Philpott: A call to end #racism in Canada’s health care systems

Of note the emphasis on practical initiatives:

I wish I could say with certainty that the death of 37-year-old Joyce Echaquan will be a wake-up call for health systems in Canada. It should be. But history gives us no confidence to make such a claim. Joyce Echaquan is not the first person to die as a direct or indirect result of racism in Canadian health care systems. Tragically she won’t be the last. But her death comes at a point in our history where Canadians may be more attuned to the dangers of systemic racism than we were, for example, when 45-year-old Brian Sinclair died in a Winnipeg hospital in 2008.

We must seize this moment in history and act to prevent more senseless deaths. There is no better place to start than with changing the way we train health professionals. A 2019 international consensus statement on Indigenous health equity notes that “Medical education institutions must acknowledge their historical and contemporary role in the colonial project and engage in an institutional decolonization process.”

Here at Queen’s University, our principal, Patrick Deane, has not shied away from declaring that racism and other forms of oppression, including colonialism, “deeply affect our institution, as they do the systems and formations of our society at large.” Such a categorical admission of institutional racism from the leader of a prominent post-secondary institution is not something we heard a decade ago. The open admission that an organization like ours is plagued with structural injustices, which permit some to be privileged and others to be harmed, is an essential step on our journey to changing those deep-rooted patterns of injustice. That kind of openness leads me to think that we are at a point in time when we can more effectively take on racism and colonialism in health care; in hopes that Joyce Echaquan’s death will not be in vain.

There is no single intervention that leads to the reduction or the elimination of racism and colonialism in health systems or in the training of health professionals. We need comprehensive and collaborative cultural transformation. We don’t need more studies; we need action on a suite of reforms. Steps have been laid out in multiple reports including the Calls to Action of the Truth and Reconciliation Commission and the Calls for Justice from the Inquiry on Missing and Murdered Indigenous Women and Girls. The Association of Medical Faculties of Canada tabled its own commitment last year entitled a Joint Commitment to Action on Indigenous Health.

As dean of the Faculty of Health Sciences at Queen’s, I’m determined to work with my colleagues to breathe life into those reports. We have hired new staff including an elder-in-residence to provide ceremonial and cultural supports. Last week we opened an Office of Equity, Diversity, and Inclusion and we now have over 150 volunteers from students, staff, and faculty participating in a Dean’s Action Table on Equity, Diversity, and Inclusion.

We have an obligation to expand the Indigenous health workforce by increasing the number of First Nations, Inuit and Métis students in medicine, nursing and rehabilitation therapy. Indigenous Peoples must see themselves reflected in the health professionals who treat them. We must continue to identify structural biases in our admissions processes and make amendments, accordingly, including diversifying the membership of admissions committees and introducing cultural safety training for their members.

We’ve already changed the focus of the Queen’s Accelerated Route to Medical School to enable 10 students who identify as Indigenous or Black to begin a pathway to medical education that addresses some of the well-known systemic barriers to access. We know this means we’ll need a broad community of support for growing numbers of Indigenous and Black students on campus and in our health professions programs, but we’ve already taken steps to enable that, by hiring mentors such as Wendy Phillips, elder-in-residence and former MP Celina Caesar-Chavannes, senior advisor on equity, diversity and inclusion.

Just as important as the diversity of our student body is what we teach our students. Our curricula must include Indigenous perspectives of history and culture. It should include concepts of power, privilege and conflict resolution. This work is underway. We have professional development courses in cultural safety, anti-racism and anti-oppression. We have started to diversify our workforce, recognizing the importance of having staff and faculty from under-represented groups in leadership positions and on decision-making bodies.

We also need tools to help us identify personal, institutional and systemic forms of racism. As we use these tools, there will be an obligation to act on what we learn, with cycles of self-reflection and informed action. Increasingly, we must learn safe and effective ways to speak up when we recognize bias, harassment, and micro-aggressions.

Speaking up is the minimum response. Our collective goal is to change the entrenched patterns of injustice in our health systems. In some cases, it’s a matter of life or death.

Source: A call to end racism in Canada’s health care systems

University of Toronto research to explore racism in health care during pandemic

Should be an interesting study which hopefully will identify some pragmatic approaches:

A new research project will look at the impact of the COVID-19 pandemic on racialized communities as well as existing biases in the health-care system.

The national project was launched by Roberta Timothy, an assistant professor with the University of Toronto’s Institute for Pandemics.

Timothy says many members of the Black and Indigenous communities already avoid interacting with the health-care system mostly due to experiences with racism and biases.

During a global pandemic, Timothy says that can have grave consequences for the well-being of those communities.

“People will seek help when it’s an emergency and by then it’s too late,” she says. “Because of the bias, because of anti-Black racism, because of violence they experience, their health becomes more at risk.”

Timothy says there’s a need for more data to effectively understand the impact of COVID-19 on racialized communities.

The Ontario government refused to collect race-based data earlier in the pandemic, but it was forced to change course in June. Now it mandates the collection of data around race, income, household size and language when following up with people who’ve been infected with COVID-19.

