The US Has Treated Immigrant Doctors as a Safety Net in Moments of Crisis

Soon after Medicare, Medicaid, and the Hart-Celler Act, also known as the Immigration and Nationality Act of 1965, became law, the federal government began to label certain geographic areas as Health Professional Shortage Areas (HPSAs), which designated an inadequate number of physicians in relation to the population. HPSAs were generally populated with people who were low-income, elderly, homeless, incarcerated, and migrant laborers — poor, medically complicated patients with public insurance and a likelihood of premature death. In a matter of months, hospitals in shortage areas were able to use the Hart-Celler Act to quickly fill their vacancies, especially in primary care specialties, with resident physicians from India, Pakistan, and the Philippines. While non-white medical care workers have a long history in the United States, much of this labor was feminized and positioned well below the doctor in the medical hierarchy. The influx of predominantly male foreign physicians was different. These practitioners had the potential to dilute the authority and prestige of the doctor’s social position — a position that was already vulnerable by mid-century.

Although foreign physicians’ labor was in high demand, organized medicine and the broader public regularly challenged their presence and expertise using ambiguous metrics of competence and protean standards of quality. Published social scientific studies characterized foreign physicians as lacking in leadership potential, anxious, unable to learn independently, and possessing poor patient skills. Despite these racialized and gendered critiques, these doctors developed creative strategies and practices that yielded effective therapeutic outcomes and “were the backbone” of the hospital system. Numerous studies show foreign physicians’ patients had either the same or even higher survival rates than patients served by U.S.-educated doctors, suggesting that quality concerns operated as an alibi for racial and xenophobic anxieties about this immigrant labor force.

A cascade of healthcare crises punctuated the late 1970s and early 1980s. AIDS unexpectedly erupted on the scene, and the cost of medical care rose much faster than patients could absorb (“medical inflation”), especially amid a deep economic recession. In response, lawmakers searched for inefficiencies in the medical system and identified two major drains on federal healthcare expenditure: safety-net hospitals and Graduate Medical Education (GME) programs. Safety-net hospitals were often located in poor, underserved minority communities with high medical needs, and these became a target for austerity measures. Predictably, this fiscal pruning had detrimental consequences on health outcomes for patients and on working conditions for staff, resulting in an inability to provide a decent standard of care. And the second site of intervention was GME programs, which received Medicare funds to offset the cost of training interns and residents. During the doctor shortage of the 1960s, GME programs expanded to accommodate the influx of foreign practitioners. Lobbyists for organized medicine and fiscally conservative lawmakers argued that these programs could be reduced or cut since the country would soon experience a crisis of physician oversupply. By this time, the long-term measures to grow the domestic labor force were expected to have materialized, rendering foreign labor unnecessary. Or so they wrongly predicted.

Yet, the issue remained, where was the crisis and for whom? Hospitals in shortage areas in urban and rural communities were certainly not experiencing this predicted glut of providers on their staffs. In fact, hospital administrators in these areas created special piecemeal programs and vouchers to continue to attract foreign physicians to their facilities. These arrangements make clear that market-based logics aimed at increasing physician supply with hopes that this scarce resource would eventually fill in the gaps were misguided.

Confronted with this miscalculation, the federal government attempted to intervene by luring physicians to shortage areas with promises of financial incentives. Despite these efforts, the enticements were unsuccessful. Data show that between 1970 and 2018, there was no statistically significant reduction in mortality — a metric tied to access to a healthcare professional — or change in physician density in shortage areas. There was, however, a steady increase of physicians practicing in non-shortage areas; these physicians included both U.S.-trained practitioners as well as foreign physicians who completed their probationary terms in underserved areas and migrated to non-shortage areas soon after. Simply growing the domestic labor force had minimal impact on the equitable distribution of health resources. Instead, it produced a scenario where scarcity exists alongside surplus — an ongoing crisis for the most disadvantaged.

