About the Author: Beth Schlachter is a program officer in the Office of Population and International Migration at the Department's Bureau of Population, Refugees and Migration. She recently spoke with Todd Pierce, the Bureau's public affairs advisor.QUESTION: You've become the State Department's expert on the migration of health workers. What's the issue all about? And what does it have to do with the U.S. State Department?
MS. SCHLACHTER: The problem is that there is a massive global shortage of health workers – the World Health Organization (WHO) estimates a current worldwide shortage of around four million. This includes all categories of medical professionals, such as doctors, nurses and midwives. The migration of health workers from poor countries to rich ones contributes to keeping health care systems in many developing countries weak.
This is an issue with a big foreign relations component, so the State Department is involved in the U.S. government’s response. Discussions at WHO and the G-8 have focused on efforts to define international standards for the "ethical recruitment" of health workers, and on ways to mitigate the negative effects of migration on the heath care systems in poor countries.
However, since professionally trained health workers are in such high demand on the international labor market, we have a complex international phenomenon that isn't easily addressed. For example, some countries, such as the Philippines and Pakistan, produce excess health workers for overseas employment because they value the remittances these workers provide, and the Philippines has set up an effective mechanism to monitor the companies which recruit there. Other countries, such as Ghana, have been devastated by an exodus of health workers in the past decade, while still others, such as South Africa, are both migration "source" and "destination" countries for health workers.
Obviously the United States doesn't have a nationalized health care system, but we do facilitate the migration of health workers through a variety of favorable visa policies. We also allocate billions of dollars every year to strengthen health systems and address the "push" factors that lead health workers to seek opportunities abroad, such as poor economic conditions in countries of origin, low job satisfaction, unsatisfactory or even dangerous working conditions, and inadequate career opportunities.
QUESTION: That sounds like a daunting problem. What is the U.S. doing to mitigate "brain drain?" It seems weird to be helping countries develop their public health infrastructure and then to allow their doctors and nurses to come work here.
MS. SCHLACHTER: Our response is based on the belief that health workers have as much right legally to migrate as any other type of worker, and that they personally should not be held to an arbitrary "moral" standard because they work in healthcare, rather than, say, information technology. This type of value judgment fosters the belief that health workers from poor countries are behaving in an unethical manner when they seek better opportunities overseas. We believe that responsibility for the viability of a health system belongs with the governments that oversee national health systems, not with the individual citizens who may be working within those systems, sometimes heroically and at great personal cost to their professional development and personal safety.
We’re also concerned that efforts to protect vulnerable health systems by limiting international employment opportunities for health workers based on where they come from could lead to employment discrimination.
Through our foreign aid programs, the U.S. addresses the "push" factors that cause people to want to migrate in the first place. For example, since 2004 one quarter of the $18 billion President's Emergency Plan for AIDS Relief (PEPFAR) program has gone to build hospitals and clinics and train nearly 2.6 million doctors and nurses.
QUESTION:Don’t we want to have foreign nurses and doctors here? If we discourage migration of doctors or nurses, will there be enough staff for our hospitals? Especially with our aging population…
MS. SCHLACHTER: The U.S. is facing a critical shortage of health workers in the coming decades for many complicated reasons: we’re under-producing health care workers to meet demand; many health care workers who train in the U.S., especially nurses, leave the profession mid-career for non-health care occupations; and we have difficulties staffing health facilities in rural and densely populated urban areas.
We’re also facing the retirement of a large cohort of health care professionals in the next ten years, which will take place simultaneously with rising consumer demand for health services from an aging population and increased demand for specialized services. This is complicated by projections that the U.S. population will grow somewhere between 14-18% by 2020, which means roughly 50 million additional people. Training sufficient numbers of health workers to meet the needs of this expanding population will be an enormous challenge.
Though the U.S can’t expect to meet all of this demand through the immigration of skilled workers, such workers are and will continue to help alleviate the problem. Based on 2000 census figures, 13% of health care providers are foreign born, which tracks closely with the percentage of all U.S. workers who are immigrants, 12.4%. Within the health sector, 25.2% of physicians and 17% of nurses and psychiatric and home health aides are foreign born.
