BY LISA ECKENWILER
Thanks in part to over a century of progress in public health and medicine, many people are enjoying longer lives. These changing demographics are generating a greater need for long-term care (LTC). In the US, while there has been considerable debate concerning the nature and extent of future LTC needs given declining rates of disability in recent decades, the consensus is that they will grow considerably (IOM, 2008). By all accounts, however, the care many older adults receive is inadequate, and LTC, as it exists, is “no longer viable” (Miller et al., 2008: 450; National Commission for Quality Long-Term Care, 2006). Worse still, experts in the field argue that the country is without “a comprehensive, coherent long-term care public policy” for the future (Levine et al., 2006: 305). We are not alone. A vision and strategic plan for LTC have been low priorities or lacking entirely in many countries (WHO, 2003; OECD, 2005).
This persistent and pervasive myopia raises serious concerns for the burgeoning population of dependent elderly as well as their family caregivers. It also has profound implications for health workers and those in need of care in parts of the global South—due to growing needs from population aging, a rise in chronic conditions, and often, the burden of HIV and AIDS. Health workers are migrating at unprecedented rates – increasingly from low-income countries with a low supply of health workers – to take up positions in the US and other affluent countries’ LTC sectors, leaving in their wake workforce shortages and what some call a global “crisis in health” (WHO, 2006).
Multiple and complex relationships among an array of policies and programs – promulgated by governments, the health care industry, international lending bodies, the for-profit sector, and others –structure care work in a global context. Tracing these relationships compels us to consider how we should think about responsibilities to the dependent elderly, those who care for them, including migrants, and people who need care in so called “source countries”, groups whose well-being is increasingly interconnected.
THE MIGRATION OF CARE WORKERS
Several factors come together to facilitate the flow of care workers from South to North. Nursing and direct care work (DCW) in the US—done by nurse aides, home health and home care aides, the front line of LTC—is now characterized by unprecedented vacancies and turnover rates, with a declining number of people entering the field, retention problems, and a growing trend toward early retirement. With pending demographic shifts, a persistent shortage in the pool of paid caregivers is expected to grow. LTC experts critical of current policy, indeed, rank an inadequate workforce as their top concern (IOM, 2008; Miller et al., 2008).
This deficit of care workers can be attributed to the poor public image and lack of respect granted to care work; poor compensation; cost-containment measures that have created difficult working conditions; and inadequate opportunity for continuing education and professional development (Folbre, 2001; Berliner and Ginzberg, 2002). Regarded as “unskilled” workers, these problems are greatest for DCWs. Not only do they earn little respect in society or the workplace, they make very low wages, have one of the highest rates of occupational injury, and tend to lack benefits (National Clearinghouse on the Direct Care Workforce, 2006). While these conditions might be addressed by any number of strategies, an increasingly popular one involves the employment—in some cases preceded by targeted recruitment—of women from the global South for nursing and direct care positions in hospitals and LTC settings (Priester and Reinardy, 2003; Redfoot, 2006). The US is now the largest importer of nurses and other care workers (Aiken, 2007; Dumont and Zurn, 2007). Although data can be hard to come by, the major source countries for LTC specifically appear to be the Philippines, Jamaica, Haiti, India, and Mexico (Redfoot and Houser, 2005; ACS, 2005).
The emergence of neo-liberal economic policies may be the greatest contributor to the modern day flow of care workers. Facing reductions in employment opportunities, or overwhelming staff and other resource shortages when they are employed, many health workers in the global South have sought work abroad (Bach, 2003; Schrecker, 2009). Governments have also taken to recruiting and exporting their own citizens for care work as part of their economic development plans. The Philippine government, for example, figures prominently in the political economy of migration as the largest source of registered nurses working overseas, with over 70 percent of graduates leaving, mostly for Saudia Arabia and the US (Lorenzo et al., 2007). India and China similarly are coming to see care work as a valuable export (Fang, 2007; Khadria, 2007).
Filipino nurses in particular have long been primed for migration to the US as a result of missionary and military involvement in the Philippines, along with targeted foreign policy strategies which began fueling the mobility of Filipino nurses over a century ago (Choy, 2003). By the late 1990s, however, a complex, labor-exporting, debt-servicing bureaucracy emerged in which care workers—especially nurses—played an integral role. “At the end of the twentieth century, Philippine gendered labour migration and its diaspora have become the primary means for servicing Philippine indebtedness” (Barber, 2000: 399). Supporting this export of care labor are government-financed institutions that educate and train nurses, chiefly for affluent foreign markets (ILO, 2006). In sum, “[t]he Philippine nurse education and labour market…has essentially become a training ground for overseas employers and the international trade in nurses” (Ball, 2008: 340).