A spokesman for the Ministry of Health said the government is engaging with people from racialized communities and other health equity experts regarding the data collection.

“We plan to share findings of this data collection, informed by this engagement,” David Jensen said in an email.

Jensen said the ministry is concerned about the spread of the virus in “certain groups of people and in certain neighbourhoods,” and would welcome additional insights and information about how COVID-19 is affecting racialized communities.

Early data compiled by Toronto Public Health showed that 83 per cent of COVID-19 cases occurred in racialized people. Black people represented 21 per cent of cases in Toronto, but only nine per cent of the city’s population.

“There is growing evidence in North America and beyond that racialized people and people living in lower-income households are more likely to be affected by COVID-19,” said Dr. Christine Navarro,  associate medical officer of health for Toronto.

“While the exact reasons for this have yet to be fully understood, we believe it is related to both poverty and racism.”

Timothy’s project will collect more data about how Black people interact with the health-care system, but also about economic impacts, evictions, support networks and essential work being done by marginalized communities.

“An underlying part of the project is not only to bring better data, but to support the community in strategizing and finding interventions to find how we get through this,” said Timothy.

Rudayna Bahubeshi, a Toronto resident and post-graduate student in public policy, says she has first-hand experience with racism in the health-care system. During a stint in a mood disorder ward when she was 18, Bahubeshi said a nurse mistook her for a 30-year-old patient — the only other Black person in the ward at the time — and tried to make her take the other person’s medication.

Bahubeshi says she argued but was ignored, and believes her race was a factor in the way she was treated by staff. She says the nurse only realized the mistake when the other patient happened to walk by.

In another hospital visit during the pandemic, Bahubeshi says she was taken to a “COVID ward” because she had fever. She says staff would not answer simple questions about whether there were risks involved with using a shared washroom, or about the fact that some staff weren’t wearing PPE.

“The way she (the nurse) was engaging with me was very much that I was the problem,” says Bahubeshi. “When I talked to a doctor afterwards they told me I was fully in the right and that was unacceptable.”

Bahubeshi says experiences like those erode her trust in the public health system and its ability to provide quality care for her. She says more data about the experience of Black people in health care will be a first step in the right direction.

“The fact that we don’t have race-based data is a way we’ve decided that Black communities are not a priority,” said Bahubeshi.

Timothy’s national project is set to begin in a few months, and will involve surveys and focus groups among Black Canadians.

Source: University of Toronto research to explore racism in health care during pandemic

Le PLQ et QS dénoncent un programme de régularisation discriminatoire

Appropriate criticism over the narrowness of the program;

Le Parti libéral du Québec et Québec solidairejugent trop sévères les conditions d’admission au Programme spécial visant à faciliter l’octroi de la résidence permanente aux demandeurs d’asile qui, au plus fort de la crise sanitaire, suaient sang et eau dans les résidences pour personnes âgées assaillies par la COVID-19.

« On circonscrit l’accès à la mesure à un secteur [la santé], et à l’intérieur du secteur, même si tout le monde a eu un risque [de contracter le coronavirus], on circonscrit encore plus… Ça, ça ne serait pas discriminatoire ? » a demandé l’élu libéral Gaétan Barrette en commission parlementaire lundi.

Le Programme spécial des demandeurs d’asile en période de COVID-19 (PSDAPC) s’adresse aux « anges gardiens » qui étaient « sur la ligne de front » à prodiguer des « soins directs à la population pendant la pandémie », a expliqué la ministre de l’Immigration, Nadine Girault. « Ceux qui ont pris le plus de risque », a-t-elle résumé.

Le PLQ et QS se sont tour à tour désolés de voir les autres travailleurs du secteur de la santé — les préposés à l’entretien des résidences pour aînés frappés de plein fouet par le coronavirus, par exemple — laissés en plan par le PSDAPC. Un « vrai, vrai, vrai geste d’humanité » serait de « remercier […] tous les gens qui ont pris un risque ». « Que je sois préposé à l’entretien ménager ou gardien de sécurité, quand le virus je l’attrape, puis que je meure, c’est moi qui suis mort, c’est ma famille qui pâtit. C’est ça un risque », a souligné M. Barrette.

On circonscrit l’accès à la mesure à un secteur [la santé], et à l’intérieur du secteur, même si tout le monde a eu un risque [de contracter le coronavirus], on circonscrit encore plus…

« On a envoyé au combat […] une armée de gens sans arme », a-t-il ajouté, tout en rappelant l’absence d’équipements de protection individuelle en quantité suffisante dans les milieux de vie pour personnes âgées après l’arrivée de la COVID-19 en sol québécois.

L’ex-ministre de la Santé soupçonne le gouvernement caquiste d’avoir « mis un frein » à la volonté du gouvernement fédéral de régulariser les employés du réseau de la santé en situation de précarité afin de respecter les seuils d’immigrationqu’il s’est fixés.