The effects of U.S. policy to induce physician migration had, and continues to have, cascading consequences. In 2010, the World Health Organization (WHO) urged its member states to consider the ethics and effects of this “brain drain” and adopt a Global Code of Practice on the International Recruitment of Health Personnel. The Code was published in response to unidirectional recruitment from the “developing” to “developed” countries and argued that this movement intensifies global health inequities. The Code urged developed countries to coordinate recruitment strategies across health systems to mitigate the “negative effects” on the health systems of developing countries. And most importantly, the WHO advised that developed countries “strive to meet their health personnel needs with their own human resources” by “strengthening their educational institutions to scale up the training of health personnel.” The WHO Code of Practice makes clear that in a globalized world of vastly unequal market power, domestic decisions in the United States reverberate globally. In short, attempts to resolve the shortage crisis in the United States engender health crises in other countries. This was made explicit during the COVID-19 pandemic when the United States was recruiting foreign physicians, and India was trying to prevent their emigration. In framing the crisis in this way, I want to emphasize that this is a labor migration and healthcare systems problem, not an individual indictment of foreign physicians and their decision to migrate. While individual actors certainly made choices, structural parameters set the conditions of possibility for the contemporary global political economy of care at the center of this book.

In the last sixty years, declarations of health labor crises have become the norm. Prior to COVID-19, it was the Affordable Care Act of 2010 that elicited ardent crisis concerns. For the effective implementation, especially because of its focus on preventative and routine care, the United States required an increase in the number of primary care physicians to serve the newly insured patient pool. Immediately, various organizations and government agencies, including the Department of Health and Human Services, the Congressional Budget Office, and the Association of American Medical Colleges, entered foreign physicians into their workforce calculations and projections as an important source of immediate and inexpensive labor that could be marshaled with haste to alleviate the impending doctor shortage crisis. As David Skorton, a cardiologist and president of Cornell University explained, “As the nation ages and more previously uninsured individuals seek treatment under the Affordable Care Act, the health of millions of Americans may depend on the availability of more physicians and health workers from abroad.” Recycling an argument made fifty years ago, Skorton continued, “Through enlightened immigration policies, we can address our physician shortage and be a beacon for the rest of the world.” Once again, in this formulation, physician immigration can serve a dual purpose; it can alleviate local doctor shortages while reminding “the rest of the world” that the United States is a land of liberal, multicultural inclusion.

In a March 2024 report, the Association of American Medical Colleges estimated that the United States will experience a shortage of 86,000 physicians by 2036, a deficit that will inevitably worsen health outcomes in designated HPSAs. Nearly 76 million Americans live in the 7,700 federally designated shortage areas in which one healthcare worker is responsible for the care of over 3,500 patients, if not more. But are these looming deaths in shortage areas enough to shift the crisis narrative? Or is this ultimately a maintenance of the status quo, a reminder that there will always exist a segment of American society whose health needs remain unmet? It seems crisis has become the very condition of the system, an “ongoing state of affairs,” as anthropologist Janet Roitman writes, where foreign physicians are added or subtracted to negotiate the political moment. This begs the question: Should the term “crisis” be used to designate what has become a perpetual state? The proliferation and ubiquity of the term has morphed “crisis” from an event with a discrete beginning and end, and a place for human intervention in between, into an inevitable condition with a predictive futurity. In this rendering, human action and decision are impotent in the face of the crisis condition that becomes a foregone conclusion. Ultimately, declarations of crisis “stabilize an institution, practice, or reality,” rendering it ahistorical and “block[ing] thought by evoking the need for an emergency response.” Foreign physicians have repeatedly become the emergency response. They are the numerical supplement built into the US healthcare system, a global reserve labor force instrumentalized as a response to crisis.

That the United States spends far more per capita on healthcare than any other country obscures its long-term underinvestment in the healthcare labor force. Without a concerted reimagining of fundamental structures, foreign physicians will likely be asked once again to provide care in the U.S.’s shortage area communities, and they will respond, shouldering this care work as they have in the past. For the last sixty years, their essential presence has allowed organized medicine and the U.S. government to prioritize profits and special interests over the health of millions of poor, marginalized people, relegating them to debilitated life or premature death. By beginning with the Cold War and the Hart-Celler Act of 1965, I emphasize the geopolitical stakes and neocolonial conditions that marked the beginning of this migratory regime, which persist into the present.

