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  • BIOETHICS FORUM ESSAY

We Need International Medical Graduates to Help Fight Covid-19. Immigration Policies Keep Them Away

Published on: March 27, 2020
Published in: Covid-19, Hastings Bioethics Forum, Health and Health Care, Public Health

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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  1. Marlissa Belay on

    Thank you for this. I know first hand how poorly international medical grads have been treated by this country due to many unfairly implemented policies that only serve to discourage them. But I think after all is said and done, after the US cleans up the carnage from cover-19, then will the politicians see how valuable these healthcare professionals are.

    Reply
    • Emiru on

      Look,
      US has squandered opportunities after opportunities when the shut the doors on the face of IMGs even after they succesdfuly passed the exams and awsrded with certification from USMLE office. I know hundreds if not thousands of physicians who fulfilled every possible criteria but could enter into residency program. Most of them left the country after years of waiting and applying but many are still in the US waiting patiently. Therefore, you don’t have to go around the world since you have them already in the US with valid certifications. All you have to do is reach out to them and make them an offer .
      I am willing to help if needed.

      Reply
  2. Stephen Ombok Muhudhia on

    Thank you for this insightful article on the important role of International Medical Graduates in the USA and the need for review of circumstances which negatively impact their work and life in the USA. The COVID 19 pandemic has exposed the need for more medical personnel in the USA . However, many countries are affected by the COVID 19 pandemic and need all the healthcare personnel available within their countries. In Third world countries, which contribute a significant amount of International Medical Graduates to USA, the shortage of medical personnel is more critical than in the USA and this will get worse as the COVID 19 pandemic worsens in these countries.
    Therefore, it will be morally wrong and a great injustice for the USA to induce doctors from Third world countries to migrate to the USA during this time of great need of doctors in Third world countries. The USA is capable of offering irresistible incentives to doctors and nurses from Third world countries to migrate to the USA, but that would be unethical.

    Reply
    • Monty Jacobs on

      Thank you Stephen for your comments. I believe that most international medical graduates enter the United States under the J-1 Exchange Visitor Visa program for residency training. For medical training, it specifically requires the IMG to return to their home country for at least two years before being able to return to the U.S. for work. There is no mystery here. No hidden trap for the unwary IMG. This 2-year foreign residency requirement attempts to limit the brain drain and recruiting incentives that U.S. healthcare organizations could use to entice IMGs to stay. Waivers are available from the 2-year residency requirement if you serve in a medically underserved area, and West Virginia benefits from those waivers. Whether these waivers are sufficiently justified to offset the moral obligation for IMGs to return to their home countries should be the focus.

      Reply
  3. Dr. Nevein Elagamy on

    In the meantime, there are many foreign medical graduates who resides in USA and practicing something else other than being medical doctors because of the restrictions that were mentioned above. They are readily available within USA and they will be more than happy to serve their country and their communities during this hard pandemic time. I am one of these foreign graduate physician and currently living in the States and I ready to help when it is required but I do not know how. Please advise accordingly. God bless and save America.

    Reply
    • Pushpa Dhilip on

      Yes I agree with this . I am ECFMG Certified USA citizen but unmatched because of the restrictions in matching procedures.
      I would like help if I am given a chance .

      Reply
  4. Kosta on

    Many IMG especially Caribean’s medical schools were trained in the USA. And some of them did pass USMLE exams.
    That would be prudent to use these doctors.

    Reply
    • Arki Shah on

      I am an anesthesiologist 50 years old from India. Recently I moved to USA on L2 visa. I have applied for EAD before 3 months which hopefully I will receive soon. I am happy to serve the people in need as a doctor. At present I am preparing for my step exam and along with that I did electronic health record course and doing ophthalmic assistant course. I am available any time happy to help in any ways but do not know how because of restrictions. Please provide details. Save people Save world is the most important thing at present.

      Reply
      • Rene Camacho on

        I’m a Mental Health and Addiction Medicine Specialist ready to help and support patients and clinical staff in The United States. My wife and two kids born in USA. I’m citizenships by naturalization and ready to help.

        Reply
  5. Sundeep Singh on

    I am a 43-year-old US Citizen “Born and Bred” in the United States, having graduated from a foreign medical school in 2011 after a late-career change. I am currently preparing for my Steps so that I can apply for residency this upcoming cycle.

    There is nothing more I would like than to help my community by providing my level and brand of specialized medical knowledge during this time of crisis but red tape and bureaucratic process make it extra tough. This article was very insightful and thoughtful as more equitable legislation is needed to assuage the pathway from education to employment for many gifted healthcare professionals trained outside of our great country.

    When the dust settles from this pandemic, our country will see how important IMGs are to the economic, political, and social health of our country.

    Reply
  6. Emiru on

    The fed has to intervene and use all ECFMG certified FMGs now and in the future. The number residents was slashed by 25% some years back and the funding to train residents was used for paying salaries for hospital stuff. Since the funding comes from the fed, it can intervene and put the number of residents back to the required. Thousands of physicians are going to retire and the replacement is not ready yet. We don’t need to wait for another pandemic to open our eyes.

    Reply
  7. Coy on

    My husband came to join me here and left his country where he practiced as a medical doctor. I’m an American citizen. He studied for the USMLE exams and got ecfmg certified. He has a masters degree (MPH) and PhD but can’t get matched. He has a lot of publications where he is a first author, he is such a good doctor, compassionate and loves practicing. He is a permanent resident, can’t go back because his whole family is here. This is his home. I wish someone can give him a chance. He is willing to volunteer during this time of need but no one wants to give him a chance. My number if you wanna reach him to help for covid19 is (678) 390-4979

    Reply

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