Filipinos have long been a mainstay of the immigrant population in the United States, with the Republic of the Philippines itself perpetuating a prominent culture of migration, maintaining 2.2 million Overseas Filipino Workers (OFW) across the world as of 2019.  Like so many societal hardships, the global pandemic has exacerbated the inequities faced by this demographic, specifically Filipino nurses, in the American healthcare and immigration system. This post recounts some of the historical dependency of the U.S. on nurses from the Philippines, explains the contemporary problems endured by nurses with Filipino heritage, and highlights some potential solutions that can ease the strains created by the strong American and Philippines’ tradition of migrating nurses.

The impact of OFW nurses emigrating from the Philippines

Filipinos currently make up the 4th largest group of immigrant populations in the U.S. with 45,920 total Filipino persons obtaining Lawful Permanent Resident status from fiscal year 2019, just behind Mexico, China, India, and the Dominican Republic. But when it comes to healthcare workers, the Philippines comes in first above Mexico, India, and Jamaica, representing 13.5% of immigrant healthcare professionals, and 2.2% of all healthcare labor generally. Statistically speaking, 1 out of every 20 registered nurses (RN) working nationwide in the American healthcare market today was trained in a nursing school in the Philippines! 

Where does this prevalence of Filipino nurses stem from? A brief historical review is telling of the trajectory building between the Philippines and the U.S. capitalization of Filipino nursing for decades. For a more thorough treatment, Empire of Care by Catherine Ceniza Choy at UC Berkeley is recommended. 

After the devastating Philippine-American War, Japanese occupation, and the overdue Philippines Independence in the late 1940’s, the U.S. started seeing a vacancy in nursing positions nationwide as women who had joined the profession left the workplace after the close of World War Two. To replace the spots left empty by American citizens, the Exchange Visitor Program was utilized in 1948 to start pulling labor from the Philippines; after all, there was already an Americanized system of institutionalized training under the guise of ‘benevolent assimilation’ that made the educating and migrating of Filipino nurses a fairly straightforward pipeline. This yielded a 700% increase over 5 years, taking the population of Filipino nurses up from 7,000 to 57,000 by 1953. That focus launched a series of concentrated migrations over the later half of the 20th century that has brought 150,000 Filipino immigrants to nursing jobs in the U.S. since 1960. 

Impacts of COVID-19 on Filipino nurses

In some ways, Filipino nurses have taken the brunt of COVID-19 exposure, both because of their prominence in the healthcare field, and because of the mistreatment experienced by them as working professionals. 

At the beginning of the pandemic, of the 318 healthcare workers lost in the densely populated New York/New Jersey area by May 2020, at least 30 were Filipino. Once we hit August last year, of the 193 RNs specifically who had lost their lives to the virus, 30% of them were Filipino, despite Filipinos only making up 4% of the RN population nationally. 

There are some convincing hypotheses as to why this is. In addition to the overrepresentation on the “frontlines,” (in communities like New York or New Jersey referenced above, of every man and woman of Philippines heritage, 1 in 4 is a healthcare worker) Filipinos might have increased risk factors, have a stronger familial culture of living as multigenerational households, and work beyond the typical age of retirement for Americans, all of which could make the virus a more deadly ailment. Most significantly, Filipino nurses often face discriminatory treatment by being assigned to the hardest or least desirable roles in the unit at bedside acute/critical care, which doesn’t allow for social distancing and increases the chances for viral transmission. So not only have Filipino nurses filled the jobs that were otherwise empty by way of national nursing shortages, they have been handed the most difficult assignments within those workplaces. 

Even before the pandemic hit, it wasn’t like Filipino nurses didn’t face vulnerability. Settlement cases have been fought (and fortunately won) over mistreatment because some Filipino nurses were forbidden to speak their first language at work, or were paid terrible wages that did not match those of their American colleagues. Add to this the anti-asian hate inflamed by the previous President, where even in Utah a Filipino food truck was vandalized with racial epithets and anti-immigrant language, and it becomes distressing how much intolerable strife Filipinos have endured despite their critical role in sustaining our healthcare institutions. 

