U.S. Plan to Lure Nurses May Hurt Poor Nations
By CELIA W. DUGGER
Published: May 24, 2006
As the United States runs short of nurses, senators are looking abroad. A
little-noticed provision in their immigration bill would throw open the gate
to nurses and, some fear, drain them from the world's developing countries.
The legislation is expected to pass this week, and the Senate provision,
which removes the limit on the number of nurses who can immigrate, has been
largely overlooked in the emotional debate over illegal immigration.
Senator Sam Brownback, Republican of Kansas, who sponsored the proposal,
said it was needed to help the United States cope with a growing nursing
He said he doubted the measure would greatly increase the small number of
African nurses coming to the United States, but acknowledged that it could
have an impact on the Philippines and India, which are already sending
thousands of nurses to the United States a year.
The exodus of nurses from poor to rich countries has strained health systems
in the developing world, which are already facing severe shortages of their
own. Many African countries have begun to demand compensation for the
training and loss of nurses and doctors who move away.
The Senate provision, which would remain in force until 2014, contains no
such compensation, and has not stirred serious opposition in Congress.
Because it is not part of the House immigration bill, a committee from both
houses would have to decide whether to include the provision on nurses if
the full Congress approves the legislation.
Public health experts in poor countries, told about the proposal in recent
days, reacted with dismay and outrage, coupled with doubts that their nurses
would resist the magnetic pull of the United States, which sits at the
pinnacle of the global labor market for nurses.
Removing the immigration cap, they said, would particularly hit the
Philippines, which sends more nurses to the United States than any other
country, at least several thousand a year. Health care has deteriorated
there in recent years as tens of thousands of nurses have moved abroad.
Thousands of ill-paid doctors have even abandoned their profession to become
migrant-ready nurses themselves, Filipino researchers say.
"The Filipino people will suffer because the U.S. will get all our trained
nurses," said George Cordero, president of the Philippine Nurse Association.
"But what can we do?"
The nurse proposal has strong backing from the American Hospital
Association, which reported in April that American hospitals had 118,000
vacancies for registered nurses. The federal government predicted in 2002
that the accelerating shortfall of nurses in the United States would swell
to more than 800,000 by 2020.
"There is no reason to cap the number of nurses coming in when there's a
nationwide shortage, because you need people immediately," said Bruce
Morrison, a lobbyist for the hospital association and a former Democratic
The American Nurses Association, a professional trade association that
represents 155,000 registered nurses, opposes the measure. The group said it
was concerned the provision would lead to a flood of nurse immigrants and
would damage both the domestic work force and the home countries of the
"We're disappointed that Congress, instead of providing appropriations for
domestic nursing programs, is outsourcing the education of nurses," said
Erin McKeon, the group's associate director of government affairs.
Holly Burkhalter, with Physicians for Human Rights, an advocacy group, said
the nurse proposal could undermine the United States' multibillion-dollar
effort to combat AIDS and malaria by potentially worsening the shortage of
health workers in poor countries. "We're pouring water in a bucket with a
hole in it, and we drilled the hole," she said.
There are now many more Americans seeking to be nurses than places to
educate them. In 2005, American nursing schools rejected almost 150,000
applications from qualified people, according to the National League for
Nursing, a nonprofit group that counts more than 1,100 nursing schools among
One of the most important factors limiting the number of students was a lack
of faculty to teach them, nursing organizations say. Professors of nursing
earn less than practicing nurses, damping demand for teaching positions.
Under the current immigration system, experts estimate that 12,000 to 14,000
nurses have immigrated to the United States annually on employment visas
that entitle them to bring their immediate family members and obtain green
cards. They must pass English and U.S. nursing exams to qualify for visas.
In recent years, there had been enough visas for foreign nurses from most
countries, but a bottleneck developed in 2005, after immigration authorities
made a big push to clear a backlog of employment visa applications. That
year, Congress set aside 50,000 additional visas for nurses and their
families. But those visas will likely have all been used up by early next
year, State Department officials said.
It is difficult to forecast exactly how removing the limit on nurse
immigration would affect the number of nurses who moved to the United
Based on past trends, Mr. Morrison, the lobbyist who represents the hospital
association, said he thought the numbers would grow 5 to 10 percent a year
over recent levels. Recruiters would focus on countries with large numbers
of well-trained nurses, mainly the Philippines, India and China.
"But it's certainly true that the longer the United States puts off
investing in training nurses, the more pressure there will be to find nurses
abroad," he said.
Senator Brownback, who has been an advocate for programs to combat AIDS and
malaria in Africa, said he did not think lifting the cap on nurse migration
would have much effect on Africa because the infrastructure of companies
that did recruiting for the United States market was not set up there, nor
did African nurses have a big community there to plug into.
And while the Philippines could see an increase in nurse immigration, such
flows could also bring benefits, he said, not just in the money they sent
home, but in the nurses' voluntary efforts to improve health care in their
But Eric Buch, the top health adviser to the New Partnership for Africa's
Development, an Africa-wide undertaking initiated by the continent's heads
of state, said he expected that recruiting agencies would set up in African
countries where nurses were trained in English and that they would advertise
the change in the American law.
"You'll see that emerge, that's my guess," Professor Buch, who teaches
health policy at the University of Pretoria, in South Africa, said in a
telephone interview. "The United States could become a place where we bleed
our health care workers."
The flight of nurses from the Philippines, a former American colony, has
provided a huge boost to a weak economy, through remittances. Some
government agencies there have encouraged the export of nurses, who send
home billions of dollars each year to their families.
A nurse in the Philippines would earn a starting salary of less than $2,000
a year compared with at least $36,000 a year in the United States, said Dr.
Jaime Galvez Tan, a medical professor at the University of the Philippines
who led the country's National Institutes of Health.
He said the flight of nurses had had a corrosive effect on health care. Most
Filipinos died without medical attention in 2003, just as they had three
decades earlier. And the percentage of women who gave birth with a doctor,
nurse or midwife attending has declined in recent years.
Based on surveys, Dr. Galvez Tan estimates that 80 percent of the country's
government doctors have become nurses or are enrolled in nursing programs,
hoping for an American green card. "I plead for justice," he said in a
telephone interview. "There has to be give and take, not just take, take,
take by the United States."