Ethical Restrictions on International Recruitment of Health Professionals to the United States

Acknowledging that migration of health professionals from less prosperous countries to privileged countries is increasing, widening the gaps between rich and poor nations,1

Noting that 

• While the developed countries have only one-third of the world's population, they contain three-fourths of the world's physicians and 89 percent of the world's migrating physicians,1 and
• In sub-Saharan Africa, 3 percent of the world's health workers must provide health services to 13.8 percent of the world's population in a region that suffers from 24 percent of the world's burden of disease,2,3 and
• 180,000 (nearly 25 percent) of America's physicians are trained abroad, with 64.4 percent of them in low and lower-middle income nations,4 and
• 90,000 nurses (4 percent of the U.S. overall nurse work force, but 14 percent of recently licensed nurses) are trained abroad, and the number is increasing at a rate faster than that of U.S.-educated new nurses,5

Understanding that the U.S. Congress is considering immigration reform legislation that would remove the limit on the number of nurses who can immigrate,6

Recognizing that ethical recruitment is only one element of the actions needed to redress the health worker crisis that is most severe in Africa,

Concerned about the growing demand for health professionals in the United States in the face of stagnant supply; the Department of Health and Human Services estimates that the United States could be short 1 million nurses by 2020,7 and academic studies estimate that the United States needs an additional 85,000 to 200,000 physicians by 2020,8

Recognizing the long-standing and serious shortage of health professionals in rural and inner city America, and the fact that international medical graduates provide a great deal of health care in those areas,9,10

Expecting that unless measures are taken to increase U.S. health work force self-sufficiency and to adopt ethical recruitment practices, aggressive recruitment from countries and companies perceiving shortages of health professionals will increase,

Respecting that individual countries, such as the United Kingdom,11 and international organizations, such as the Commonwealth Health Ministers,12 the World Conference of Family Doctors13 and the International Council of Nurses,14 have adopted codes of practice for the international recruitment of health care professionals, and while these Codes of practice have not solved the recruitment problem, they signify concern and have probably slowed the pace of recruitment,15

Noting that in May of 2004 the World Health Assembly (WHA) adopted a resolution (57.19) on the international migration of health personnel, urging member states to develop strategies to mitigate the adverse effects of migration of health personnel and minimize its negative impact on health systems,16

Acknowledging that the World Federation of Public Health Associations adopted a resolution at its General Assembly in Geneva, Switzerland on May 16, 2005, supporting ethical restrictions on international recruitment of health professionals from developing countries,17

Recognizing that health worker recruitment and migration to the United States and other rich countries has varying effects on the countries of origin, in some cases benefiting them through remittances and beneficial training and experiences, but in many cases undermining the economic, social and health status of exporting poor countries18 by increasing their shortage of physicians, nurses and other health workers,

Recognizing the plight of health care workers in poor countries who often work under dangerous conditions that do not meet their needs or those of their patients, and understanding their frequent desire to leave their countries,

Affirming the right of health workers to migrate as guaranteed them by the 1948 Universal Declaration of Human Rights,19 while also seeking to balance the responsibilities of heath workers to the countries in which they were initially trained and that invested in their education,

Affirming the right to the highest standard of health as guaranteed by the International Covenant on Economic, Social and Cultural Rights,20

Noting that the Joint Learning Initiative,21 a collection of more than 100 global health experts, has estimated that Africa needs about 1 million more health care workers to achieve the health-related Millennium Development Goals;22 and that these goals were established by all 191 United Nations member states, who pledged to meet the goals by 2015. The goals set internationally agreed upon targets for reducing poverty, hunger, disease, illiteracy, environmental degradation and discrimination against women, and to meet these requirements will require an adequate health workforce,

Noting that the World Health Organization's World Health Report 2006: Working Together for Health identified "a threshold in workforce density below which high coverage of essential interventions, including those necessary to meet the health-related Millennium Development Goals (MDGs), is very unlikely."Based on these estimates, there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives,

Acknowledging the U.S. Physicians for Human Rights (PHR)23 and the New York Times editorial recommendations that low-income countries be compensated for the loss of health professionals to rich countries,24

Recognizing the regrettable absence in the United States of a rational, unified national health system that can adopt ethical recruitment policy in the face of a health care marketplace that is growing increasingly dependent on foreign-trained health workers,

Acknowledging the need for the United States to adopt a national ethical recruitment code,

Therefore, the American Public Health Association:

1. Urges U.S. health worker employers, including public and private hospitals, long-term care facilities and outpatient facilities, to voluntarily adopt an industry-wide code of ethics that guides their judicious management of the recruitment and employment of health professionals (including unlicensed caregivers) from abroad; 
2. Recommends that this code of ethics be developed in accordance with standards developed by the World Federation of Public Health Associations, the World Health Organization and other international bodies concerned with this issue; 
3. Strongly encourages U.S. health care employers to develop the code in consultation with ministries of health and other stakeholders in developing countries;
4. Encourages U.S. health professional training programs to expand their class sizes to develop a sufficient internally trained work force; 
5. Encourages government to both subsidize better pay and working conditions, health professional class size expansions and provide incentives to better distribute the health professionals in the United States; 
6. Recommends that the U.S. government encourage compliance with the ethical code by contracting for health care services (for Medicare and research purposes, for example) only with health care delivery organizations that have developed and are abiding by a code; and 
7. Recommends that the U.S. government ask health care employers to report regularly on their recruitment practices, results of which would be gathered into an annual U.S. government report on recruitment and retention practices of U.S. health care employers.