QUESTION: What sort of arrangements are you making with the Department of Homeland Security (DHS) to make it easier for doctors or nurses to come to the U.S. and to stay? Is there any program in place that would allow doctors or nurses to practice part-time in the U.S. and part-time at home?
MS. SCHLACHTER: Most foreign doctors come to the U.S. to complete their graduate medical training and residency programs before they've started a professional career, and after living and working in the U.S. for a number of years, they often decide to stay and continue to build their lives here. Graduate medical students can come to the U.S. to study on a J1 exchange visitor visa, or on an H1B visa if they only need to complete a two-year residency program. If they've come on an H1B visa they can usually adjust their status through DHS to legal permanent resident without too much difficulty if they choose to do so after completing their residency program. However, if they're on a J1 visa, they must return home for two years once they have completed training.
A waiver is available of the two-year foreign residency requirement if a state or an interested federal agency sponsors the physician to work in a hard-to-fill area or specialty within the state for three years as a non-immigrant in H1B status.
Nurses immigrating for work purposes typically enter the U.S. using Employment Third Preference (E3) immigrant visas, which are subject to an annual cap shared among a variety of skilled worker categories, including individuals who are already in the U.S. and are adjusting their status through DHS. They can also be eligible for the special H1C visa category that was authorized by Congress through 2009 to allow registered nurses to work in disadvantaged areas for up to three years.
There's been a lot of discussion about establishing programs that allow for "circular migration" programs, but so far the U.S. hasn't established any formal exchange programs for health care workers who wish to split their time between the U.S. and their home country. Many private medical associations and medical schools have organized creative professional and educational exchange programs, however.
QUESTION: What areas of the U.S. have the most foreign-born doctors and nurses? The fewest?
MS. SCHLACHTER: Like most countries, the U.S. struggles to attract workers to traditionally underserved areas, such as in rural and inner-city communities, and in particular specialties, such as pediatrics, psychiatry, obstetrics and in general practice. Many foreign trained doctors elect to work in these areas because of the J-visa waiver program. Foreign trained nurses, on the other hand, are not offered any sort of visa incentive to work in underserved areas. However, since regions throughout the U.S. are struggling to address nursing shortages, foreign trained nurses can be found working in most communities across the country. They are more evenly dispersed throughout the medical system, though many find that when they are initially recruited to work in the U.S., it’s for placement in extended care facilities.
QUESTION: How did you become interested in this issue? Did you ever want to be a doctor, nurse or midwife?
MS. SCHLACHTER: I was never a pre-med student, but as a Peace Corps volunteer in Guinea I was assigned to a rural health clinic as a health extension worker. Later, in my first Foreign Service post as the Regional Human Resources Officer in Kampala, Uganda, I spent a significant portion of my time helping the office of the Centers for Disease Control with HR issues. CDC was the agency with the largest locally-employed staff at post because they were running two, large research programs, one near the capital in Entebbe and another near the border with Kenya, in Tororo. The Tororo office was developing a home-based, anti-retroviral drug distribution program that could be duplicated in rural settings around the world; it was an attractive employment opportunity because they offered higher salaries relative to the local standard. Because CDC felt they were contributing to "internal brain drain," that is, drawing workers out of the national health system, sometimes "under employing" them in positions below their education and training, the USG tried to mitigate this effect by creating a two-tiered pay schedule, one for Entebbe and another for Tororo.
Though the intent was to behave "ethically" by creating a disincentive for health workers to leave the national system, what we really created was a morale problem for our staff who felt unappreciated and disrespected. We weren't even effective in discouraging health workers from coming to work for us - even at a pay schedule closer to the local standard there were other attractive factors that we couldn't manage, such as the opportunity to conduct research with U.S. based medical professionals, travel and training opportunities, and the prestige of working for the U.S. Government. So I learned firsthand how complicated this issue is to manage, and how difficult it can be to do what you perceive to be the right thing on behalf of other people in the workplace.