Dr. Saif Muhsin started thinking about Canada after President Donald Trump issued an executive order Jan. 27 barring people from seven Muslim-majority countries, including Muhsin's native Iraq, from entering the U.S. for 90 days.
Muhsin, 34, is halfway through a four-year nephrology fellowship in Boston in a joint program of Massachusetts General Hospital and Brigham and Women's Hospital. He sees patients and works in the lab of Sylvie Breton, a Canadian-born cell biologist, who has made recent breakthroughs in acute kidney injury. Muhsin plans to continue both medicine and research after he finishes his fellowship.
Adding to the confusion is this past weekend's legal debate over the travel ban. On Friday, a federal district court in Seattle blocked the ban. The U.S. Justice Department's appeal to immediately restore the ban was rejected Sunday. The Trump administration now must reply by the end of the day.
Although the sudden travel restrictions sparked protests at airports across the country, immigration officials have suggested they might expand the scope of the restrictions by extending them beyond 90 days or by adding more countries to the list. That possibility raises questions about what a more permanent ban would mean for the healthcare industry, whose heavy dependence on an immigrant workforce is expected to increase in the coming years.
“We are going to keep folks out of the U.S. who we know are filling key roles in our healthcare and research systems,” said Nikki Cicerani, CEO of Upwardly Global, a New York-based not-for-profit that helps immigrants with careers. “It's sending a message about who is welcome here, and when we have such an important field so dependent on foreign-educated professionals, that's going to have an impact.”
Few U.S. industries have benefited more from immigration than healthcare, where foreign-born individuals accounted for 16% of its more than 14 million workers in 2015, according to figures provided by the Institute for Immigration Research at George Masony. More than 60,000 were from the seven countries targeted by Trump's order. More than 11,000 of those are not U.S. citizens.
“For healthcare in general, a well-working immigration system has been critical to our success,” said Dr. Darrell Kirch, CEO of the Association of American Medical Colleges. “In terms of the scientific side, one of the reasons for American leadership in health sciences research is the fact that the best and brightest from all over the world seek to come here.”
The U.S. also needs these immigrants to fill gaps in healthcare services and as a result has admitted immigrant healthcare professionals through a variety of avenues.
Many have used the U.S. State Department's H-1B Temporary Visitor and J-1 Exchange Visitor visa programs, which permit foreign healthcare professionals to work in federally designated shortage areas. And many medical graduates who complete their medical education in the U.S. under a J-1 visa get a waiver that allows them to remain in the country to work.
About 78% of international medical graduates are involved in direct patient care, according to the George Mason researchers. Foreign-born physicians often fill a primary-care role that has been less frequently taken up by U.S.-born medical graduates, who increasingly opt to practice in more lucrative specialties.
Forty-six percent of the physicians with a J-1 visa practice in internal medicine, compared with just 15% of U.S.-born medical graduates. International medical graduates are also more likely than their U.S.-born counterparts to work in medically underserved communities.
If tougher, indiscriminate immigration policies drive foreign-born medical graduates and researchers to seek opportunities outside the U.S., those policies could hurt the country's capacity to meet rising demand for healthcare services expected in the coming years as the elderly population increases. A 2016 AAMC report projected that by 2025 the physician shortfall will exceed 90,000.
Even though the number of medical schools in the U.S. has increased since 2002, the increase in U.S. medical graduates they have produced has not been sufficient to fill available residency slots. During the 2014-15 academic school year, there were 22% more residency positions available than could be filled by graduates from U.S. medical schools, according to Merritt Hawkins, a medical staffing agency.
“The shortage of physicians is acute, especially in primary care, and eliminating 25% of the available pool of candidates obviously makes a difficult situation even more difficult,” said Jim Stone, president of the Medicus Firm, another physician-staffing agency.
Foreign-born scientists, engineers and doctors in the U.S. contribute significantly and in some cases disproportionately to medicine and scientific research. Across the country's top seven cancer research centers, 42% of researchers were foreign born, the National Foundation for American Policy found in a 2013 study. In New York City, 46% of medical professionals were foreign born, the city's comptroller reported in January.
At the 10 universities that earned the most patents in 2011, nearly 8 out 10 patents for pharmaceutical drugs or drug compounds had a foreign-born inventor. Immigrants also played a role in three-quarters of molecular and microbiology patents, according to a 2012 study by Partnership for a New American Economy.
“Much of our productivity in academia is because of that free exchange of innovation and ideas that occurs around the world,” said Dr. Mark Poznansky, director of the Vaccine and Immunotherapy Center at Massachusetts General Hospital. “This represents a very troubling change to that approach.”
Scientists who come to the U.S. to study and do research uproot their lives to do so. Knowing that they will land in a welcoming community is vital to that decision, several scientists who are naturalized U.S. citizens said. Trump's travel ban sends a message of hostility that could make foreign students and scientists reconsider coming to the U.S., if they aren't already.
