- BIOETHICS FORUM ESSAY
We Need International Medical Graduates to Help Fight Covid-19. Immigration Policies Keep Them Away
As the U.S. health care system faces the strain of responding to the coronavirus pandemic, critical services are being provided by international medical graduates, who, in the years and months leading up to this crisis, have found their capacity to contribute limited by increasingly restrictive immigration policies.
International medical graduates, physicians trained in other countries, are an essential part of an already fragile and increasingly threatened social safety net in the United States, particularly in areas of rural poverty, and are critical to addressing a growing physician shortage and distribution problem. In West Virginia, for example, among the poorest U.S. states and already facing a staggering opioid epidemic and high rates of chronic disease, international medical graduates comprise almost 28% of all practicing physicians. On top of its already significant health burden, West Virginia can now expect that up to 51% of its adult population is at increased risk of developing serious illness if infected with COVID-19. International medical graduates in the U.S. as a whole account for substantial proportions of physicians. Yet recent moves to expand restrictions on immigration to the U.S. have made the lives of many international medical graduates increasingly precarious and undermined their capacity to contribute to the health system. These policies, coupled with anti-immigrant sentiment and ongoing uncertainty about immigration status, amplify the emotional and logistical burdens many international medical graduates face.
Migration of health care workers is ethically challenging because it both exacerbates and helps to solve a persistent problem of health care justice: disadvantaged groups in all parts of the world are underserved in terms of the care accessible to them. Strategies to stem the flow of health workers from sending countries, such as compulsory service, raise tensions between health workers’ rights and liberties and the urgent health needs of underserved populations. Immigration policies in receiving countries that make it more difficult for international medical graduates to train and work there might be considered a partial solution for the injustices magnified by medical migration.
Yet immigration policies that constrain international medical graduates’ capacity to contribute to the health system in receiving countries risk trading one form of injustice for another. Coupled with a climate hostile to immigrants these policies can exacerbate existing health inequities in countries like the U.S. that cannot meet their health care obligations without international medical graduates. In addition, immigration policies that negatively impact international medical graduates disregard moral responsibilities held by government institutions and the communities that international medical graduates serve—moral responsibilities to support them in return for their contributions to the capacity of the health system to serve its neediest communities. Reciprocity, meaning proportional return for contributions made, is an important ethical justification for extending rights and benefits to immigrants. In the case of international medical graduates, reciprocity requires, in addition to other forms of support, immigration policies that accommodate and support their work and lives.
A public health crisis puts into sharp relief the close relationship between health, well-being, and social justice. It is when our health is threatened that we recognize most acutely the moral urgency of our collective claim to “the hightest attainable standard of physical and mental health.” Like other core elements of social justice, such as education or social security, government institutions assume (at least some) moral responsibility for ensuring equitable access to essential health care services for everyone. Meeting this responsibility requires access to skilled and motivated health workers.
Recent analyses highlight that critical health care roles in the U.S. are filled by international medical graduates from countries targeted in President Trump’s 2017 executive order restricting travel to the U.S. from eight (later seven) Muslim-majority countries. The American Medical Association has argued that this executive order will have negative consequences for the U.S. health care system, including by exacerbating workforce shortages. That order has since been extended to include 13 countries, making its impact on the U.S. health care system likely to be even greater. The current public health crisis will no doubt make the consequences of this order more immediately apparent. In an amicus brief urging the Supreme Court to reinstate an injunction against a later iteration of the order, the Association of American Medical Colleges, with other professional organizations, notes that the health care workforce in the U.S. “relies upon health professionals and scientists from other countries to provide high-quality and accessible patient care.” It argues that “a fair and efficient immigration system strengthens the American healthcare system and advances the nation’s health security.” Advancing health security through robust support for international medical graduates helps to ensure that the U.S. has the health workforce capacity to provide equitable access to health care during crisis events like the current COVID-19 pandemic.
Given all the benefits it receives from international medical graduates, the U.S. health care system has reciprocal responsibilities to support them in residing, training, and practicing in the U.S. These responsibilities exist at at least three levels, and reflect deficits in the current U.S. health care system that cannot be fully remediated without immigrants. First, at the federal level, the responsibility to support international medical graduates includes making immigration policies more hospitable to them, for example, by not imposing policies that leave them unable to re-enter the U.S. after traveling abroad and developing flexible policies that allow them to work, travel, and support their families at home and abroad. Second, at the institutional level, organizations and programs that employ and train international medical graduates have a responsibility to provide support tailored to the specific challenges that they face practicing in a new country, especially in rural regions. Such challenges are related to cultural and language differences, skepticism about their competence, and other forms of workplace bias and discrimination. Some of these challenges can be addressed by institutional- or program-level initiatives, such as mentoring, and policies that reduce workplace discrimination and increase cultural awareness. More importantly, meeting institutional responsibilities requires explicitly and publicly valuing international medical graduates’ contributions to the communities they serve. This means respecting and promoting them in their institutions and broader communities as skilled professionals who offer much beyond their labor, including unique perspectives often relevant to providing health care in underserved areas. Institutions and professional organizations also have an important role to play in advocating for immigration policies that enable international medical graduates to continue contributing to the U.S. health care system. Third, community leaders and organizations have a responsibility to support international medical graduates working in their communities by pushing back against hostility towards immigrants.
The public health crisis we face today will reveal the extent to which the social safety net has been eroded by policies that make health care less accessible for those who need it most. International medical graduates are an essential component of what remains of that safety net. Health care professionals, their employers and institutions, and the communities they serve all have a direct stake in safeguarding the capacity of international medical graduates to provide health care services in high-needs areas. At this challenging moment for both health care and immigration, it is critical to establish and strive to meet our moral responsibilities to those whose work makes the U.S. health system more just, and to those whose health depends on them.
Elizabeth Fenton, PhD, MPH, is a lecturer in the Bioethics Centre at the University of Otago in New Zealand. Kata Chillag, PhD, is Hamilton McKay Professor in Biosciences and Human Health at Davidson College. This work is supported by the the Greenwall Foundation Making a Difference in Real-World Bioethics Dilemmas Program. It is part of a larger empirical project about the impact of immigration policy and sentiment on international medical graduates and the institutions and the underserved communities in which they train, practice, and live, focusing especially on West Virginia.
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