Le député solidaire Andrés Fontecilla a suggéré lundi d’accroître la portée du Programme spécial afin que les préposés à l’entretien, les agents de sécurité, les travailleurs agricoles, les travailleurs d’abattoirs ou d’entrepôts en situation de précarité puissent aussi s’y inscrire.

La ministre de l’Immigration, Nadine Girault, a dit être en paix avec sa décision de permettre seulement aux demandeurs d’asile ayant prodigué des soins directs à des patients — dont des préposées aux bénéficiaires et des aides-infirmières — de s’inscrire au PSDAPC, ce qui leur permettra de s’établir au Québec. « Ce n’était pas un programme discriminatoire. C’était un programme pour remercier les gens qu’on voulait remercier chez les “anges gardiens” qui ont pris soin de nos gens. C’est tout simplement ça », a-t-elle fait valoir.

Puis, elle a cédé, sans avertissement, la parole au nouveau sous-ministre de l’Immigration, Benoit Dagenais. Béant de surprise, le haut fonctionnaire s’est mis à la tâche d’énumérer les 10 orientations de la Planification pluriannuelle de l’immigration 2020-2022 léguée par l’ex-ministre Simon Jolin-Barrette.

Il a par la suite mentionné que le Plan d’immigration du Québec 2021 sera établi à la lumière de la situation économique du Québec, qui a été fragilisée par l’arrivée du coronavirus en sol québécois le printemps dernier. « La crise sanitaire, évidemment, on va la prendre en considération », a souligné M. Dagenais.

De son côté, Mme Girault a indiqué qu’« il n’y aura pas de baisse des seuils d’immigration ».

Lutte contre le racisme

Le PLQ a aussi jeté le doute sur la volonté du gouvernement de lutter contre le racisme au Québec, lundi, après que Mme Girault eut refusé net de nommer les groupes rencontrés jusqu’à aujourd’hui par le Groupe d’action contre le racisme (GACR), dont elle assure la coprésidence.

Le « groupe des sept » élus de la Coalition avenir Québec, qui a été mis sur pied au lendemain de la mort de l’Afro-Américain George Floyd sous le genou d’un policier de Minneapolis, doit présenter une série d’actions visant à faire reculer le racisme au cours de l’automne.

« C’est malheureux et c’est décevant de ne pas avoir l’information », a dit la députée libérale Jennifer Maccarone, tout en invitant le GACR à solliciter sans délai l’avis de la Ligue des Noirs, du Congrès maghrébin au Québec, de la Ligue des droits et libertés…

Source: Le PLQ et QS dénoncent un programme de régularisation discriminatoire

‘Why not us?’: Asylum seekers on COVID-19 front lines demand permanent residency

All too predictable, the understandable debates over who’s in and who’s out, which happens with respect to most government programs, whether immigration or other:

Doll Jean Frejus Nguessan Bi says he couldn’t sleep at all last night.

The asylum seeker from Ivory Coast works as a security guard in hospitals and long-term care homes in the Montreal area, where he watched many of his colleagues stop coming in as deaths linked to COVID-19 began to mount this spring.

But while Nguessan Bi kept working, he said he found out Friday that he would be excluded from a new government program to fast-track the permanent residency applications of some asylum seekers working on the front lines during the pandemic.

“Why (not) us? We who gave our hearts and our love… Why are we abandoned?” he said in an interview at a protest camp across the street from Prime Minister Justin Trudeau’s Montreal riding office Saturday. “What did we do to deserve this?”

Ottawa announced Friday that asylum seekers working in specific jobs in the health-care sector would be eligible for permanent residency without first having to wait for their asylum claims to be accepted, as is typically the process.

Immigration Minister Marco Mendicino said the move came in response to public demand for so-called “Guardian Angels” — many in Quebec — to be recognized for their work.

“They demonstrated a uniquely Canadian quality in that they were looking out for others and so that is why is today is so special,” Mendicino said in an interview Friday afternoon.

But asylum seekers and their supporters say Ottawa’s plan excludes thousands of workers without permanent status in Canada who have laboured on the front lines during the pandemic, often at great personal risk to themselves and their families.

That includes security guards and janitorial staff, factory workers, and farm labourers, among others.

“I have friends who worked with me in security that abandoned (their posts) because they were afraid of getting infected. But I stayed,” said Nguessan Bi.

He said he wants Trudeau and Quebec Premier Francois Legault to do something to help asylum seekers who are not eligible for the new program.

Several dozen people rallied in front of Trudeau’s office on Saturday to demand permanent residency for all asylum seekers.

“It’s an act of recognition. They deserve status,” Joseph Clormeus, a member of Debout pour la dignite, a Montreal advocacy group that organized the rally, told the crowd.

Anite Presume, a Haitian asylum seeker who came to Quebec in August 2017 from the United States, was among the protesters.

She works in a medication factory, and said she kept working during the pandemic despite the risks.

“To take the bus, we were all stressed, but we still went to work because it was essential. They needed medication for the hospitals,” she said in an interview.

