- Almost one in four doctors in the United States are foreign born.

Today's guest helps us understand how that came to be and just how critical foreign-born physicians are to American healthcare today.

She's Eram Alam, this week on "Story in the Public Square."

(lively music) (lively music continues) (lively music ending) Hello and welcome to "Story in the Public Square" where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller, also with Salve's Pell Center.

- And our guest this week is Eram Alam, an associate professor in the Department of History of Science at Harvard University.

She's also the author of a new book, "The Care of Foreigners: "How Immigrant Physicians Changed US Healthcare."

She's joining us today from Boston, Massachusetts.

Eram, thank you so much for being with us.

- Thank you so much for having me.

I'm really looking forward to the conversation.

- So "The Care of Foreigners" is an important and timely book, particularly here at the end of the first year of the second Trump administration with its policies about immigration and immigrants in general.

Tell us though, what was your inspiration for writing this book?

- So I started off my graduate career thinking about health disparities, and I was really interested in researching how and why these came about.

And I realized that there's all of this literature that shows that a health disparity exists.

So you see these percentage differentials.

And then I just started to ask this question, who's actually providing care in these communities?

So I get that these exist, but what is actually happening in the background?

And I started digging into it and I realized that it's this huge, important immigrant labor workforce that's actually doing the everyday care work all across the United States.

- So as you write in the book, this really sort of emerges after some legal and policy changes in the 1960s, what did American healthcare look like?

Who made up American healthcare prior to the introduction of immigrant physicians?

- Yeah, so it was largely white male physicians and there were few of them who were operating in the space.

And that has a long history of the organized medicine or the American Medical Association doing a lot of work in the first 50 years of the 20th century that kind of keep the profession small.

So in order to make sure that their expertise and authority was recognized, they really promoted a scarcity kind of model to make sure that they were able to, you know, be the prime actors in the healthcare space.

So they were providing care, there are nurses who are working, but by and large, it's a very local-based kind of thing where people are trying to get care when and wherever they can.

- So Eram, what were the historical roots of that primarily white male medical system?

I mean, they're old and were well established before, you know, foreign doctors began to come to America.

Tell us a little bit about that 'cause I found that absolutely fascinating.

- Yeah, so in the beginning of the 20th century, the US medical system and medical education was very, very haphazard and very chaotic.

And Europe was much more advanced than the United States was during this time.

And so the US decided, especially these elite medical men at places like Harvard, Hopkins, at the University of Pennsylvania, they decided we need to have something that looks much closer to the European model because right now, you can have such a variability in what it means to be a physician.

So sometimes people can have four months of training, sometimes people can be called a physician if they're an apprentice.

Sometimes you have people who go to places that are elite medical schools that have two years of training, clinical practice, et cetera.

But the point being that all of these people can call themselves physicians.

And so there's this huge effort in the beginning of the 20th century to create some kind of standardization around medical education, clinical training, and then licensure after that.

And so as a consequence of all of those things, what happened is that there were so many medical schools, they were called diploma mills in the United States during this time.

And so they started to close because these new requirements came into place that you need to have two to three years of book learning, you need to have a few years of clinical training on top of that, that students should have access to laboratory sciences in addition to just hospital practices in the work that they're doing.

And a consequence was that women, they had some of their own medical schools, Black physicians, those medical schools that were catering to those populations were not able to meet this new standard.

And so as a result, they ended up closing.

And so these few elite places were able to stay in operation and they recruited elite, wealthy white men essentially to join their schools.

- And they dominated not only healthcare, but also the scientific literature.

Is that correct?

- Yeah, absolutely.

I mean, those things... You know, what really happened in the beginning of the 20th century is those things started going hand in hand.

And so academic medicine, you know, this idea that we really emerged during that moment of this new kind of triad of clinical medicine, medical education, and the laboratory really coming together.

- So what role did the American Medical Association, the AMA, play in this?

And it was a critical role and you get into it in great detail in your book.

Elaborate on that for us please.

- Yeah, so the AMA, I mean, they're the prime movers and shakers, especially in the early 20th century.

And they continue to be a huge lobbying political force even today.

And they were integral in making these kinds of decisions.

And they used this language, again, this sort of standardization of licensure to kind of close and cohere the whole profession around a very particular kind of identity.

