Nurturers by Nature?

A Look at the Overrepresentation of Filipina women in the U.S Health Care Industry

By Christina Leano - December 2007.

As child I wondered why all of my mother’s friends who were Filipina were always nurses, and whenever we met a new Filipino family, more often than not, the mother was a nurse. I began to believe that it was just common knowledge to know that if you see a Filipina lady in the United States she must be a registered nurse, nursing assistant, or work as a health care provider of some sort. This leads me to question Filipino/as and their predisposition towards medicine and caring for people. Are Filipinos, and Filipina women in particular, nurturers by nature? What would explain the overwhelming representation of Filipina nurses in the United States? As I look into my family’s own immigration history I see that structural and cultural integration has been facilitated by the fact that they possessed the professional and technical skills needed in the United States. This mimics the immigration story of thousands of other Filipino/as who came into the United States in search of high skilled jobs within the health care industry.

My grandfather immigrated to Mississippi in the early 1960s, his immigration into the southern United States was not due to networks already established but in fact was due to active recruitment of American hospitals that needed doctors. My grandfather was a doctor and his brother is a doctor who has a private practice in New Jersey. My mother, who arrived in America at twelve years old, is also a registered nurse who works in intensive care, my aunt deals with psychiatric patients, and another aunt works in geriatrics. As a first generation Filipina American, I do not feel a calling towards medicine or nursing but in fact study economics and foreign policy. My cousins who are also first generation, integrated Filipina-Americans are not studying nursing but have aspirations of being writers, professors, and musicians. The differences between first generation Filipinos and their parents, who primarily work in health care, illustrates that as compassionate as Filipina nurses are, there were, and still are, strong economic, social, and cultural push factors that have led many students in the Philippines to become health care providers.

Filipino immigration into the United States in the early 1900s was predominantly male, as they first migrated into Hawaii as inexpensive immigrant labor that was able to replace Japanese and Chinese workers. The Philippines was a commonwealth of the U.S from 1935 to 1946, before that it was designated as a U.S territory since it was gained after the Spanish American War in 1989. As a U.S colony many plantation owners saw it easy to bring cheap Filipino workers since they were technically U.S nationals unlike their Asian counterparts. Many laborers worked on Hawaiian sugar plantations and California farms in the 1920s since Chinese and Japanese laborers were increasingly being discriminated against with the erection of anti-Asian immigration policies such as the Barred Zone Act in 1917. Employers sought out Filipino laborers because they were easily exploited because they did not know their rights; this is similar to the exploitation that Mexican migrant workers face today. “Filipinos were perceived to be docile, subservient, and uneducated and therefore would not join labor unions and be prone to strikes” (philippinehistory.com).

Philippine migration into the United States was characterized by low skilled, poor and uneducated males however, in 1946 there was an increase in Filipino migration because they were given Naturalization Rights. This allowed workers to sponsor their families to rejoin them in the states; parents, siblings and wives were given the chance to immigrate. Many women also immigrated from 1946 to 1965 as wives of American Service men who were stationed in the Philippines (Rosenstein 492). After Naturalization Rights were granted, immigration was not only males, however those who did immigrate were low skilled and uneducated which matched the socioeconomic characteristics of the Filipino migrant workers that were in America prior to 1965. Immigration patterns began to change after 1965 in which there was a shift from low skilled laborers to immigrants of high skilled technical training, predominantly in the health care industry, another difference is that the immigration was overwhelmingly female.

In 1965 the United States implemented the Immigration and Nationality Act which eliminated national origin quotas, this allowed for more family members to be reunited. More importantly the Act was installed in order to relieve occupational shortages. The United States was experiencing severe shortages in the medical fields and needed to recruit trained doctors and nurses from abroad. Foreign medical professionals were able to immigrate through the help of hospital recruitment; therefore immigration post 1965 was not due to social networks that were already established. “Metropolitan hospitals faced with ongoing shortages especially in the 3 pm to 11 pm shift and in critical care units, placed ads in Manila newspapers, worked with agencies, and sent their own recruiters across the pacific” (Posadas 39). Philippine colleges saw a rise in medical students because of the opportunities that it provided to go abroad. Many Filipina women saw nursing as their chance to go to Canada, the United States, and England. They would be able to gain independence, social status, and would be able to provide for their families back home. There were, and still are, huge incentives for women to earn nursing degrees, it served as a passport to a better life abroad.

