Editor's note: This op-ed is in response to op-eds written by Immigration Attorney Greg Siskind and the response from President Carter.

Dear President Carter:

I was disappointed to read your USA Today editorial on international health care recruitment, especially because I am such a big fan of yours.  I began following your policy initiatives closely when I was an intern for Senator Bayh in 1978, and your embracement of human rights inspired me to seek a career in immigration law.  I am sending this letter because I know you as a uniquely dedicated, compassionate, and principled former leader of the free world.  No one doubts that the statistics you cite are true, and reflect the horrible conditions in Africa .  I share your concern for the millions of sick and dying people in Africa and other impoverished areas around the world.

I hope your assistant who is reading this for you will pass this letter on to you. 

You mentioned international nurses in your article. I am not an expert on international doctors. I have much more experience with international nurses.  I have helped many nurses come to the US , I speak with them every day, and I recently finished editing a comprehensive book on Nurse Immigration and Migration.  This book contains articles on all aspects of international nursing, including technical immigration issues, international trends, nurse perspectives, and several articles on the economic issues of health care worker migration, written by leading international experts in the field.  Working with these authors I came to learn that the old "brain drain" paradigm simply does not reflect reality and promotes a distorted oversimplification of what is happening with health care migration.  Brain-gain, brain-circulation and related issues are continually debated by international economists, with no clear consensus.  But there is a very strong argument that nurse mobility is a win-win strategy.

Your article reminds me of a front-page New York Times article on Philippine nurses by Celia Dugger (Plan to Lure Nurses May Harm Their Homelands, May 24, 2006).  The vast majority of foreign nurses come from the Philippines .  With what I am sure were the best of intentions, Ms. Dugger painted a completely inaccurate portrait of nursing and nurse migration, leaving the impression that Americans were plotting to steal "their" nurses, leaving poor people to suffer and die.

It all looked like a quite dramatic exposé, but it was just wrong.  The idea that there is a shortage of nurses in the Philippines is plainly absurd.   All those nursing schools were created for the express purpose of training nurses to work abroad.  Filipino nurse migration is an enthusiastically embraced national policy.  The Philippine Overseas Employment Authority and the Office of Workers Welfare Administration were designed to facilitate the deployment of its workers abroad.  The country trains many more nurses than the country could afford to hire, specifically for the purpose of emigration.  The Philippines has hundreds of nursing schools, most subsidized by the government, and the vast majority of graduates, 85%, leave to seek employment elsewhere, especially in the US, Europe, Australia, and the Middle East.  They gain their training by volunteering their services, because there are no jobs. There is a shortage of nursing jobs, not nurses.  The only reason these bright young men and women go into nursing in the first place is because of the global opportunities that await them.  The Philippines has too many nurses, on purpose. Nurse emigration is one of the best things that ever happened to the Philippines , and to young Filipinos with dreams. 

A similar educational phenomenon is occurring in India , where hundreds of new nursing schools have opened in the past two decades.  Yet more than 50% of their nurses are unemployed. As we saw with IT workers from India , many are training specifically to travel abroad.  Anyone with even a passing interest in global economics can see that India has not suffered from this professional mobility.  Most of these traveling professionals send desperately needed money home, and many return home to raise families after several years abroad. 

Remittances to developing nations, briefly mentioned in the Times article, total $200 billion to $300 billion per year.  Because of their informal nature, remittances are impossible to measure with complete accuracy, but the Institute for Labor Studies (Manila) estimates that the Philippines alone receives over eight billon dollars a year, over 10% of its GDP. 

In the Times article, Ms. Dugger’s biggest fault was laziness. She did not take the time to learn about the subject.  She got some great quotes from what seemed like respectable sources (one of whom has since been arrested for nurse credentials fraud), but she did not have the knowledge to put the information in perspective.  The Times editorial page later issued a vague half-hearted regret, citing the importance of nurse migration and the human rights issues involved, but the damage had been done.

For the past several decades, registered nurses have entered the U.S. (after thorough credential reviews, language reviews and background checks) to fill work shortages.  Until recently typical RN visa processing time was about a year, but now visas have become unavailable.  There is now a five-year backlog and only a few nurses are trickling in. 

Congress has not moved to eliminate all immigration restraints on foreign nurses.  Temporary, limited, visa availability has been discussed in some committees.  All of the long, difficult, credentials evaluations, training and experience reviews, spoken and written English tests, security checks, and other restraints would remain.  Even the most modest considerations are being blocked by Senator Richard Durbin.  Senator Durbin has stated that foreign nurses are causing the nurse shortage. He has even suggested that hospitals hiring foreign nurses should pay at penalty of $20,000 per nurse, because that is what it costs to train a nurse. I have no doubt that Senator Durbin has the best of motives, and actually believes this, but is a bit troubling that such a powerful man is so misinformed on this issue.