Care From the Postcolony

Immigrant laborers have always been foundational to U.S. economic operations. What makes this migration regime different is the kind of labor and the laborers’ point of origin, namely elite physicians from South Asia. Their care work, combined with the fact that they responded to an urgent U.S. need, meant these workers occupied a special position in both national policy and public perception. Understanding how and why this has come to be requires acknowledging that the Immigration and Nationality Act of 1965 is in some ways arbitrary, a false start. Although it ushered in repeated pronouncements of Asians as a “model minority” — a supposedly welcome addition to the nation — its execution carries the markers of a far more fraught historical relation. The groundwork for the 1965 physician migration was set in motion decades earlier, a consequence of various economic, political, and social circumstances both in the United States and South Asia.

From the mid-nineteenth century until the Hart-Celler Act, US immigration policy regarding people from Asian countries amounted to recruiting “cheap” unskilled labor, while simultaneously disallowing citizenship. Asian laborers from countries including China, Japan, the Philippines and, to a much lesser degree, India, entered the United States in the nineteenth century, establishing their lives as agricultural and construction workers. As their numbers increased, politicians and business owners feared that this “cheap” labor was being oversupplied, posing threats to the market and to the homogeneity of the nation. To thwart this flow of foreigners, US Congress passed the Chinese Exclusion Act of 1882 prohibiting the entry of all Chinese laborers. As time went on, the exclusions were extended to Asian Indians in 1917, Japanese immigrants in 1924, and Filipinos in 1934. During and after World War II, due to shifting economic and political demands, the embargo on Asian labor was loosened slightly. For example, in the realm of healthcare, catalyzed by a shortage “crisis,” Filipina nurses were the first cohort to immigrate in significant numbers to the United States, followed soon after by nurses from India. Foreign nurses worked in those hospitals and clinics considered least desirable and avoided by their US-trained counterparts, mapping migratory patterns for their foreign physician colleagues a few decades later.

While the United States was eventually the main beneficiary of medical labor from the Global South, other countries — the United Kingdom, Canada, and Australia — also profited from skilled migration; and within this movement, South Asia figured prominently. The reasons for this include legacies of heavy colonial investment in biomedical institutions in South Asia, medical missionaries committed to civilizing agendas, and paracolonial organizations, such as the Rockefeller Foundation, that cooperated with national governments to promote technocratic, biomedical visions. Combined, these strategies saturated the Indian subcontinent with Western biomedical familiarity and training possibilities and produced generations of practitioners able to move between colony and metropole. By the 1960s, stricter immigration laws to the United Kingdom, along with new credentialing mandates and rising racial animus, caused foreign physicians to shift their trajectories toward North America. Canada was unveiling its national health insurance program called Medicare and needed more physician labor for effective implementation. Canadian politicians turned to immigration to solve this shortage dilemma, and foreign physicians were welcomed as salaried governmental workers.

This was the opposite case in the United States where the market continued to dictate compensation and allowed for a greater earning potential. Alongside the federally funded Medicare and Medicaid programs, private healthcare occupied a massive, influential market share of healthcare expenditures. Like Canada, the United States was contending with a dearth of medical labor to provide care and turned to immigration to remedy this deficit. With the 1965 passage of the Hart-Celler Act, particular forms of Asian labor that satisfied skill requirements constituted the first full wave of legal Asian migration to the United States. Racializing immigration in this way ensured that Asian immigrant labor was a distinct category, with a spatially and socially consigned place with little political power. Asians were triangulated within a “field of racial positions” by which they were simultaneously ordered as more valuable than Black people, less valuable than white people, and more foreign than both.

Furthermore, in the context of the Cold War, it was politically imperative to amend this discriminatory orientation toward Asian people, even if only nominally. Newly independent, postcolonial Asian nations were the sites of Cold War battles, and US legislators understood immigration to be a useful ideological weapon against Communist encroachment. Put differently, migration policy was used as a strategy of containment, a “long-term, patient but firm and vigilant” tactic that could slowly erode “Russian expansive tendencies.” Yet immigration had the potential to be dangerous when uncontrolled and, thus, it was vital to sift the “good and the bad … in such a way that the inherent dangers of this circulation are canceled out.” By permitting certain routes and peoples, the United States could control and manage circulation, which was essential for both ideological and material purposes.

