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This article is an adapted excerpt from The Care of Foreigners: How Immigrant Physicians Changed US Healthcare by Eram Alam. This text was originally published by Johns Hopkins University Press in 2025 and has been reprinted here with permission.

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.

Trump Administration Seeks Strict Time Limits on Visas for Physicians, Academics

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”........

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