At the same time, selective immigration is increasingly an “instrument of industrial policy” (Ahmad, 2005: 44). Lobbying for an easing of immigration requirements in order to gain access to nurses are employers and industry organizations, such as the American Hospital Association, the American Health Care Association, and the National Center for Assisted Living, who have come to regard international recruitment as a way to keep hiring costs down and improve retention (Buchan et al., 2003; Pittman et al., 2007). As “unskilled”, DCWs confront more challenges when it comes to immigration. Some worry that increasing demand may contribute to illegal immigration, especially in the rapidly expanding, often informal, home care sector (IOM, 2005; Redfoot and Houser, 2005).
With the growing demand for lower cost care workers and the compulsion of many to migrate given conditions at home, a lucrative international recruitment industry involved in a range of activities related to recruitment, testing, credentialing, and immigration has begun to flourish (Connell and Stilwell, 2006; Pittman et al., 2007). Not only has the size of the industry surged from roughly forty companies in the late 1990s to over 270 in 2007, but so too has the number of countries in which recruiters operate, rising from half a dozen to over seventy. Many have high burdens of disease and low care worker-to-population ratios (Polsky et al., 2007).
Finally, the plight of family caregivers contributes to the growing need for paid care workers. As many governments restructure their roles to spend less on health and social needs, and health care institutions cut costs, a “care gap” has emerged that ultimately relies upon family caregivers—mostly women—to contribute additional energy and resources (Donelan et al., 2002; Ogden et al., 2006). Most women in high-income countries, however, are employed in the paid labor force and, for the most part, neither public policy nor their employers offer adequate support (Johnson and Wiener, 2006; WHO, 2003). Family caregivers often turn, then, to paid care to garner additional support. While paid care work has long been done by women of color, the modern commodification of care work tends to take a transnational form (Bosniak, 2009; Parrenas, 2000). “Cheap and flexible, this model is [increasingly being embraced] to overcome the structural deficiencies of public family care provision and strikes a good balance between the conflicting needs of publicly supporting care of the elderly and controlling public expenditure” in privileged parts of the world (Bettio et al., 2006: 282).
CONCERNS FOR SOURCE COUNTRIES AND MIGRANT CARE WORKERS
While remittances indisputably channel billions of dollars in money and other goods, there is little consensus on the overall impact of migration on countries that export workers (Page and Plaza, 2006). What is now uncontroversial is that when health workers leave, population health erodes. Fifty-seven countries are facing severe health worker shortages according to the World Health Organization, shortages that serve to exacerbate global health inequalities (WHO, 2006). These shortages are said to be the most critical constraint in achieving the U.N. Millennium Development Goals and the WHO/UNAIDS 3 by 5 Initiative (Chen et al., 2004). The loss of nurses and other care workers is especially troubling given that they are the backbone of primary and LTC (Lynch et al., 2008). Current evidence suggests, indeed, that the adverse effects of losing health workers are not compensated by remittances (OECD, 2008).
Losing its nursing workforce faster than it can replace them, the Philippine health system is facing serious threats. An estimated 84% of employed nurses work abroad. In some hospitals, the ratio of nurses to patients is as low as one to sixty, and in some rural areas, far worse (ILO, 2006; Lorenzo et al., 2007). Hospitals’ failures to meet standards for accreditation and eventual closing are other signs of growing system inadequacies (Lorenzo et al., 2007). In the Caribbean, estimates are that approximately two-thirds of the country’s nurses have left, with roughly 400 per year migrating to the US, Canada, and the UK (ECLAC, 2006). Yet, the Caribbean has the second highest prevalence rate of HIV/AIDS, after sub-Saharan Africa, and population aging is generating a growing demand for chronic care. Along with weakening health systems and eroding population health, source countries can be harmed by lost investments made in health workers education, and over time, diminished intellectual capital and innovation.
As for migrant care workers, they face a difficult plight. Stereotypes of Filipinas as caring, obedient, meticulous workers, and “sacrificing heroines” (Schwenken, 2008), or of Caribbean women as naturally warm-hearted and joyful, serve the aims of governments, industry organizations and employers, recruiters, even affluent families, yet can constrain the imaginations and opportunities of women and girls (Barber, 2000; Brush and Vasupuram, 2006). Additionally, while the feminization of migrant labor might contribute to women’s economic, social, and political empowerment, it does not necessarily do so when they are engaged in low-wage, high risk, and at times “flexible” and/or underground work. Many trained as nurses (and a growing number of physicians) take jobs below their education and skill level, a phenomenon known as “down-skilling” (Pittman et al., 2007) and thus, can experience, at once, upward and downward mobility while their skills and expertise go underutilized.