She said she has not received a response yet to her application for asylum in Canada, and lives under a cloud of uncertainty and stress about her future.

“It’s a feeling of rejection,” Presume said, about not being included in Ottawa’s regularization program. “They rejected us as if we did nothing.”

To apply for residency under the new program, applicants must have claimed asylum in Canada prior to March 13 and have spent no less than 120 hours working as an orderly, nurse or another designated occupation between the date of their claim and Aug. 14.

They must also demonstrate they have six months of experience in the profession before they can receive permanent residency and have until the end of August 2021 to meet that requirement.

The program was the result of negotiations between the federal government and Quebec, who have had a strained relationship on the question of immigration, and in particular the asylum claimants, in recent years.

Public support has been building for asylum seekers’ demand for permanent residency after it was revealed that refugee claimants were among those toiling in Quebec’s long-term care facilities, which were hard-hit by COVID-19.

Source: ‘Why not us?’: Asylum seekers on COVID-19 front lines demand permanent residency

For Doctors of Color, Microaggressions Are All Too Familiar

Of note:

When Dr. Onyeka Otugo was doing her training in emergency medicine, in Cleveland and Chicago, she was often mistaken for a janitor or food services worker even after introducing herself as a doctor. She realized early on that her white male counterparts were not experiencing similar mix-ups.

“People ask me several times if the doctor is coming in, which can be frustrating,” said Dr. Otugo, who is now an emergency medicine attending physician and health policy fellow at Brigham and Women’s Hospital in Boston. “They ask you if you’re coming in to take the trash out — stuff they wouldn’t ask a physician who was a white male.”

After years of training in predominantly white emergency departments, Dr. Otugo has experienced many such microaggressions. The term, coined in the 1970s by Dr. Chester Pierce, a psychiatrist, refers to “subtle, stunning, often automatic, and nonverbal exchanges which are ‘put downs’” of Black people and members of other minority groups; “micro” refers to their routine frequency, not the scale of their impact. Dr. Otugo said the encounters sometimes made her wonder whether she was a qualified and competent medical practitioner, because others did not see her that way.

Other Black women doctors, across specialties, said that such experiences were all too common. Dr. Kimberly Manning, an internal medicine doctor at Grady Memorial Hospital in Atlanta, recalled countless microaggressions in clinical settings. “People might not realize you’re offended, but it’s like death by a thousand paper cuts,” Dr. Manning said. “It can cause you to shrink.”

The field of medicine has long skewed white and male. Only 5 percent of the American physician work force is African-American, and roughly 2 percent are Black women. Emergency medicine is even more predominantly white, with just 3 percent of physicians identifying as Black. The pipeline is also part of the problem; at American medical schools, just 7 percent of the student populationis now Black.

But for Black female physicians, making it into the field is only the first of many challenges. More than a dozen Black women interviewed said that they frequently heard comments from colleagues and patients questioning their credibility and undermining their authority while on the job. These experiences damaged their sense of confidence and sometimes hampered teamwork, they said, creating tensions that cost precious time during emergency procedures.

Some physicians said they found the microaggressions particularly frustrating knowing that, as Black doctors, they brought an invaluable perspective to the care they offer. A 2018 study showed that Black patients had improved outcomes when seen by Black doctors, and were more likely to agree to preventive care measures like diabetes screenings and cholesterol tests.

In May, four female physicians of color published a paper in Annals of Emergency Medicine on microaggressions. The authors, Dr. Melanie Molina, Dr. Adaira Landry, Dr. Anita Chary and Dr. Sherri-Ann Burnett-Bowie, said they hoped that, by shining a spotlight on the problem, they might reduce the sense of isolation that Black female physicians experience and compel their white colleagues to take specific steps toward eliminating conscious and unconscious bias.

Discussions about lack of diversity in medicine resurfaced in early August, when the Journal of the American Heart Association retracted a paper that argued against affirmative action initiatives in the field and said that Black and Hispanic trainees were less qualified than their white and Asian counterparts.

Dr. Phindile Chowa, 33, an assistant professor of emergency medicine at Emory University, was in her second year of an emergency-medicine residency when an attending in her department mistook her for an electrocardiogram technician, even though she had previously worked with him on rotations. She approached him to give a report on her patients, and he wordlessly put out his hand, expecting her to hand over an electrocardiogram scan.

“He never apologized,” Dr. Chowa said. “He did not think he did a single thing wrong that day. I was the only Black resident in my class. How could he not know who I am?”

The derogatory encounters continued from there. Colleagues have referred to her as “sweetie” or “honey.” She recalled one patient who asked repeatedly who she was over the course of a hospital visit, while quickly learning the name of her white male attending physician. When she was first admitted to her residency, at Harvard, a medical school classmate suggested that she had had an “edge” in the selection process because of her race.

Such comments can create an environment of fear for Black women. Dr. Otugo recalled overhearing her Black female colleagues in Chicago discuss how they were going to style their hair for their clerkships. Many of them worried that if they wore their hair naturally, instead of straightening it or even changing it to lighter colors, their grades and performance evaluations from white physicians might suffer.