1. Alfonso Mejia. "Migration of Physicians and Nurses: A World Wide Picture," WHO Bulletin 2004, 82:8.
2. World Health Organization. "World Health Report 2006: Working Together for Health," Geneva, 2006, at 8 (Africa's health worker and disease burden percentages)
3. Commission for Africa, Our Common Interest: Report of the Commission for Africa (2005), at 191. Available at: http://www.commissionforafrica.org/english/report/thereport/english/11-03-05_cr_chapter_6.pdf. Accessed June 11, 2006 (Africa's population percentage).
4. Amy Hagopian, Matthew J Thompson, Meredith Fordyce, Karin E Johnson and L Gary Hart. "The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain," Human Resources for Health 2004, 2:17.
5. Linda Aiken, James Buchan, Julie Sochaliski, Barbara Nichols and Mary Powell. "Trends in International Nurse Migration," Health Affairs 2004, 23:3. 
6. Dugger CW. New York Times, May 24, 2006, U.S. Plan to Lure Nurses May Hurt Poor Nations. 
7. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis, "What is Behind HRSA's Projected Supply, Demand, and Shortage of Registered Nurses?" September 2004. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/behindshortage.htm. Accessed June 11, 2006.
8. David Blumenthal. "New Steam from an Old Cauldron- The Physician-Supply Debate," NEJM 2004, 350:17, 1780-1787
9. Leonard Baer, et al. "If Fewer International Medical Graduates were Allowed in the U.S., Who Might Replace them in Rural Areas?" Chapel Hill, NC: North Carolina Rural Health Research and Policy Analysis Center; 2001. Working paper 71. 
10. Amy Hagopian, et al. "The Role of International Medical Graduates in America's Small Rural Critical Access Hospitals," The J of Rural Health 2004, 20:1, 52-58.
11. Code of Practice for the International Recruitment of Healthcare Professionals, U.K. Department of Health, December 2004 (revised).
12. Commonwealth Code of Practice for the International Recruitment of Health Workers, Commonwealth Health Ministers, May 2003 (Geneva).
13. A Code of Practice for the International Recruitment of Health Care Professionals: The Melbourne Manifesto, Melbourne Australia, May 3, 2002.
14. International Council of Nurses (ICN). (2005). ICN position statement on ethical nurse recruitment (2001). Retrieved June 13, 2005 from http://www.icn.ch/psrecruit01.htm. accessed June 11, 2006.
15. James Buchan. "International rescue? The dynamics and policy implications of the international recruitment of nurses to the UK," J Health Serv Res Policy 2004, 9 Suppl 1:10-6.
16. World Health Organization, 57thWorld Health Assembly (May 22, 2004), Res. WHA 57.19, International Migration of Health Personnel: A Challenge for Health Systems in Developing Countries. Available at: http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R19-en.pdf. Accessed June 11, 2006.
17. Ethical Restrictions on International Recruitment of Health Professionals from Low-Income Countries, adopted at the 10th WFPHA Congress. Available at http://www.wfpha.org/pdf/05_policy_Recruitment.pdf Accessed June 11, 2006.
18. Barbara Brush, Julie Sochalski, and Anne Berger. "Imported Care: Recruiting Foreign Nurses to U.S. Health Care Facilities," Health Affairs 2004, 23:3.
19. General Assembly of the United Nations, Universal Declaration of Human Rights 1948, available at: Accessed June 11, 2006.
20. International Covenant on Economic, Social and Cultural Rights (entered into force Jan. 3,1976), available at: . Accessed June 11, 2006
21. Lincoln Chen, Timothy Evans, Sudhir Anand, Jo Ivey Boufford, et al. "Human Resources for Health: Overcoming the Crisis," The Lancet 2004, 364:9449.
22. The Millennium Development Goals are detailed at http://www.un.org/millenniumgoals/ (accessed June 11, 2006). The U.N. Millennium Project, an independent advisory body commissioned by the U.N. Secretary-General, was established to advise the U.N. on strategies for achieving the Millennium Development Goals. Headed by Professor Jeffrey Sachs, the U.N. Millennium Project presented its report, Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, to the Secretary-General in 2004.
23. Physicians for Human Rights, Eric Friedman (author). "An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa," Boston, June 2004.
24. New York Times, August 13, 2004, editorial: Africa's Health Care Brain Drain.