And they were absolutely instrumental in making sure that certain lists of schools were allowed to get licenses, other schools were disallowed from doing so.

And then also throughout, you know, when there were conversations about 1940s of potentially having a national medical system in the United States, they were on the forefront of saying, "Absolutely not.

This is going to ruin this practice of medicine.

It is going to take away any kind of physician autonomy that we have worked so hard to maintain."

- So this is... Well, I wanna get to sort of what changes in the middle of the 1960s, but I'm wondering, how accessible was healthcare in that old system?

So you talked about, in graduate school, you were interested in sort of economic and health disparities.

I'm wondering if you were poor, if you were in rural America in that system, you know, in the 1940s and the 1950s, how easy was it to access care?

- It wasn't very easy at all.

It was not available because again, you have this concentration in cities like Boston, Chicago, these major metropolises.

And in addition, you have to remember, we're in the middle of Jim Crow segregation.

So for Black patients, for example, they're not even allowed into hospitals that are... They're only allowed into segregated facilities.

And so this is also why you start to see movements around like the Black Panthers, for example, and why health becomes so integral into their whole political campaign in the 1960s because there's this huge population of non-white people that are actually just disallowed and have zero access to healthcare.

- So 1965, there's a change in US law that makes it possible for foreign physicians to enter the United States.

It's a change in law.

There's a series of changes in policy.

Walk us through what happened in the mid-1960s.

- Yeah, so the 1960s, we have to imagine the US is in this space of global superpower at this time.

And they're really trying to promote this capitalist vision of interconnectedness, that these liberal democracies are all coming together and they're trying to thwart the rise of a communist rise.

And these newly emergent post-colonial nations in Asia and Africa become these really important political sites of contestation because the US essentially wants to make sure to persuade these new countries to stay within its orbit, to stay within its sphere of influence, and not move towards the USSR, and the communist sphere of influence.

But there's this huge problem, which is that immigration legislation in the United States, the most comprehensive one that was on the books was this 1924 bill.

And that bill had two components to it.

One was the National Origins Act, which limited immigration from Southern and Eastern Europe, and the other was the Asian Exclusion Act, which is exactly what it sounds like.

And so you have these countries that you're trying to say, "Hey, we wanna be your friend, but you actually can't come physically into this country."

And so lawmakers really started to understand that immigration has to be very much a part of the foreign policy conversation, and that it has to be a tool and a mechanism to say to these newly emergent countries that "We are your friend, we welcome you.

Look, we're even welcoming your citizens into the physical geographic United States."

So that's huge change number one in terms of immigration.

Then you have this domestic issue that's concurrently happening in the United States where we have this shortage of scientists, of engineers, and of physicians.

So a little bit back to the Cold War context.

So much of the Cold War is an ideological battle, and science and medicine are absolutely key public arenas where this is being played out.

So this is why you see things like Sputnik, this is why, you know, there's this huge, huge investment in science and medicine.

And so the United States to broadcast a deficiency in this realm is a point of weakness.

It's a point of political weakness.

And so we have this labor deficiency in terms of these skilled experts.

We have this problem, especially with physicians, where there is a post-World War II population boom.

And at this time, people that are old and people that are young are the largest users of healthcare.

And so you have this huge increase in healthcare demand that's happening.

And you have, again, back to what I was saying earlier about there's this political awareness that healthcare should not be a luxury good, that it should be something that is a right for all people.

And so political sensibilities around it change, this whole demographic change happens.

And then finally the biggest change is 1965, July, Medicare, which people over 65 receive federally subsidized health insurance, and Medicaid, people who are low income receive federally subsidized health insurance.

So all of a sudden, about 23 million more people are entering into the healthcare marketplace.

So all of these things really came together to catalyze this urgent need for physicians.

And then immigration became this mechanism for allowing their speedy entry into the country.

- So many of the foreign doctors who came to the US established practices in rural and other underserved areas.

Two questions here.

Why did they do that?

And how were they received by people in these areas, many of whom, to be perfectly blunt, were suspicious of foreigners?

- Yeah.

So why they did that was because that was part of the arrangement for their entry.

So they had with their legal entry that they had to work in these, what were called shortage area communities in the United States.

And these are communities, the ratio for physicians to population is 1 to 3,500.