Foreign nurses didn’t cause the nurse shortage – it is a product of demographics, and lack of long-term planning in nurse education, and to some extent working conditions. The RN schools are full.  There are many thousands of qualified applicants turned away every year.  Everyone agrees that we should be opening more nursing schools and training more nursing teachers, as quickly as possible.  This is where our domestic efforts should be focused. The problem is that there are not enough trained and educated nurse teachers available to open new nursing schools, and it will take many years to get new schools accredited and opened, no matter how much money is spent now.  In the mean time the current U.S. shortage of nurses, with real, high-salaried jobs available now, will grow from 200,000 to twice that, or more, in the coming years.

Highly skilled, qualified, and dedicated foreign nurses (perhaps 10,000 to 20,000 per year, based on past levels) are obviously not a cure-all to such a huge problem, but offer some partial amelioration for needy patients, especially in the hard-to-fill positions in sub-acute and long-term care.

There is absolutely no evidence that any health care facility is hiring foreign nurses rather than contributing to homegrown nurses.  The nurse shortage is so severe that hospitals are trying everything they can, including bigger bonuses, better compensation, improved work conditions, training programs, and other retention strategies. Unfortunately, the biggest result is re-circulation of the same nurses from one facility to another.  Until the nursing school capacities increase, there are not many options available to hospitals. Americans are literally dying every day because of the shortage of nurses, and we should do whatever we can to help.

Clearly conditions are horrible in the countries you mentioned.   The health care crisis in Africa is tragic, but overwhelmingly a result of poverty and corruption, not nurse mobility.  Most nurses in sub-Saharan Africa are either unemployed or paid a pittance. In Nairobi alone, there are over 8000 idle, unemployed nurses.  Many are driven from their countries by war, famine, and disease.  As you know, in several countries, the death rate from infectious disease for these health care workers is very high.  Based on census records of the largest nine receiving nations, there are approximately 70,000 nurses who have migrated from Africa to wealthy countries in the past two decades, compared to approximately 760,000 nurses in Africa now.  Even assuming that all these nurses were trained in Africa and left to pursue RN jobs abroad, we are looking at an aggregate of approximately 8%, a significant figure, but similar to migration patterns in Europe and Asia.

One of the key sources of confusion is in defining what a "shortage" is.   There are two very different types of shortages. In the US , we have a classic market shortage of RNs, which means there are at least 200,000 high-salaried positions open today, just waiting for qualified candidates.  In the developing world, there is no such shortage.  There we see a "moral" shortage of health care, and just about everything else.  There we see people dying by the thousands from lack of care, not because there are no health care workers to fill vacant positions, but because these countries lack the resources to build the needed medical infrastructure and offer real careers to health care workers. It is horrible. We wish it wasn’t true, and we want to find people to blame.

Most people do not make that important distinction, and I often hear people in the field succumb to the zero-sum perspective, saying such things as "well, there are only so many nurses in the world…"

Health care conditions in Africa are tragic, but health care worker migration is not.  And hiring unemployed or miserable nurses is not selfish. These nurses are not chattels; they are intelligent, thoughtful people, with an inherent right to seek a better life.  Talk to them. Learn about them. This opportunity, that most of us take for granted, has given these nurses and their families previously unimaginable independence and empowerment (especially for women).  The rights of these people should not be a peripheral side issue, to be mentioned in passing as a "perhaps." 

People listen to you.  Political and social leaders take you very seriously.  You are greatly respected, not only for your knowledge of the world, but more importantly for your integrity.   I would like for you to consider the potential harm of migration restrictions.  Should we tell Indian and Filipino nursing students to quit school?  To give up hope?

Approximately 20,000 people in the U.S. die every year because of unavailable nursing care.  No one in the Philippines or India dies because a nurse migrates to the U.S.   Not one.  In fact they have many more nurses available because of the overseas employment incentive. And, because of this global mobility, our planet now has many, many thousands more dedicated professional nurses.

A couple of months ago, one of my clients, a nurse from Manila , was working the 11-7 overnight shift in a sub-acute ward near Boston . This is a shift that is perpetually understaffed – there are no U.S. nurses available.  In her rounds she noticed a door that would not open. She was able to pry the door open and found the patient, recovering from difficult and painful surgery, had blocked the door and cut his wrists.  The foreign nurse, who was unemployed in the Philippines , was able to stop the bleeding enough to keep him alive. This patient would have died if she had not been there, but he has since recovered and is home with his family.  No one keeps tracks of stories like these, or of the grimmer stories when help is not there.

The "obvious solution" is indeed to increase the number of healthcare workers throughout the globe.  The best American policy is not based on restrictions and reprimands, but on opportunity and hope.  The best way to do that is to follow the examples of the Philippines and India and give dedicated young men and women around the world the opportunity to become working nurses.

I hope you can help to correct some of these serious inaccuracies about these critical issues.  But even if you won’t, please keep up your good work around the world. You are truly an inspiration.

Reprinted with permission from Joseph Curran.

About The Author

Joseph Curran is a partner in Curran & Berger Law Firm. He has been exclusively involved in the practice of immigration and nationality law since 1985, with experience representing clients in all aspects of this area of law.