Dr. Sheryl Heron, a Black professor of emergency medicine at Emory University School of Medicine, who has worked in the field for more than two decades, said microaggressions can exact a long-lasting toll. “After the twelve-thousandth time, it starts to impede your ability to be successful,” she said. “You start to go into scenarios about your self-worth. It’s a head trip.”

This comes on top of the stresses that are already pervasive in emergency departments. A 2018 survey of more than 1,500 early-career doctors in emergency medicine found that 76 percent were experiencing symptoms of burnout.

But Black women doctors said they have seen how Black patients rely on their presence to get the best care. Monique Smith, a physician in Oakland, Calif., was working in the emergency room one night when a young Black man came in with injuries from a car accident. She was confused when some of her colleagues called him a “troublemaker,” so she visited the patient’s bed and asked him about his experience being admitted. He told her that he had begun to lash out when he felt he was being stereotyped by staff members because of his skin color and the neighborhood he came from.

“I was able to go into the room and say, ‘Hey dude, Black person to Black person, what’s up?’” Dr. Smith said. “Then I advocated for him and made sure he got streamlined care.”

The conversation made Dr. Smith more attuned to the degrading comments that Black patients experience at hospitals, and she now tries to intervene and identify her colleagues’ biases. She believes, for example, that physicians are sometimes quicker to order drug testing for Black patients, even if their symptoms are most likely unrelated to substance abuse.

But many Black physicians find it challenging to be advocates for themselves and their patients, particularly within the rigid hierarchies of the medical system. “You’re faced with situations where you’re going to be perceived as the angry Black woman even though you’re just being your own advocate,” said Dr. Katrina Gipson, an emergency medicine physician. “You’re constantly walking the line of how to be a consummate professional.”

Dr. Landry, an author of the recent paper and an emergency medicine physician at Brigham and Women’s Hospital, said that hospital and residency directors who are looking to address the deep-rooted problem should begin with hearing and validating the personal experiences of Black doctors. Continuing to diversify emergency medicine departments is also critical, she added, so that Black physicians are not working in isolation to implement cultural changes and arrange mentorship from more senior Black colleagues.

“I’m the only African-American female physician faculty member in my department, and that creates this feeling of not having a support system to speak up when something happens to you,” Dr. Landry said. “Having this paper is a validating tool for people to say, ‘See, I’m not the only one this is happening to.’”

Dr. Molina, an emergency medicine resident at Brigham and Women’s Hospital and one of the paper’s authors, said that spotlighting diversity in medicine was particularly important amid a pandemic that disproportionately impacts Black patients. “The Covid pandemic has served to emphasize health disparities and how they impact Black populations,” she said. “As emergency physicians, we have to present a united front recognizing racism is a public health issue.”


ICYMI: Black Children Are More Likely to Die After Surgery Than White Peers, Study Shows

Yet another study showing racial disparities in healthcare:

Black children are more than three times as likely to die within a month of surgery as white children, according to a study published in the journal Pediatrics on Monday.

Disparities in surgical outcomes between Black and white patients have been well established, with researchers attributing some of the difference to higher rates of chronic conditions among Black people. But this study, which looked at data on 172,549 children, highlights the racial disparities in health outcomes even when comparing healthy children.

Researchers found that Black children were 3.4 times as likely to die within a month after surgery and were 1.2 times as likely to develop postoperative complications. The authors performed a retrospective study based on data on children who underwent surgery from 2012 through 2017.

Olubukola Nafiu, the lead author of the study and a pediatric anesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio, said the authors were not surprised to find that healthy children, across the board, had extremely low rates of mortality and rates of complications after surgery. But what surprised them was the magnitude of the difference in mortality and complication rates by race.

“The hypothesis we had when we started was that if you studied a relatively healthy cohort of patients, there shouldn’t be any difference in outcomes,” Dr. Nafiu said.

The authors, in their paper, acknowledged limitations of the study: They did not explore the site of care where patients received their treatments or the insurance status of patients, which can be used as a proxy for socioeconomic status. This meant they could not account for differences in the quality of care that patients received or the economic backgrounds of the patients.

Another limitation was that because mortality and postoperative complications are so uncommon among healthy children, it is possible that most of the cases came from a few hospitals, Dr. Nafiu said.

But while Black people are more likely to receive care in low-performing hospitals, that may not be the main factor driving the gap this study found, Dr. Nafiu said. The hospitals examined in the study were all part of the National Surgical Quality Improvement Program, a voluntary program, meaning they had the resources to be part of the program and the belief that quality improvement is important.

Adil Haider, dean of the medical college at Aga Khan University, who was not involved with the study, said that it told a key piece of the story about racial disparities in surgical outcomes, but that there were still many questions about what drives disparities.

