should be given a path to potential citizenship." But of course, the issue here is not what to do with foreign nurses who are already in the United States, but what the nation's policy should be for visas and the activities of nurse recruiters, and more basically, why we can't find enough home-grown nurses. To its credit, the editorial does argue that the U.S. must start trying to solve the problem "on its own," and to that end rightly recommends increased government spending on nursing education, especially faculty. That would at least allow the nation to train more of the apparently qualified people who now want to be nurses. The piece also notes that despite rising salaries, nurses still complain of low pay, and it suggests that the nation still "does not seem to have quite adjusted to the idea" that nurses actually wish to be paid. The editorial has the following to say about working conditions:
But like doctors and other medical practitioners, [nurses] also report dropping job satisfaction because of the pressures of modern cost-driven medical care. Their dissatisfactions mirror those of today's patients: too few medical workers serving too many very sick people. And none of those things are going to be solved on the cheap.
This is OK, but "dropping job satisfaction" doesn't quite capture the effects of the short-staffing that many nurses report has driven them to the brink of exhaustion and despair. It also suggests that nurses are just complaining about something that all health workers now face, but we are not aware that the staffing pressures on those other workers have helped to created shortages of crisis proportions. In fact, some recent research suggests that nurse staffing could be greatly improved without a significant net cost because of efficiencies such as the likely drop in needless errors and complications. Finally, the editorial fails to note that the most important consequence of the nursing crisis is not "dissatisfaction," but needless deaths.
The city "wakes up"
A fair June 18 piece in the Daily News & Analysis (Mumbai), Nida Mariam's "City wakes up to nurse exodus," describes how these pressures work in one of the nations that is sending nurses to the U.S. The piece reports that the Indian health care system is already hurting because of the flow of nurses to Europe and the Gulf States. But now the U.S. is also luring the nurses, it says, and the immigration bill the U.S. Senate passed would make it even easier for Indian nurses to emigrate. The piece reports that about 18 of 20 nursing graduates from "a prestigious nursing college" now go abroad (presumably meaning each year). It quotes health experts who say that the outflow deprives developing nations of basic health services and the resources they have spent on the nurses' educations. One local recruiting agency executive answers that such emigration could benefit India just as "outsourcing" has. The piece does not note that there have been few complaints that traditional outsourcing has deprived developing nations of vital skills and threatened lives. But it does close with a short discussion of nurse short-staffing in India. "M. Panderkar, head matron, JJ Hospital," notes that the government does not hire nearly enough staff to meet international nurse-to-patient ratio standards. The piece also quotes one "student nurse" as saying that "you're giving intravenous there, while doling out pills there, and then you're running to answer the phone. There is no time to observe the patient."
A June 29 Associated Press piece, "Nurses lead Kenyan brain drain," suggests that the proposed change to the U.S. immigration law could have a significant effect even in African nations that have traditionally sent fewer nurses to the U.S. The piece tells the story of Carolyne Mujibi, a Kenyan nurse who is preparing to leave for the U.S. It says she is one of "thousands of overworked, unemployed and underemployed nurses, teachers and other professionals leaving East Africa's largest economy for more lucrative opportunities" throughout the world. The piece notes that despite the huge foreign remittances these workers send home--Kenya received at least $500 million last year--this "brain drain" is "making it harder for Africa to pull itself out of poverty." Mujibi, who lives in a one-room house, has been studying for the U.S. nursing certification exam for months. She "hopes to take advantage of proposed U.S. immigration laws that would allow more visas for nurses." She wants to help her family, and to pay for her siblings' educations. Mujibi cites nursing colleagues who have gone to the U.S. and quickly saved enough money to build relatively modern homes for their parents back in Kenya. The piece reports that Kenya actually has 7,000 unemployed nurses. But the government says it has no money to hire them--despite the intense need in what National Nurses Association president Frederick Omiah says is a nation of 34 million "beset by HIV/AIDS, malaria, tuberculosis, respiratory and intestinal ailments as well as other diseases."
"The lure of America"
The above AP piece's final section is entitled "The lure of America" (in some publications). It reports that the U.S. is "a major draw" for African nurses because of its "quality of life as well as an aging nurse work force, low enrollment in nursing schools and increasing demand for nurses by the aging baby boomers." The piece includes statistical data to support this impression, including the wealth of new nursing jobs expected over the next decade, and the failure of U.S. nursing schools to keep enough faculty. It closes with a quote from U.S.-bound nurse Mujibi:
I love Kenya and if I'd get a good job, I'd never go anywhere else...Going out there is a big risk. It is a new culture, you have to adapt, but you find the benefits are so big that it is worth it.