A subcommittee of the U.S. Congress has just approved a bill that would let modestly more foreign nurses work in the United States. New York Times reporters are concerned that measures like this, by encouraging movement of nurses out of developing countries that need them, could literally kill children. Today, the World Health Organization agrees that health worker movements contribute to disease and death in poor countries.
Should you be outraged at our government? Should our representatives who encourage nurse migration be locked up alongside the murderous Radovan Karadzic, as a stunning article in the respected medical journal The Lancet asserts?
The debate on this topic often misses three big facts: 1) Blocking the movement of developing-country professionals does certain harm to them, 2) supposedly softer measures like overseas recruitment restrictions tend to block movement just like migration barriers, and 3) there is no scientific evidence that restricting their movement by force can meaningfully affect the health problems devastating many poor countries. Without such evidence we should be very hesitant to take strong steps that prevent overseas health workers from accessing the very high-paying jobs that Americans take for granted by birthright. I'll discuss recent research on these three points.
1. Evidence on harm to health professionals who want to move
Any discussion of this issue must recall that nurses who come from poor countries to work in the United States dramatically improve their lives and their families' lives. Registered Nurses I met in Mozambique earn about $3,000 per year. Here, the same person can easily earn more than 20 times as much. Marko Vujicic at the World Bank has gathered related data for several countries.
Suppose someone informed you that you could not have your current job, even though your employer wanted you and could find no one else. Suppose they went on to inform you that instead you'd have to take a job you don't want, in a neighborhood you don't want to live in, earning one twentieth as much as you do now. Your life would probably turn suddenly into a debased struggle for survival. You might even question the ethics of what was done to you. A recent paper of mine, "The Place Premium", discusses in detail how this is precisely analogous to wage discrimination that, domestically, we abhor.
2. Policy proposals to block health worker movements
Even this new bill severely limits the number of health professionals who can make it past border guards. But many of the people fighting health worker movement want more than that: they would like to see restrictions on the recruitment of health professionals overseas, and would like the U.S. government to move the U.S. toward "self-sufficiency" in health professionals so that none need come here. These two policies are espoused, for example, by Harvard's Lincoln Chen, who co-authored this piece.
Though they are not strictly immigration policies, both of these measures would block the movement of people. Limiting recruitment means forbidding people from going to other countries and informing them about job opportunities here, opportunities that they are free to accept or decline. This would tend to block movement, because you cannot move to take a job you never found out about. 'Self-sufficiency' means the U.S. taking policy steps to ensure that no healthcare jobs for foreigners exist here, because they have been filled by people who are already here. This too would block movement, because those jobs are the basis of entry for many. All of these measures have the consequence of restricting movement, and all are coercive: they limit the choices available to health professionals, without consulting those professionals.
3. Evidence on the effects of health worker movement
But does any method of blocking movement actually save children's lives? In order to believe this, you have to believe that trapping people in a place they don't want to live – by itself, and all else equal – saves children. There's no evidence at all that forcibly stopping nurse movement, without changing anything else in the countries they come from, saves people.
Take Africa, for example. Most health professionals live in the cities and although most of the people who could benefit from their care are in the rural areas. The main childhood killers are infectious diseases that are better battled through preventive public health measures rather than treatment. And those treatments that are most urgently needed do not require the skills of a Registered Nurse with a university education. Finally, because of all this, and poorly funded health systems to boot, there are large numbers of unemployed nurses in many countries.
In this context, we should not be surprised at all that there is no causal relationship between the pure presence of African health professionals outside the borders of their countries – the only thing that can be affected by curbs on international movement – and a variety of indicators of healthcare availability and health outcomes in the countries they come from. My paper on this subject, called "Do Visas Kill?", points out that it is precisely the African countries with the most health workers abroad that have the most at home. Whatever is the principal determinant of shortages in Africa, it is not international movement.
(And I can't finish without getting one thing out of the way: those new nurses Congress contemplates admitting will not displace any Americans. We currently have vacant nursing positions numbering in the hundreds of thousands -- a shortage that the U.S. government predicts will grow to around one million a decade from now -- and the bill would let in a maximum of 20,000 per year, for three years only.)
Africa needs stronger health systems, to be sure, but can we build those systems with our immigration policy? There is no scientific evidence that this has happened anywhere, or is possible anywhere. We should be very hesitant to force real people with real families to accept wages that we would never accept, without overwhelming and indisputable proof that by itself this blunt act does enormous good.
Until such evidence arrives, America's increasing willingness to give opportunity to low-income health workers should be welcomed around the world.