Brain Waste among U.S. Immigrants with Health Degrees: A Multi-State Profile

Good in depth study by MPI. Suspect similar patterns in Canada:

The coronavirus pandemic that swept into communities across the United States beginning in Spring 2020 has placed enormous strain on health-care systems and highlighted the work of both U.S.- and foreign-born health professionals. But even as the need for testing, treatment, and care is high, an estimated 263,000 immigrants and refugees with at least a four-year degree in a health field have largely been sidelined, either employed in jobs that require no more than a high school diploma or out of work.

U.S. and State Data

This spreadsheet offers estimates of immigrants and refugees with health-related undergraduate degrees who are underemployed or unemployed, both nationwide and in selected states. It includes details on their race/ethnicity, legal status, degree majors, origin countries, and the languages other than English that they speak. Click here.

This fact sheet offers the first state-level profile of this untapped pool of immigrant health professionals. Using data from the U.S. Census Bureau and U.S. Department of Labor, it provides estimates of the number and key characteristics of underutilized immigrants with health degrees, including their English proficiency, the other languages they speak, their top fields of study, and the legal statuses they hold.

Among the key findings of this analysis are that these immigrants are widely distributed across the United States, not concentrated in traditional immigrant-gateway states. There is also considerable overlap between the languages other than English that they speak and those spoken by Limited English Proficient populations in the states where they live, making them a potentially valuable resource in providing linguistically and culturally competent care.


Immigrant Health-Care Workers in the United States

Another good analysis by MPI. Similar picture in Canada with respect to immigrants and visible minorities:

Immigrants represent disproportionately high shares of U.S. workers in many essential occupations, including in health care—a fact underscored during the coronavirus pandemic as the foreign born have played a significant role in frontline pandemic-response sectors. In 2018, more than 2.6 million immigrants, including 314,000 refugees, were employed as health-care workers, with 1.5 million of them working as doctors, registered nurses, and pharmacists. Immigrants are overrepresented among certain health-care occupations. Even as immigrants represent 17 percent of the overall U.S. civilian workforce, they are 28 percent of physicians and 24 percent of dentists, for example, as well as 38 percent of home health aides.

Overall, immigrants ranging from naturalized citizens, legal permanent residents, and temporary workers to recipients of Temporary Protected Status (TPS) and the Deferred Action for Childhood Arrivals (DACA) program accounted for nearly 18 percent of the 14.7 million people in the United States working in a health-care occupation in 2018. As a group, immigrant health-care workers are more likely than their U.S.-born counterparts to have obtained a university-level education. Immigrant women in the industry were more likely than natives to work in direct health-care support, the occupations known for low wages. In contrast, immigrant men were more likely than the U.S. born to be physicians and surgeons, occupations that are well compensated. Compared to all foreign-born workers, those employed in the health-care field were more likely to speak English fluently and had higher rates of naturalization and health insurance coverage.


The term “foreign born” refers to people residing in the United States at the time of the Census survey who were not U.S. citizens at birth. The foreign-born population includes naturalized citizens, lawful permanent residents (LPRs, also known as green-card holders), refugees and asylees, legal nonimmigrants (including those on student, work, or certain other temporary visas), and persons residing in the country without authorization. The terms “immigrant” and “foreign born” are used here interchangeably.

The terms “U.S. born” and “native born” are used interchangeably and refer to persons with U.S. citizenship at birth, including persons born in Puerto Rico or abroad born to a U.S.-citizen parent.

Most analyses in this article divide health-care occupations into the following occupational groups:

Health-Care Practitioners and Technical Occupations

  • Physicians and surgeons
  • Therapists (i.e., occupational therapists, physical therapists, respiratory therapists, and speech-language pathologists)
  • Registered nurses (RNs)
  • Health-care technologists and technicians (i.e., clinical laboratory technologists and technicians, dental hygienists, emergency medical technicians and paramedics, licensed practical and licensed vocational nurses, pharmacy technicians, and radiologic technologists and technicians)
  • Health practitioners and technical occupations, all others (i.e., dentists, nurse practitioners and nurse midwives, optometrists, pharmacists, physician assistants, podiatrists, and veterinarians

Health-Care Support Occupations

  • Home health aides
  • Personal care aides
  • Nursing assistants
  • Health-care support, all others (i.e., dental assistants, massage therapists, medical assistants, phlebotomists, and physical therapist assistants and aides).

As the Migration Policy Institute (MPI) has documented, significant numbers of immigrant college graduates with health-related degrees are facing skill underutilization, in other words are working in low-skilled jobs (for example registered nurses working as health aides) or are out of work. This skill underutilization, often referred to as brain waste, affects 263,000 immigrants in the United States with college degrees—a workforce whose talents could be tapped amid the pandemic.

Even before the COVID-19 pandemic, a number of health-care occupations were among the fastest-growing occupations, as projected by the U.S. Bureau of Labor Statistics (BLS) for the 2018-28 period. The more immediate trends now are less clear. Like other parts of the U.S. economy, the health-care sector has suffered job losses since February 2020, which may continue until the economy rebalances. Nonetheless, the main drivers for a greater demand for health-care services—population aging and longevity—remain valid. As in the past, immigrants can be expected to play a significant role in the future of U.S. health care.