While countries like the US incentivize immigration for some skilled workers, including some categories of care workers, questions of immigration and citizenship continue to be contested. Migrant care workers often find themselves with a limited set of political rights (Dauvergne, 2009; Glenn, 2006; Kofman and Raghuram, 2006). Often separated from families, many engage in transnational care practices for their own parents and children (Parrenas, 2005; Romero, 2006). They have, as one migrant nurse notes, “a foot here, a foot there, and a foot nowhere” (DiCicco-Bloom, 2004: 28). These care workers, then, contribute to social reproduction for the more privileged, while compromising it, along with their own membership as engaged citizens, at home.
The transnational transfer of care labor, indeed, threatens to perpetuate and worsen health inequalities, and risks constraining women’s agency and prospects for equality in many respects. In separating families, it also stands to erode the very foundation of social life. For the care done within families in most instances, especially when supported, generates public goods, namely, people who participate in social life and who serve as the next generation of citizens, and their well-being as embodied agents over the course of life (Kittay, 2001; Tronto, 2006). To the extent that those with more resources have greater capacities to care—now by importing it—and so, to produce and sustain more capable citizens, the outflow of caregivers may generate profound global inequalities in social and political capacity.
KEY QUESTIONS AND NEXT STEPS
What are our responsibilities to respond to gross and growing health (and other) inequalities in health around the world—inequalities made worse by migration? How should we organize health care systems in the wake of economic globalization and fund, train, and deploy human resources, arguably their most integral element? How should we conceive of our responsibilities to migrant care workers who leave home, often under less than voluntary conditions, and participate in the social life of more affluent countries in the most meaningful of ways? As we—policy makers, employers and citizens of countries whose policies and practices have transnational reach—formulate policy in LTC, fairness demands that we ask.
Lisa Eckenwiler is Associate Professor in the Department of Philosophy, Associate Professor in the Department of Health Administration and Policy, and Director of Health Care Ethics at the Center for Health Policy Research and Ethics at George Mason University.
Ahmad, O.B. 2005. Managing medical migration from poor countries. BMJ 331: 43-45.
Aiken, L.H. 2007. US nurse labor market dynamics are key to global nurse sufficiency. Health Services Research, 42(3): 1299-320.
Ball, R.E. 2008. Globalised labour markets and the trade of Filipino nurses. In The International Migration of Health Workers, ed. John Connell. New York: Routledge, 30-46.
Barber, P. 2000. Agency in Philippine women’s labour migration and provisional diaspora. Women’s Studies International Forum 23: 399-411.
Bettio, F., Simonazzi, A., and Villa, P. 2006. Changes in care regimes and female migration: The “care drain” in the Mediterranean. Journal of European Social Policy 16(3): 271-285.
Berliner, H.S., and Ginzberg, E. 2002. Why this hospital nursing shortage is different. JAMA 288(21): 2742-2744.
Bosniak, L. Citizenship, noncitizenship, and the transnationalization of domestic work. In Migrations and Mobilities: Citizenship, Borders, and Gender, eds. Seyla Benhabib and Judith Resnik. New York: NYU Press, 127-156.
Brush, B. and Vaspurum, V. 2006. Nurses, nannies, and caring work: importation, visibility, and marketability. Nursing Inquiry 13: 181-185.
Buchan, J., Parkin, T., and Sochalski, J. 2003. International Nurse Mobility: Trends and Policy Implications. Geneva: WHO.
Chen, L., Evans, T., Anand, S., et al. 2004. Human resources for health: Overcoming the crisis. Lancet 364: 1984-1990.
Choy, C.C. 2003. Empire of Care: Nursing and Migration in Filipino American History. Durham, NC: Duke University Press.
Connell, J. and Stilwell, B. 2006. Recruiting agencies in the global health care chain. In Merchants of Labour, C. Kuptsch, ed. Geneva: ILO, 239-253
Dauvergne, C. 2009. Globalizing fragmentation: New pressures on women caught in the immigration law-citizenship law dichotomy. In Migrations and Mobilities: Citizenship, Borders, and Gender, eds. Seyla Benhabib and Judith Resnik. New York: NYU Press, 333-355.
DiCocco-Bloom, B., 2004. The racial and gendered experiences of immigrant nurses from Kerala, India. Journal of Transcultural Nursing 15: 26-33.
Donelan, K. Hill, C. A., Hoffman, et al. 2002. Challenged to care: Informal caregivers in a changing health system. Health Affairs 21 (4): 222-231.
Dumont, J.C. and Zurn, P. 2007. Immigrant health workers in OECD countries in the broader context of highly skilled migration. International Migration Outlook. Paris: OECD Publishing.
ECLAC. 2006. Emigration of Nurses from the Caribbean: Causes and Consequences for the Socio-economic Welfare of the Country; Trinidad and Tobago-A Case Study. Port of Spain: ECLAC.
Fang, Z. Z. 2007. Potential of china in global nurse migration. Health Services Research 42(3): 1419-28.
Folbre, N. 2001. The Invisible Heart: Economics and Family Values. New York: The New Press.
