I wish I could remember her exact words. "Don't cry honey," she -- one of my grandmother's regular evening caregivers -- urged when I came back to her room from the hospital. "It will keep her spirit from passin'"... or something close to that. Later, when I spoke with the night aide who had called at 4 a.m. to tell me they had taken her to the hospital, she told me everything that happened before the emergency medical technicians arrived and while they were there.
I had persuaded my grandmother -- the brightest star in my childhood galaxy -- to move to be near us, arranged for and coordinated her care, taken her to doctors' appointments and emergency rooms, visited her every few days and talked with her every night, and spent the day spooning with her as she died. Yet these were the women -- one Jamaican and one African American -- who did the daily work of caring for her. Many family members could share similar stories.
Efforts to formulate policy around immigration should take account of the plight of one vital but often invisible sector of the labor force: long-term care workers. Long a low-wage, female, "minority" industry, long-term care has become a transnational one. In the United States, as in other high-income countries, a growing number of migrant care workers -- mostly women -- now find employment in the long-term care sector, in settings ranging from private homes to independent and assisted living facilities and nursing homes. An estimated 30 percent of foreign-educated registered nurses (RNs) work in long-term care, and approximately 48 percent of RNs working in home care come from abroad. Among foreign-educated licensed practical nurses (LPNs), as many as 80 percent are employed in long-term care. A similar trend can be seen among direct care workers -- nurses aides and home health workers -- the frontline of the paid long-term care workforce. Approximately 20 percent of direct care workers are born outside the United States, most of them in low-income countries. Among home health aides, the foreign-born and educated make up an estimated 24 percent. Although data are difficult to come by, the top countries of origin appear to be the Philippines, Jamaica, Haiti, India, and Nigeria and Ghana.
Several things align to encourage the flow of care workers across borders. Colonialism, and longstanding relationships between countries have contributed to transnational health worker production and exchange. More recently, the re-structuring by international financial institutions of economies and public institutions in low and middle-income countries has generated job losses in many sectors, including health care. At the same time, these countries have come to support the training and export of human resources with the hope that remittances will help to reduce the burden of debt. In this environment, a for-profit recruitment industry that services health care corporations has blossomed. As well, efforts are underway to craft global trade policies to allow for the commodification and trading of care services on the global market.
Selective immigration, especially for skilled workers and workers in areas with shortages, is an essential instrument of industrial policy under globalization. Health and long-term care industry organizations in high income countries, who regard international recruitment as a way to address shortages and reduce hiring costs and improve retention, often lobby to ease immigration requirements in order to gain access to nurses and other care workers. Meanwhile, poor working conditions and inadequate planning for long anticipated demographic has resulted in long-term care workforce shortages. A recent report argues, indeed, that the unprecedented reliance on migrant care workers around the world is a symptom of the lack of comprehensive, coordinated long-term care policy.
These workers face formidable challenges. For starters, long-term care boasts some of the worst working conditions. According to experts, "many people who are working in long-term care are devalued, treated as criminals and paid extremely low wages" (Miller, Booth, and Mor 2008: 455). They report high rates of job stress and low satisfaction, even when they say that they believe in the importance of their work. They suffer one of the highest rates of job-related injury among all occupations.
For those care workers who migrate, especially the allegedly "unskilled," things can be considerably more difficult. Many leave their families, and so manage their own care obligations across distance. These workers often lack citizenship in the countries where they are employed. They therefore have a limited set of political rights, limited labor protections, and access to health and social services. Home care workers -- a substantial percentage of whom are migrants and undocumented -- may be the most vulnerable among members of the long-term care labor force. Many confront abuse and due to fear and/or a lack of language skills and knowledge of available mechanisms, may not report it. Migration can also have adverse effects on health on these already vulnerable workers. Undocumented care workers cannot seek work in institutional settings that offer employer-sponsored health insurance. While many care workers who are U.S. citizens do not have health insurance as part of their employment package, they might qualify for Medicaid. In contrast, all undocumented non-citizens were rendered ineligible for Medicaid by the 1996 "Illegal Immigration Reform and Immigrant Responsibility Act." Moreover, fears of deportation deter them from seeking care in public health clinics or emergency rooms. Although undocumented care workers are increasingly essential to social welfare in destination countries, indeed, they are often excluded from its benefits.
Another dimension of health worker migration is its relationship to health equity. Because many so-called "source countries" have higher burdens of disease and suffer from lower health care worker-to-population ratios than do destination countries, and often more rapidly growing aging populations, the migration of care workers is deepening health inequities, creating what many have described as a global "crisis in health." The problem is so grave that the Joint Learning Initiative concluded that the fate of global health and development in the 21st century lies in ensuring the equitable management of human health resources.
We might be said to be responsible for addressing harms migrant care workers (and their countries' health systems and ill and aging populations) suffer because of our shared humanity, or our participation in processes that generate injustice. Another way of thinking about this is in terms of their intimate and crucial contribution to our identities. The care provided by migrant workers -- nannies, nurses, home care aides and others -- is now an increasingly integral part of who are - as beneficiaries of care, members of families and elder-care support systems, and citizens of an affluent country who benefit from economic and labor policies that rely on low wage workers.
Responsible policy making, then, calls for seeing the connections between immigration and the quality care of the elderly and dependent, not just here but also abroad. We owe migrant care workers immigration reform that shows them respect and promises them fair treatment. And we owe source countries suffering under shortages a commitment to taking concrete steps to manage health worker migration in a way that neither threatens opportunity for migrants nor deepens global health inequities.