Impacts of US immigration policy on Filipinos

Despite the apparent desire on the part of the U.S. for Filipinos to emigrate, America hasn’t made immigration an easy task to accomplish. In April 2019, the wait for a U.S. citizen to sponsor their relatives from the Philippines was 12 years, compared to a 7 year wait to sponsor adult, unmarried children for most countries. This isn’t to say that immigration isn’t happening at a rapid pace, especially along family lines. Fiscal year 2019 had 27,460 total immigrant visas issued to people coming from the Philippines – 9,872 of those were for immediate relatives, 13,171 were for family preference, and 4,304 were for employment preference. However, the limitations imposed by U.S. immigration laws, such as per-country caps for employment-based and family-based immigration, bottlenecks the number of applicants allowed to migrate by basing the allocation of green card entries on the percentage of applicants. In practice, this means that under the Immigration Act of 1990, no country can surpass 7% of the total number of visas given each year. For someone in the Philippines, or India, where the demand for a visa is high and the number of applications annually climbs to the thousands, this creates a kafkaesque, decade-long waitlist. 

The constant stream of migration, as bottlenecked as it is, still creates problems for domestic Filipinos still at home in their own country. The emigration of so many out of the Philippines has been coined by some as the “brain drain:” the Philippines losing some of its best and brightest as nurses to the rest of the world. And tragically enough, exporting its surplus of nurses has led to hospitals in the Philippines themselves being short 20,000 nurses. In an advocate’s zeal for improving the prospects of immigrants, we need to remember the cost that comes when people leave their nation of birth to come to America. Perhaps, for the Philippines, the years and years of a flowing nursing pipeline has taken its toll, and a balance needs to be struck in meeting the needs of hospitals in the U.S. with those in the Philippines. A middle ground between “all Filipino nurses easily and quickly migrating” (to the U.S., where the healthcare shortages and problems described above persist) and “all Filipinos staying put” (in the Philippines, where there is not enough opportunity for all Filipino nurse graduates annually to find work) must be struck. 

Impacts of potential solutions 

Some policy suggestions aim to do just that. Talks between the Philippine Nurses Association of America (PNAA) with the World Health Organization on the need for programming to encourage return migration have taken place, and a joint conference back in 2013 with the PNAA and its contemporary the Philippines Nurses Association addressed the same topic. The Global Scholarship Alliance was created by Todd Bol, a state representative from Minnesota, and Remy Junio from St. Paul’s University in Manila, to facilitate immigration support and full scholarship funding for nurses to come to the U.S. for 4 ½ years of study for a BSN or MSN degree and to work in American hospitals. Upon completion, participants would then be required to return back to the Philippines for two years of work, administration, or leadership and instruction in the nursing industry in-country before being free to return to the U.S. or stay in the Philippines. This sort of long term alumni-building, if still ongoing, could foster a strong and sustainable opportunity for Filipino nurses to pursue economic opportunity, without the Philippines or the U.S. being left to fend for itself in terms of nursing shortages. 

The immigration pathway for Filipino nurses can also be streamlined and made easier to navigate. For example, when seeking an employment-based visa to immigrate, an individual is required to have a visa screening certificate. These certificates come from the international authority on credential evaluations for healthcare workers globally, the Commission on Graduates of Foreign Nursing Schools (CGFNS). To qualify for the visa screening, nursing graduates need to pass the CGFNS pre-certificate exam, or the full NCLEX required to become an RN, but only the pre-certificate exam is administered in the Philippines. Experts have begun lobbying for changes in nursing licensure to allow for administration of the NCLEX in the Philippines, instead of complicating the process for grads by arbitrarily requiring that they pass the CGFNS exam, then get the visa screening certificate, and then immigrate, and then pass the NCLEX. It would be much simpler for aspiring nurses in the Philippines to simply take the NCLEX to satisfy the visa screening criteria, and then be ready as licensed RNs upon arrival in the States.

Overall, the per-country caps are a more significant hurdle that can only be cleared by Congress. But Representatives in the House have introduced legislation doing just that (although some advocates are concerned it doesn’t mitigate negative effects on some immigrant populations by the provisions of the bill) and have made some progress in garnering 73 cosponsors. 

Prosperity for individual Filipino nurses, as well as the needs of both the U.S. and Philippine nations, would be served by policies that ease the frequency and means of immigration between the countries. Furthermore, diversifying the healthcare positions incentivized in both countries, decreasing discriminatory work assignments, and streamlining licensing procedures or deploying new innovative policies ensures that not only can Filipino nurses be free to work where they please, but that they can do so without being at the complete mercy of tragedies born of the pandemic.

Author Biography: Garrett May is a senior moderator for the International Law and Policy Brief (ILPB) and a J.D. candidate at The George Washington University Law School. May received a B.A. in Interdisciplinary Humanities with an emphasis in History and a double minor in Asian Studies and Linguistics from Brigham Young University in 2020. His primary interest is Immigration Law.