The process of sifting was operationalized through paperwork, a “technology of citizenship.” Phrases such as “undocumented immigrant” and “having papers” indicate the discursive linkage between documentation, immigration, and governance. Much necessary scholarship explores the catastrophic conditions endured by those without papers — migrants suspended in a state of indeterminacy or sacrificed for liberal security. These works center the expelled, or the dispossessed, and their suffering to show how migrants negotiate legal status in relation to “the border” or the nation-state, and are often analyzed in contradistinction to the privileged post-1965 Asian professional — an entity bracketed and treated as exceptional. Examining the processual nature of documentation rather than the objects produced, however, challenges any clean divisions between skilled and unskilled, or documented and undocumented. Instead, what emerges is a bureaucratic regime wherein the border was respatialized and dispersed, recursively emerging at the juncture between a migrant and their paperwork; these Asian laborers were no longer on the margins of the nation, seeking legal entry. They were granted entry, but how they moved, when, and where they could go became contingent on the correct assemblage of paperwork.

The documents consisted of medical competency exams, certificates, licenses, diplomas, questionnaires, and reference letters, among others, and became the medium through which movement was made possible. In the production of a physician’s case file, the figure of the expert and the figure of the migrant confront one another, exposing the frictions and incompatibilities engendered when these categories overlap. New relations to documentation emerge that reveal how claims of underdocumentation, incorrect documentation, and overdocumentation regulate immigrant possibilities to produce particular documentary subjectivities. In adopting this approach to the case file, I show how the banality of bureaucracy operates as a racializing, disciplinary strategy across categories of immigrant labor, even those deemed exceptional.

Paper regimes were designed to collapse difference, a challenging task when transforming a diverse global medical labor force into standardized foreign medical graduates eligible to work in the United States. Foreign physicians’ documents contained a promise to reform knowledge acquired elsewhere to align with US metrics, mores, and expectations. The Educational Commission for Foreign Medical Graduates (ECFMG) was assigned to oversee this transition and was initially confounded by the task; designing a system that could absorb a myriad of difference, eliminate the noise, and generate a standard, commensurable, physician labor force proved overwhelming. And it remains so today. The ECFMG announced that as of 2024, it would require graduation from a formally accredited medical school as the first step of certification. Unsurprisingly, this has produced more questions than confidence: Who will be responsible for accrediting all the medical schools around the world, and what criteria will they use?

By the 1980s, the migration and presence of foreign physicians in the United States was a regular occurrence, yet discriminatory attitudes toward these practitioners remained. Their movements were often punctuated with starts and stops, with checks and rechecks of paperwork along the way. Frustrated by the uncertainty and unpredictability of the US medical system, foreign physicians organized and lobbied Congress and the medical establishment for equal standards and equal treatment. During this campaign, South Asian physicians emerged as the most vocal contingent. They spent time and resources to hire lobbyists, contributed to congressional election campaigns, challenged the American Medical Association’s dismissive posture, and deployed ethnic media to raise awareness for their cause. In assembling these resources, South Asian physicians developed political acumen and recruited a social infrastructure that resulted in a unique, recognizable political brand.

The early 1990s and 2000s witnessed the maturation of South Asian physician communities. While new foreign physicians working as interns and residents were continually arriving, the first wave of elite migrants was firmly established in the United States. After their probationary period in shortage areas, these physicians often migrated to wealthier urban and suburban communities, where they established families and lucrative practices. Outward mobility from country of origin resulted in upward mobility in the United States.

Over the last four decades, the South Asian physician figure — encompassing both immigrants and their children — has become normalized in American life. A recent study of US medical school enrollments shows that students who identify as Asian are significantly overrepresented compared to US census numbers, and of this Asian cohort, South Asians comprise the largest subgroup. Alongside this demographic transition, there has been a migration of this entity into mass mediatized form that proliferates with ease in the public sphere; the South Asian physician figure has achieved a singular position. Scholars have long engaged in a critique of the flattening effects of the category of “model minority,” arguing that history and political economy must be reintroduced into this monolith. I apply this insight to the figure of the South Asian physician and argue that the morality attributed to care work and the trust necessary for this kind of labor enabled this racialized professional to enter popular mass media as a non-threatening expert. This is particularly significant today when the rhetorical threat of foreignness and racial difference is mobilized to incite fear and paranoia.