And these communities are in desperate need of labor.

And so this was a stipulation of their visa requirement that they would have to go and work in these shortage area communities.

And it continues to be the case now with the current ways that these visa categories are written is that you have to perform service in these particular communities for a distinct period of time before you can actually move out of them.

So that was part of the reason why they went to work there.

And also, this is where these shortages were.

You know, in Boston, when you don't have a shortage and people who think immigrant physicians are of questionable caliber and character, they're not gonna necessarily be welcome in these communities where you have US-trained graduates from Harvard and from, you know, BU, and all these other places that are competing for the same positions.

And so this is where the vacancies were, and this is why these positions were sent to these communities.

And how they were received, it was a complicated dynamic of really complicated social dynamics.

So I talk about in the book that in this 1965 moment, one of the really important acts that the US government passed was the Civil Rights Act in 1964.

And this forced the desegregation of healthcare facilities if anybody wanted to receive any federal money.

So remember, 1965, Medicare and Medicaid became huge inputs of federal money.

So into this kind of crucible of change, you have forced desegregation in the clinical space.

And then you have these immigrant physicians who are showing up, claiming to be doctors, claiming to have expertise and authority that is coming from some place else.

So it's already in question.

And so often in doing my research, they talked to about having to doctor differently, that they were not allowed the same kinds of scripts or the same kinds of access to what it meant to be a physician that their US-trained colleagues had, and they were met with suspicion.

Their education was often questioned.

"Are you good enough?

Can you actually do this work?

Can we trust you?"

And so they had to develop different kinds of strategies of talking to patients, of entering a room differently, of just different ways of carrying themselves, of speaking such that they were able to establish trust in order to yield a therapeutic outcome.

And these were things that their US-trained counterparts just didn't have to do.

They could walk into a room with a white coat and their authority, their expertise, their position within the system was granted to them.

- You know, one question, we may have touched on this just a little bit, but why didn't in the 1950s and '60s, and I guess even today, why doesn't the United States produce enough physicians just from the American population that's already here?

Why do we have to import physicians?

- Yeah, I mean, this is, you know, that longer history and longer question of why?

What work does scarcity do in creating expertise and prestige around any kind of profession?

If you have an abundance, if you have a nationalized system where people are salaried, like you do in the NHS in the UK, for example, it's a very different... They still, they too have shortages, but they're for slightly different reasons than in the United States.

So I think it's this focus on maintaining the prestige, the economic prestige, the social prestige of the physician.

And by virtue of, yeah, just making sure that there are a limited number and so it doesn't dilute the integrity of that social position.

- So many of the foreign doctors who came to the US were well-trained.

They were well-qualified.

What about the issue of the so-called brain drain?

They come to this country and the countries they left now have populations that are not served by these high-quality people.

Was that a morality issue?

And how did that play out?

How does it still play out?

- Yeah, it's a really complicated dynamic.

And, you know, there were times when this whole immigration flow started in 19... Really, really started to gain momentum in '66, '67 that people like Walter Mondale were saying this exact same thing.

They were saying, "You know, is this a fair thing for the United States to do?

On the one hand, as the leader, should we be siphoning this labor, that is the expert labor that's going to allow what, you know, in their language, these countries to develop?

And in fact it's a very extractive process that's happening."

So you're absolutely right.

These physicians are trained at elite medical schools, which in country of origin, especially India, Pakistan, and the Philippines, these are government-subsidized medical schools.

So these are people who are receiving educations with the assistance of taxpayer dollars, unlike in the United States where, you know, the most elite schools are the private schools.

And there were times where physicians would tell me that in their classes, out of 155 people, 154 would go to the US or the UK.

And so you're right to point out that that is a huge drain and it creates this huge gap within their own national health infrastructure.

And there were attempts to prohibit this, there continue to be attempts to try to slow it down a little bit.

But one of the complicating factors is that, you know, a part of Declaration of Human Rights is a right to movement and it's a right to mobility, and this is the basis of the liberal governance structure.

And so you can't impose a restriction or you shouldn't impose a restriction on people making that choice.

And so how I have to think about it or I try to think about it is what are ways of incentivizing people to stay or what are different configurations of healthcare delivery that we can imagine such that a loss of a physician can be compensated with the assistance of other kinds of practitioners in that space?