So if the United States was experiencing shortages in the health care industry why did a large influx of nurses and doctors come from the Philippines and not other third world countries such as Puerto Rico, the Dominican Republic, or Vietnam? “Between 1965 and 1988, more than seventy thousand foreign nurses entered the United States. . .the Philippines is by far the leading supplier of nurses to the them” (Choy 1). This can be explained through a historical context of the Philippines as being a former U.S colony and having a high degree of interaction with the United States. Filipinos are accustomed to American culture and language and are used to their presence within the region. In fact, two major bases, the Clark Air Force base and Subic Naval Station were training facilities for U.S marines in WWI and the Korean War (1950-1953). This has led to many interactions between Filipinos and Americans and also intermarriages.

The United States is also predisposed to hiring Filipino health care providers because of the education system and English language proficiency in the country. Education is taken seriously and is funded by the government, private sector, and religious denominations. Many schools are from the Catholic order and also are similar to the model of American state colleges. Ateneo de Manila “one of the most distinguished private universities in the country” (Perlman 120) has links to another Jesuit school in the U.S, Fordham University. “In a country of forty million, three quarters of a million students are enrolled in some six hundred colleges and universities" (Perlman 119). Filipinos are preferred because English is also widely spoken within the country and is “the language of instruction in all colleges and universities in the Philippines as it is in elementary schools and secondary schools as well” (Perlman 121). These workers can be brought in without having to learn the language as opposed to those from Latin America. Immigrating Filipinos do not face a large barrier when integrating since they have been widely exposed to American culture, products, and language as a former colony.

An Americanized educational system has predisposed Filipinos to successfully fill the health care shortages in the U.S. Historically, teaching American medical practices was a form of white man’s burden. American colonizers felt compelled to teach Filipinos about hygiene and “proper” medical treatments (unlike indigenous remedies). They saw it as preparing the Filipinos for self rule. It seems as if the U.S has long primed the Philippines by endowing them with the methods and infrastructure to produce nurses, but nothing else. This has left the country in a perpetual state of poverty due to brain drain. The Philippines’ main export is health care workers, this type of trade does not build the country’s business or manufacturing sector but instead keeps it dependent on remittances. This continues the cycle of producing nurses in order for them to work abroad. The Philippines has very competitive educational instruction in order to train nurses similar to those trained in the U.S. “The construction of an Americanized nursing curriculum in the Philippines was one of the most significant preconditions for the mass migration of Filipina nurses in the late twentieth century” (Choy 12).

Students, as early as in 1915, were able to take courses in anatomy, physiology, obstetrics, pharmacy, graduate courses and advanced and colloquial English (Choy). The Philippines continued to follow American trends in nursing such as raising educational requirements of students in order to keep the quality competitive. There were higher standards of nursing and the specialization of public health nursing. This rigorous educational system is what helped Filipina nurses be chosen to enter the U.S. In 1976, the Health Professional Educational Assistance Act required that foreign medical graduates take an exam before being admitted into the U.S. This made it difficult for professionals from other countries such as the Dominican Republic to become accredited in the U.S. This gave an advantage to Filipina nurses who sought entry since they were English speaking and trained in an American fashion.

The large degree of acceptance that Filipina nurses have received from American hospitals is one reason that many decide to study nursing, however the over all economic state of the Philippines is a major push factor for women to become nurses and gain higher wages abroad. “The highly educated, English speaking workforce of the Philippines is considered one of the most technically proficient in Asia, but the country faces increasing pressure from heightened global competition for market and capital” (asiandevbank.org). The Philippine economy is wrought with debt and inflation which does not make the country attractive to foreign investors. The unstable government and erratic environmental climate accustomed to having earthquakes and El Niño does not ensure investors. This lack of foreign direct investment makes the country less competitive in the manufacturing sector which leads to a stunted domestic industry and makes it difficult to provide jobs for citizens. “Fiscal deficit and the national government debt are the Achilles heel of the Philippine economy” (asiandevbank.org).