Glenn, E.N. 2006. From unequal freedom: How race and gender shaped American citizenship and labor. In Global Dimensions of Gender and Carework, M. K. Zimmerman, J. S. Litt, and C. E. Bose, eds. Stanford, CA: Stanford University Press, 123-127.
Institute of Medicine (IOM). 2008. Retooling for an Aging America: Building the Health Workforce. Washington, DC: National Academies Press.
International Labour Office. 2006. Migration of Health Workers: Country Case Study Philippines. Geneva: ILO.
Johnson, R. W. and Wiener, J. M. 2006. A Profile of Frail Older Americans and Their Caregivers. Washington, DC: The Urban Institute.
Khadria, B. 2007. International nurse recruitment in India. Health Services Research 42(3): 1429-36.
Kofman, E. and Raghuram, P. 2006. Gender and global labour migrations: Incorporating skilled workers. Antipode 38(2): 282-303.
Levine, C., Albert, S. M., Hokenstad, A., et al. 2006. “This case is closed”: Family caregivers and the termination of home health care services for stroke patients. The Milbank Quarterly 84 (2): 305-331.
Lorenzo, F.M.E., Galvez-Tan, J., Icamina, K., et al. 2007. Nurse migration from a source country: Philippine country case study. Health Services Research 42 (3): 1406-1418.
Lynch, S., Lethola, P., and Ford, N. 2008. International nurse migration and HIV/AIDS: Reply. JAMA 300 (9): 1024.
Miller, E.A., Booth, M., and Mor, V. 2008. Assessing experts’ views of the future of long-term care. Research on Aging 30(4): 450-473.
National Clearinghouse on the Direct Care Workforce. 2006. Who Are Direct Care Workers? Paraprofessional Healthcare Institute. Accessed 6 July 2008, http://www.directcareclearinghouse.org/download/NCDCW%20Fact%20Sheet-1.pdf.
National Commission for Quality Long-Term Care. 2006. Out of Isolation: A Vision for Long-Term Care in America. Washington, DC: National Commission for Quality Long-Term Care.
Ogden, J., Esim, S., and Grown, C. 2006. Expanding the care continuum for HIV/AIDS: Bringing carers into focus. Health Policy and Planning 21 (5): 333-342.
Organisation for Economic Cooperation and Development (OECD). 2005. Ensuring quality long-term care for older people. OECD Policy Brief. Paris: OECD.
Organisation for Economic Co-operation and Development (OECD). 2008. The Looming Crisis in the Health Workforce: How Can OECD Countries Respond? Paris: OECD.
Page, J., and S. Plaza. 2006. Migration remittances and development: A review of global evidence. Journal of African Economies 00 (Supplement 2): 245-336.
Parrenas, R.S. 2000. Migrant Filipina domestic workers and the international division of reproductive labour. Gender and Society 14 (4): 560-581.
Parrenas, R.S. 2005. Children of global migration: Transnational families and gendered woes. Stanford, CA: Stanford University Press.
Pittman, P., Folsom, A., Bass, E., et al. 2007. U.S.-Based International Nurse Recruitment: Structure and Practices of a Burgeoning Industry. Washington, DC: Academy Health.
Polsky, D., Ross, S. J., Brush, et al. 2007. Trends in characteristics and country of origin among foreign-trained nurses in the United States, 1990 and 2000. American Journal of Public Health 97(5): 895-9.
Priester, R. and Reinardy, J.R. 2003. Recruiting immigrants for long-term care nursing positions. Journal of Aging and Social Policy 15(4): 1-19.
Redfoot, D. 2006. Health and long-term care for aging populations: Are international workers the solution? Presented at International Dialogue on Migration, Migration and Human Resources for Health: From Awareness to Action. Available at www.iom.int/jahia/webdav/site/myjahiasite/shared/…/abstract_redfoot.pdf Accessed February 15, 2010
Redfoot, D.L. and Houser, A.N. 2005. “We Shall Travel On”: Quality of Care, Economic Development, and the International Migration of Long-term Care Workers. Washington, DC: AARP Public Policy Institute.
Romero, M. 2006. Unraveling privilege: Workers’ children and the hidden costs of paid childcare. In Global Dimensions of Gender and Carework, M. K. Zimmerman, J. S. Litt, and C. E. Bose, eds. Stanford, CA: Stanford University Press, 240-253.
Schrecker, T. 2008. Denaturalizing scarcity: a strategy of enquiry for public-health ethics. Bulletin of the World Health Organization 86 (8): 600-605.
Tronto, J. 2006. Vicious circles of privatized caring. In Socializing Care, M. Hamington and D.C Miller, eds. Lanham, MD: Rowman and Littlefield.
World Health Organization (WHO). 2003. Key Policy Issues in Long-term Care. Geneva: WHO.
World Health Organization (WHO). 2006. World Health Report 2006: Working Together for Health. Geneva: WHO.