“It's a very delicate balance,” said Manu Prakash, an Indian-born bioengineer at Stanford University who runs the Prakash Lab there. “It has nothing to do with just these seven countries,” he said. “It is much more what it speaks to, what it means to be invited into a home.”
Prakash, A MacArthur Fellow, developed a folding paper microscope and a human-powered centrifuge. The microscope costs less than $1 to manufacture. His lab has distributed them to more than 50,000 people in 135 countries for use in research and education.
When foreign students and scientists come to the U.S., the benefit is mutual. Peter Walter, a professor of biochemistry and biophysics who runs the Walter Lab at the University of California, San Francisco, recalled “eye-opening” freedom and engagement and ongoing research in the U.S. when he left his native Germany more than 30 years ago. “As a young unknown student, I was just thrown into exploring the unknown,” he said.
Today, Walter's research explores the fundamentals of how cells work. His lab has discovered mechanisms and pathways that could be used as a weapon against cancerous cells, and the team is collaborating with biotech companies Genentech and Calico to develop small molecules—precursors to drugs—targeting a variety of cancers and neurodegenerative diseases. These laboratories and the research they carry out depend heavily on foreign students, researchers and faculty.
Sylvie Breton, the cell biologist who runs the lab at Massachusetts General-Harvard Medical School where Muhsin is a fellow, said that of the roughly 30 people in her immediate research environment, no more than five are American. “The biomedical field is really, truly international,” she said. “A major strength of U.S. medical research is to bring in highly educated people from outside and to provide them with an environment that allows them to thrive here. These outstanding scientists are key players in our international leadership position in biomedical research and advanced medicine.”
Poznansky said that over the past decade, his laboratory and center has employed and trained 140 scientists, and 55% were either on visas or were naturalized citizens. They came from the U.K., China, India, Singapore, Iran, Israel, Dubai, Egypt and elsewhere.
The Sabeti Lab, part of the FAS Center for Systems Biology at Harvard University and headed by Iranian-born Pardis Sabeti, has five other scientists from Iran or of Iranian descent.
Prakash, the Stanford bioengineer, described scientific education as a delicate ecosystem. He and other scientists worry that Trump's order, while limited in scope, could destroy that balance, cultivated over decades. The quality of science in the U.S. is not simply because of its well-endowed research institutions or its state-of-the-art technology and facilities, he said. “We have people who embrace ideas from a broad view, and that social context is as important.”
For now, Muhsin will remain in the U.S. If he leaves the country, he will be unable to re-enter under the current ban. His wife has canceled her plans to visit her family in Iraq in the spring.
Muhsin, who left Iraq for Qatar in 2006, at the peak of the violence during the war there, eventually did his residency in internal medicine at New York-Presbyterian/Weill Cornell Medical Center in New York City. There, he was recognized for “dedication and commitment to patients,” for “demonstrated excellence in clinical medicine,” for “outstanding teaching skills” and for “outstanding service for patients.”
Breton's lab, where Muhsin is a fellow, recently discovered a biomarker that can predict the onset of acute kidney injury, which kills 300,000 people a year, and they are working on a small molecule that could someday be developed into a drug to treat it.
The Trump administration has suggested it might extend the ban indefinitely for the countries on the list, as well as expand it to include Pakistan, which produces the second-largest share of international medical graduates who come to the U.S., after India.
“Think about the number of doctors, foreign medical graduates and others who come from Pakistan,” said
Dr. Alexi Nazem, a practicing internal medicine specialist who's also CEO of New York-based Nomad Health, a tech startup that provides an online platform for hospitals to address temporary health staffing needs.
Nazem's family emigrated from Iran to the U.S. in the 1960s. He said Trump's immigration policies threaten to alienate the very people that the U.S. has sought to attract through its worker visa programs for decades.
“Foreign medical graduates from Pakistan should really be thinking 'what if I apply for residency and I get accepted and then they expand the ban to Pakistan?' ” Nazem said. “The wise thing for a lot of those people to do is to take their talents elsewhere. But it would be a terrible loss for America.”
Elizabeth Whitman is the quality-and-safety beat reporter for Modern Healthcare in the New York office. She previously covered breaking news and healthcare for a year and a half at the International Business Times. From 2013 to 2014, she lived in Amman, Jordan, writing about the Syrian refugee crisis, public health and women’s rights for The Nation, Al Jazeera and other outlets. She speaks Arabic and Mandarin and holds a degree in history from Columbia University.Follow on Twitter
Steven Ross Johnson has been a staff reporter for Modern Healthcare magazine since 2013 and covers issues involving public health and other healthcare news. Johnson has been a freelance reporter for the Chicago Tribune, Progress Illinois, the Chicago Reporter and the Times of Northwest Indiana and a government affairs reporter for the Courier-News in Elgin, Ill. He received a bachelor's degree in communications from Columbia College in Chicago and a master’s degree in journalism from the Medill School of Journalism at Northwestern University.Follow on Twitter