The Philippines has steadily declined in world market exports since the 1980s making it necessary for them to borrow international capital, this is a reason for the high inflation rates. The lack of exports is due to the highly competitive industries seen in China, Indonesia, and Vietnam, which are all able to produce electronics with higher quality, cheaper labor and more advanced technology (asiandevbank.org). The Philippines cannot compete by exporting massive amounts of goods, their competitive advantage lies in producing highly skilled nurses, however this export is detrimental for the country since they lose many educated individuals.

An inefficient government has also contributed to the flight of educated Filipinos (usually nurses) since the government is unable to provide enough jobs in the labor market to absorb all the college graduates. This shows that the lack of opportunities and modes in order to make money push Filipinos to migrate. About 50 percent of the population lived below the poverty line in 1990; an explanation is the overpopulation of the country and political inability due to corrupt government rulers who do not implement sound fiscal policies for the best interest of the people. Due to the high population growth the country cannot cope with creating enough jobs and weak ruling governments’ lack of vision to help poverty alleviation and the building of industry and job creation, leaving the Philippines with its dire economic status. Poverty is never properly dealt with because of inconsistency within the government and changes of administrations that never follow through on poverty programs. The population explosion has led to scarce pickings in the job market however due to the importance of the church and the Catholic nature of the country, the use of contraceptives is low. This has led to large families. A graduate nurse thus feels pressure to help her family and provide income through remittances in order to put other brothers and sisters to school.

The lack of social mobility and economic opportunities within the Philippines is an important push factor for Filipinas to become nurses and migrate, but this is also tied to social and personal reasons as well. The most important reason that women feel compelled to become nurses abroad is because of familial duty or utang na loob, women want to be able to help their parents have a comfortable life in the Philippines, they want to be able to put siblings to schools, and most of all they want to provide for their children who they would hope to bring to the U.S in the future. “The primary reason that women live and work in the United States was a desire to better provide for their children and parents back in the Philippines” (Tung 74).

Women will forgo raising their children at home (Philippines) in order to secure a better future for them by providing financially (Tung). Motivating factors to become a nurse was in order to access opportunities abroad since the salaries in the home country was incomparable, “some government agencies employing nurses paid them lower wages than their janitors, drivers, and messengers” (Choy 68). Also with the devaluation of the peso a nurse’s earning in the U.S was so much more when they sent it home. An annual salary in the U.S would be approximately 60,000 pesos but in the Philippines it was merely 4,200 pesos in 1974” (Choy 70).

The economic gains that came with becoming a nurse were huge. More women started training to be nurses in order to go abroad because they knew what it would bring them and their families. Therefore, families invested in their daughters’ education and also saved for their plane tickets to go abroad. Going abroad was facilitated by airline payment plans that allowed nurses to pay their tickets in installments, this occurred because of the large volume of nurses going abroad. Families invested in their daughters with the hopes that they would one day work in America and send remittances as well as American gifts called pasalubongs. These gifts such as stereos or Avon lipstick were a sign that the family’s daughter or relative “made it” in the U.S and this would also enhance the family’s status in the Philippines.

Young Filipinas also saw nursing not only as providing financial security for them and their families but as a way to achieve independence, away from men, and as a way to experience adventure in America. America offered leisure, travel, and material (luxury) goods not readily available in the U.S, things like kitchen appliances and cosmetics (Choy 70). The lure of liberation, mobility, and independence made more women in the Philippines study nursing. “In 1962 there were more student applicants for nursing studies than Philippine colleges and schools of nursing were able to accommodate” (Choy 73). When Filipinas migrated under the Exchange Visitor Program, they often adjusted their visas in order to stay since there were more cultural freedoms, diversity, and entertainment in the U.S.

Immigration out of the Philippines post 1965 was largely seen as a female phenomenon. This is because in the 1970s there was no longer a shortage in American doctors and in 1976 the Eilberg Act made it more difficult for doctors (foreign medical graduates) to enter requiring them to already have an established job before they immigrate. The Health Professions Educational Assistance Act declared “there is no longer an insufficient number of physicians and surgeons in the United States” (Posadas 38). However, there was still a shortage of nurses and they were still arriving in large numbers, “by 1985, about 667,000 Filipinos had entered the United States” (Rosenstein 492).