This Spotlight provides a demographic and socioeconomic profile of foreign-born health-care workers residing in the United States. The data come primarily from the U.S. Census Bureau’s 2018 American Community Survey (ACS) and BLS. All data refer to civilian, employed workers ages 16 and older, unless otherwise noted.

Source: Immigrant Health-Care Workers in the United States

As U.S. Health-Care System Buckles under Pandemic, Immigrant & Refugee Professionals Could Represent a Critical Resource

Another good analysis by MPI:

In this time of crisis when health-care workers are not only on the frontlines of fighting COVID-19 but are themselves among its primary targets, it is more essential than ever to have enough qualified professionals to meet the needs of a buckling U.S. medical system. As governors call retired physicians back into service and medical schools graduate students on an accelerated basis, another pool can be tapped: Immigrant and refugee physicians, nurses, and health-care technicians who could offer not only critical professional knowledge but also essential linguistic and cultural skills. Around the globe, a number of countries battling the virus (among them France, Colombia, Spain, Chile, and Ireland) and subnational governments (including New York State, California, New Jersey, and the province of Buenos Aires in Argentina) are actively seeking ways to engage this population.

There are 1.5 million immigrants already employed in the U.S. health-care system as doctors, registered nurses, and pharmacists. At the same time, Migration Policy Institute (MPI) analysis finds another 263,000 immigrants and refugees with undergraduate degrees in health-related fields are either relegated to low-paying jobs that require significantly less education or are out of work. Along with 846,000 U.S.-born adults whose health-related college degrees are similarly underutilized—a phenomenon MPI has long referred to as “brain waste”— these immigrants represent a potentially important source of staff for the U.S. health corps. And because these immigrants tend to be younger than their U.S.-born counterparts, they represent an important pool of responders to a disease that is particularly dangerous for those 60 and older.

Figure 1. Adults (ages 25 to 64) Whose Health-Related Undergraduate Degrees Are Not Fully Utilized, by Nativity and Place of Education, 2017

Source: Migration Policy Institute (MPI) tabulation of U.S. Census Bureau 2017 American Community Survey (ACS) data.

Definitions & Methodological Note

Underutilized adults are defined here as civilians between ages 25 and 64 who currently are employed in jobs that require no more than a high school diploma, are unemployed, or are not engaged in the labor force.

Immigrants refers to persons who were not U.S. citizens at birth. This population includes naturalized U.S. citizens, lawful permanent immigrants (or green-card holders), refugees and asylees, certain legal nonimmigrants (including those on student, work, or other temporary visas), and persons residing in the country without authorization. The term U.S. born refers to those born in the United States or abroad to at least one U.S.-citizen parent.

Foreign trained are defined here as immigrants who came to the United States at age 25 or later and who have at least a bachelor’s degree (i.e., they likely obtained their degrees abroad), while U.S. trained are those who arrived before age 25 and obtained their four-year college degrees in the United States.

Methodological note: The analysis here differs from the Migration Policy Institute’s earlier work on immigrant skill underutilization (also known as brain waste), in that for the purposes of examining an urgently needed talent pool that could be tapped during this crisis, it also includes college-educated immigrants of prime working age who not engaged in the labor force. Foreign-trained health-care graduates are significantly more likely to be out of the labor force than their U.S.-trained immigrant counterparts and could thus represent a substantial potential pool of workers. This analysis finds 140,000 immigrants with health-related degrees ages 25-64 are not employed and not looking for work, representing 53 percent of all 263,000 immigrants with a four-year health-care degree who are underutilized. Forty percent are employed in jobs requiring no more than a high school degree, and the remaining 7 percent are unemployed.

MPI research over the years has shown that a sizeable share of immigrant college graduates faces significant challenges in securing jobs that take full advantage of their prior education and work experience. The analyses presented here affirm that this underutilization is common among the foreign born who hold undergraduate degrees in the health-care field. What, then, are some of the most policy relevant characteristics of this population?

Place of Education

Where immigrants receive their education matters. Almost two-thirds (or 165,000) of all underutilized health-care immigrant workers likely obtained their health-related education outside the United States. The underemployment of these health-care professionals is in some ways not surprising: employers may be reluctant to hire workers with degrees from universities that are unfamiliar to them. Also, immigrants may lack important professional networks that connect them to employment opportunities or a sufficient level of professional English competence to get promoted. Further, their credentials may not be aligned with those required by U.S. health-care systems and licensing authorities. And it is common knowledge that obtaining U.S. licenses to work is difficult, time-consuming, and costly.


As with health-care workers overall, college-educated immigrant and U.S.-born workers stuck in jobs requiring no more than a high school degree or out of work are overwhelmingly female (roughly 80 percent). They differ, though, in their age distribution—one factor that may be important in combatting a disease that is particularly dangerous for older persons. These immigrants tend to be younger than their U.S.-born counterparts: 56 percent are between ages 25 and 44, versus 45 percent among U.S.-born underutilized health professionals.

