As the United States runs short of nurses, senators are looking abroad. A little-noticed provision in their immigration bill would throw open the gate to nurses and, some fear, drain them from the world's developing countries.
The legislation is expected to pass this week, and the Senate provision, which removes the limit on the number of nurses who can immigrate, has been largely overlooked in the emotional debate over illegal immigration.
Most Filipinos died without medical attention in 2003, just as they had three decades earlier. And the percentage of women who gave birth with a doctor, nurse or midwife attending has declined in recent years.
Senator Sam Brownback, Republican of Kansas, who sponsored the proposal, said it was needed to help the United States cope with a growing nursing shortage.
He said he doubted the measure would greatly increase the small number of African nurses coming to the United States, but acknowledged that it could have an impact on the Philippines and India, which are already sending thousands of nurses to the United States a year.
The exodus of nurses from poor to rich countries has strained health systems in the developing world, which are already facing severe shortages of their own. Many African countries have begun to demand compensation for the training and loss of nurses and doctors who move away.
The Senate provision, which would remain in force until 2014, contains no such compensation, and has not stirred serious opposition in Congress. Because it is not part of the House immigration bill, a committee from both houses would have to decide whether to include the provision on nurses if the full Congress approves the legislation.
Public health experts in poor countries, told about the proposal in recent days, reacted with dismay and outrage, coupled with doubts that their nurses would resist the magnetic pull of the United States, which sits at the pinnacle of the global labor market for nurses.
Removing the immigration cap, they said, would particularly hit the Philippines, which sends more nurses to the United States than any other country, at least several thousand a year. Health care has deteriorated there in recent years as tens of thousands of nurses have moved abroad. Thousands of ill-paid doctors have even abandoned their profession to become migrant-ready nurses themselves, Filipino researchers say.
"The Filipino people will suffer because the U.S. will get all our trained nurses," said George Cordero, president of the Philippine Nurse Association. "But what can we do?"
The nurse proposal has strong backing from the American Hospital Association, which reported in April that American hospitals had 118,000 vacancies for registered nurses. The federal government predicted in 2002 that the accelerating shortfall of nurses in the United States would swell to more than 800,000 by 2020.
"There is no reason to cap the number of nurses coming in when there's a nationwide shortage, because you need people immediately," said Bruce Morrison, a lobbyist for the hospital association and a former Democratic congressman.
The American Nurses Association, a professional trade association that represents 155,000 registered nurses, opposes the measure. The group said it was concerned the provision would lead to a flood of nurse immigrants and would damage both the domestic work force and the home countries of the immigrants.
"We're disappointed that Congress, instead of providing appropriations for domestic nursing programs, is outsourcing the education of nurses," said Erin McKeon, the group's associate director of government affairs.
Holly Burkhalter, with Physicians for Human Rights, an advocacy group, said the nurse proposal could undermine the United States' multibillion-dollar effort to combat AIDS and malaria by potentially worsening the shortage of health workers in poor countries. "We're pouring water in a bucket with a hole in it, and we drilled the hole," she said.
There are now many more Americans seeking to be nurses than places to educate them. In 2005, American nursing schools rejected almost 150,000 applications from qualified people, according to the National League for Nursing, a nonprofit group that counts more than 1,100 nursing schools among its members.
One of the most important factors limiting the number of students was a lack of faculty to teach them, nursing organizations say. Professors of nursing earn less than practicing nurses, damping demand for teaching positions.
Under the current immigration system, experts estimate that 12,000 to 14,000 nurses have immigrated to the United States annually on employment visas that entitle them to bring their immediate family members and obtain green cards. They must pass English and U.S. nursing exams to qualify for visas.
In recent years, there had been enough visas for foreign nurses from most countries, but a bottleneck developed in 2005, after immigration authorities made a big push to clear a backlog of employment visa applications. That year, Congress set aside 50,000 additional visas for nurses and their families. But those visas will likely have all been used up by early next year, State Department officials said.
It is difficult to forecast exactly how removing the limit on nurse immigration would affect the number of nurses who moved to the United States.
Based on past trends, Mr. Morrison, the lobbyist who represents the hospital association, said he thought the numbers would grow 5 to 10 percent a year over recent levels. Recruiters would focus on countries with large numbers of well-trained nurses, mainly the Philippines, India and China.
"But it's certainly true that the longer the United States puts off investing in training nurses, the more pressure there will be to find nurses abroad," he said.
Senator Brownback, who has been an advocate for programs to combat AIDS and malaria in Africa, said he did not think lifting the cap on nurse migration would have much effect on Africa because the infrastructure of companies that did recruiting for the United States market was not set up there, nor did African nurses have a big community there to plug into.
And while the Philippines could see an increase in nurse immigration, such flows could also bring benefits, he said, not just in the money they sent home, but in the nurses' voluntary efforts to improve health care in their home countries.
But Eric Buch, the top health adviser to the New Partnership for Africa's Development, an Africa-wide undertaking initiated by the continent's heads of state, said he expected that recruiting agencies would set up in African countries where nurses were trained in English and that they would advertise the change in the American law.
"You'll see that emerge, that's my guess," Professor Buch, who teaches health policy at the University of Pretoria, in South Africa, said in a telephone interview. "The United States could become a place where we bleed our health care workers."
The flight of nurses from the Philippines, a former American colony, has provided a huge boost to a weak economy, through remittances. Some government agencies there have encouraged the export of nurses, who send home billions of dollars each year to their families.
A nurse in the Philippines would earn a starting salary of less than $2,000 a year compared with at least $36,000 a year in the United States, said Dr. Jaime Galvez Tan, a medical professor at the University of the Philippines who led the country's National Institutes of Health.
He said the flight of nurses had had a corrosive effect on health care. Most Filipinos died without medical attention in 2003, just as they had three decades earlier. And the percentage of women who gave birth with a doctor, nurse or midwife attending has declined in recent years.
Based on surveys, Dr. Galvez Tan estimates that 80 percent of the country's government doctors have become nurses or are enrolled in nursing programs, hoping for an American green card. "I plead for justice," he said in a telephone interview. "There has to be give and take, not just take, take, take by the United States."
Copyright 2006 The New York Times Company