Nurses from the Philippines were heavily recruited to alleviate shortages especially in inner city hospitals and for time slots that white nurses would not work. The immigrant status of Filipina nurses led to a degree of exploitation, in which they were given unwanted hours or were stationed at hospitals in undesirable neighborhoods. Thus, immigration was taken up by mainly females because of the low numbers of males who became nurses. This is because nursing had become socialized as a woman’s profession due to its caring and compassionate nature. Nurses as a feminized occupation led to the male-female immigration imbalance. Women are able to benefit from the stereotype of “women’s work” as being caring and nurturing since there is a shortage in the U.S.

The highly paid occupation of nurses has granted the women freedom, independent from the needing men. In fact, it can be argued that women are more valuable in the family than men because it is easier for them to become a nurse, find a hospital which will recruit them, and migrate out. Due to the stigma of nursing as being a feminized occupation, Filipino males do not enter into the lucrative field, leaving it to women to be able to become financially more powerful and the number one bread winner. Though this does have social implications for the status of Filipino males who are not as financially stable as Filipina women, it is a major step that feminists can looks at as progress- women in the Philippines are valuable, invested in, highly skilled and educated, and are viewed as having the potential to achieve wealth and status abroad.

In conclusion, the overwhelming majority of Filipinas as nurses in the United States is not due to the fact that they are more caring than women in the Ukraine, Puerto Rico, or Albania or that Filipinas have an innate ability to work in the medical field. In fact there were (are) very strong economic, social, and personal push factors that drove many women to becoming nurses. Becoming a nurse ensured a way to migrate and receive a steady income. I now understand why Filipinas have been concentrated in the health care industry. It also illustrates why younger generations who have recently migrated into the U.S with their families often study nursing at the urge of their parents, who see it as a good way to have a stable income since that is what they have come to know through the historical linkages of Philippine labor migration into America.

This is in contrast to first generation American born Filipino/as who have integrated into American culture and society and do not have the pressure of immigrating. They are fortunate enough to be able to pursue a passion not connected to occupations with job shortages since their parents and mothers have already paid the dues by taking on jobs that they may not necessarily have wanted but needed in order to provide for family and children. When looked at it this way, perhaps Filipinas are nurturers by nature.

Choy, Catherine Ceniza. Empire of Care: Nursing and Migration in Filipino American History. Durham and London: Duke University Press, 2003.

Lasker, Bruno. Filipino Immigration. New York: Arno Press, 1969.

Posadas, Barbara M. The Filipino Americans. London: Greenwood Press, 1999.

Bonacich, Edna, Paul Ong, and Lucie Cheng, eds. The New Asian Immigration in Los Angeles and Global Restructuring. Philadelphia: Temple University Press, 1994.

Balisacan, Arsenio M. “Why Does Poverty Persist in the Philippines?” Agriculture and Development Discussion Paper. SEARCA, 2007.

Asian Development Bank. “Causes of Poverty in the Philippines”-Chapter 6. www.asiandevbank.org.

Tung, Charlene. The Cost of Caring: The Social Reproductive Labor of Filipina Live-in Home Health Caregivers. Frontiers Editorial Collective, 2000.

Montes, Manuel F. “Overcoming Philippine Underdevelopment: An Alternative Programme.” Third World Quarterly 107-119 Jul. 1989.

Liu, John M., Paul M. Ong, and Rosenstein Carolyn. “Dual Chain Migration: Post-1965 Filipino Immigration to the United States.” International Migration Review, Vol. 25, No. 3 pp. 487-513, 1991.

Perlman, Daniel H. “Higher Education in the Philippines: An Overview and Current Problems.” Peabody Journal of Education, Vol. 55, No 2 pp. 119-126, 1978.

“The Economy” www.countrystudies.us/philippines

“Political Economy of Development” www.countrystudies.us/philippines

“Poverty and Welfare” www.countrystudies.us/philippines

The Philippine History Site- http://opmanong.ssc.hawaii.edu/filipino/filmig.html