But I think you're absolutely right to point out that it's a huge dilemma.

And so there was a time in India, in 1967 I believe, where they tried to prevent this flow from happening.

And so they said, "Okay, this exam, that's a really important requisite for entry into the United States, we're gonna disallow it from being administered in US embassies."

And people like Deepak Chopra then just went to Sri Lanka and they took the exam in Sri Lanka.

And other physicians, who remember, these are generally elite members of society, they would go to Iran and they would take the test there and circumvent that, and then come to the United States through other means.

And so again, it's very difficult, it's challenging.

During COVID, India again tried to institute some of these policies, instituting a fine, but people are wealthy and they can just pay the fine often or they just don't come back.

And so they don't have to deal with the consequences of the action or the fine that they may have incurred for leaving.

- You know, Eram, we're at the end of 2025, the first year of the second Trump administration, an administration that has taken a number of, I think what could be safely characterized as aggressive actions to reduce the number of immigrants coming to the United States, and to make it more difficult for some of those who are already here.

What's the likely outcome for American healthcare, for foreign-born physicians in this environment?

Here we are again at the end of 2025.

- Yeah, I think it's gonna be devastating.

I think that the consequences are going to be such that those who are the most marginalized in society, the most vulnerable, the sickest are gonna be the ones who are gonna be subjected to suffering and premature death as a result.

And I mean, I say this, you know, with a lot of heaviness around this whole situation that has been a problem for the last 60 years and is gonna continue to be exacerbated as a result of these immigration policies.

So just to think about the H-1B visa issue, which is the most recent one.

So September 19th, the executive order went into place that H-1B visa sponsorship was now going to incur a 100,000 fee that the employer was going to have to absorb.

And the whole order is aimed at tech workers predominantly, 70% of whom come from India.

But a consequence is that H-1B visa users are also immigrant physicians who come to this country.

And many of the hospitals where they work are not going to be able to absorb the costs.

So just a quick, you know, math lesson in this.

So say that a rural hospital has 10 immigrant physicians on their staff, and many rural hospitals are fully staffed by immigrant physicians because US-trained physicians don't wanna go and work there.

And so prior to this new imposition of the 100 K fee, visa fees were anywhere from 2,000 to $5,000 per applicant that a hospital would pay.

So you go from a place where a hospital is paying 20,000 to $50,000 in order to sponsor 10 workers to come for anywhere from three to six years to provide healthcare.

And now that has increased to a million dollars per year that the hospital is going to have to generate.

Already these hospitals are working with razor-thin margins.

Medicaid cuts are gonna further decimate, with this budget bill, further decimate these institutions.

So what's gonna happen?

Maybe in the future, they'll be able to have, instead of 10, they'll have six physicians that they can actually support, that they can pay the cost of.

And the consequence is going to be that fewer physicians means longer wait times, fewer patients actually being seen, and dire health consequences that are gonna continue in these communities.

And so I think it's going to be extremely devastating.

And not to mention just the general xenophobia and the rise in hate crimes, I think is going to dissuade people from wanting to make a decision to come to the United States when they can go to Canada, they can go to the UK.

Things aren't perfect there, but there aren't as many guns.

- And what I hear you saying is that they have options.

- Yeah, absolutely they have options.

- So, you know, we've talked about the overall trend in American healthcare, if you have your crystal ball and, you know, Donald Trump won't be president forever, what is the future for foreign physicians in the United States?

We've got about 45 seconds left.

- So foreign physicians are absolutely integral to the functioning of the US workforce.

They do so much of the primary care labor in this country.

So the frontline workers are immigrant physicians.

And I think what we have to do is support them in their journey through the United States and also think about other kinds of ways of organizing healthcare such that they are not alone in doing this kind of work.

So how can we reinvigorate community health workers, physicians' assistants, nurse practitioners to work in concert with these physicians so that they can provide a wider range of care to a greater swath of Americans who are really suffering?

- Eram Alam, the book is "The Care of Foreigners."

Thank you for spending some time with us this week.

That is all the time we have this week.

But if you wanna know more about the show, you can find us on social media or visit salve.edu/pellcenter where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes asking you to join us again next time for More "Story in the Public Square."

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