These immigrants also have long years of U.S. residence, with 62 percent having been in the United States for more than a decade. On the one hand, many may have gained or improved their English proficiency and acquired U.S. work experience. On the other hand, many may have been outside the health-care field for years, and their skills and education may have atrophied.

Degree Field

Nursing is the most common degree held by underutilized immigrants and refugees. Approximately 118,000 immigrants with undergraduate degrees in nursing are underutilized, representing 45 percent of all immigrant-health care professionals working below their skill level or sidelined. The data analyzed here indicate that many are working in low-paying jobs such as nursing assistants, home health aides, personal care aides, or as domestic help. Another 10 percent received undergraduate degrees in pharmacy and pharmaceutical sciences, followed by 8 percent with treatment therapy and 5 percent with medical technology technician degrees.

Language Skills

Underutilized immigrant health-care professionals could provide an important linguistic and cultural resource for their own communities now, during this time of crisis, and in the future. More than two-thirds are English proficient, that is, they speak English very well or only English. They also speak a variety of languages other than English, including Spanish (17 percent), Tagalog (15 percent), Chinese (6 percent), Korean and Arabic (4 percent each), as well as Haitian, Russian, Vietnamese, Hindi, Portuguese, French, and Telugu (2 percent each).

States of Residence

State Estimates of Health-Care Professional Underutilization

Find estimates of the size of the population of health-care professionals, immigrant and U.S. born alike, experiencing skill underutilization, as well as their place of education, for the top 20 states. Click here for the data.

More than 60 percent of underutilized immigrant health-care professionals live in traditional immigrant-receiving states. California has, by far, the largest number of such workers: 24 percent of the national total, or 60,000 workers. Other top states: Florida, 11 percent (or 29,000); Texas, 9 percent (23,000), New York, 8 percent (22,000), New Jersey, 5 percent (14,000), and Illinois, 4 percent (11,000).

Figure 2. Immigrant Adults (ages 25 to 64) Whose Health-Related Undergraduate Degrees Are Not Fully Utilized, by State of Residence, 2017

Source: MPI tabulation of Census Bureau 2017 ACS data.

Tapping This Talent?

Even before the COVID-19 pandemic, the skills of 263,000 immigrants and refugees with college degrees in health-related fields had not been put to the best use in the U.S. labor market. However, in a time of crisis with growing shortages of staff in hospitals, community clinics, health departments, and testing centers, many of these immigrants could be mobilized and re-employed in jobs across the health-care field.

While state governments and medical systems must remain vigilant about the quality of health-care services their residents receive, some opportunities to make adjustments to the arduous licensing process exist. States could speed up the certification process by allowing immigrant health-care professionals who pass all requirements except the final exam to work under supervision, or they could extend short-term, provisional approval for a limited set of tasks. The data presented here indicate that workers with nursing training could represent a promising target group. These nurses could be employed in assisting with testing for the virus. At minimum, these immigrant health-care professionals could be engaged in providing language and cultural assistance to overburdened health systems and frightened patients alike.

As hospital emergency rooms, community health centers, and other medical offices reel from the tremendous strain that the COVID-19 pandemic has brought, immigrant health-care professionals whose skills have not been fully utilized represent a promising candidate pool for policymakers, licensing authorities, and health-care providers to tap in a moment of national crisis.


Portugal gives migrants and asylum-seekers full citizenship rights during coronavirus outbreak

Of note. Best approach from a public health perspective (not full rights, can’t vote):

Portugal has temporarily given all migrants and asylum seekers full citizenship rights, granting them full access to the country’s healthcare as the outbreak of the novel coronavirusescalates in the country.

The move will “unequivocally guarantee the rights of all the foreign citizens” with applications pending with Portuguese immigration, meaning they are “in a situation of regular permanence in National Territory,” until June 30, the Portuguese Council of Ministers said on Friday.
The Portuguese Council of Ministers explained that the decision was taken to “reduce the risks for public health” of maintaining the current scheduling of appointments at the immigration office, for both the border agents and the migrants and asylum seekers.
Portugal declared a State of Emergency on March 18 that came into effect at midnight that day and was due to last for 15 days. Portuguese Prime Minister Antonio Costa said during a news conference that “democracy won’t be suspended.”
The country was a dictatorship for decades, with democracy being restored in 1974.
President Marcelo Rebelo de Sousa called the Covid-19 pandemic “a true war,” which would bring true challenges to the country’s “way of life and economy.”
Rebelo de Sousa also praised the behavior of Portuguese citizens, “who have been exemplary in imposing a self-quarantine,” reflecting “a country that has lived through everything.”
Portugal has has 6,408 cases of coronavirus, with 140 deaths and 43 recovered, according to figures from Johns Hopkins University.

Source: Portugal gives migrants and asylum-seekers full citizenship rights during coronavirus outbreak