Our friend, a physician, had just witnessed the death of a 27-year-old man with no chronic conditions. In his hospital, doctors were already making decisions about who to put on ventilators. “It’s a mess and there’s no help,” he told us. The young residents—doctors in training—were completely disillusioned; one of them told him, “When this is over, I don’t want to do this anymore, if this is what our health care system has come to.”

We should all be afraid about that reaction to COVID-19. If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection and protocols they need to survive. Physicians, nurses, and other hospital workers are overwhelmed by endless streams of patients, the extra-long hours, and the deaths they see all around them. Scared and confused, they fight on. We should expect that when their duty is done, some of our best and brightest will decide never to return to the battlefield again.

In this respect, this pandemic is an extension of the ordinary. The United States routinely neglects the needs of one of its most vital workforces. If COVID-19 has any silver linings, the most important one will be its exposure of the fault lines in American healthcare, including the fact that even before the epidemic hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care about their patients.

More broadly, this epidemic shows that many aspects of the way we speak and think about healthcare, and the way we provide it, need to be reconceived and redesigned. To do that, we need to listen to doctors, nurses, and other healthcare professionals.

Despite the health risks of treating COVID-19 patients and the lack of masks and basic protection in many hospitals, healthcare professionals are not running from the challenge. Instead, they are building their own masks out of office supplies, coming out of retirement to offer aid, and isolating themselves in garages and trailers to protect their families.

Such commitment is particularly impressive when you consider that even before COVID-19, a significant proportion of them were unhappy in their jobs. According to research from the National Academy of Medicine, between 35 percent and 54 percent of U.S. nurses and physicians feel substantial symptoms of burnout, including exhaustion, depression, and emotional numbness. For medical students and residents, the prevalence of burnout ranges from 45 to 60 percent.

Our caregivers are not just tired or stressed—they are experiencing “moral injury.” The term moral injury was coined in 2009 to describe how soldiers’ mental health suffered from having to act against their own moral compass in times of war. Dr. Simon G. Talbot and Dr. Wendy Dean applied this term to the healthcare setting to describe the “suffering, anguish, and loss” clinicians feel when they cannot deliver the care patients need in our profit-based healthcare system.

In our profit-based healthcare industry, billing is king, and clinicians bear the brunt of the busy work that’s required. According to an annual survey conducted by Medscape, an online medical news outlet, the most common contributor to moral injury is the absurd number of bureaucratic tasks healthcare workers now do. For example, a 2016 study found that physicians in four specialties spend about half of their work day filling out electronic medical records and paperwork. Family physicians spend another 1 to 2 hours at home after work doing coding and billing in the electronic medical record.

Another casualty of profit-driven healthcare is the time doctors get to spend with patients. More patients per day means more billing opportunities, and many clinicians are pressured to fit as many patients in their schedule as possible. The “15-minute visit” in primary care has become routine. Many physicians barely have time to listen to patients’ concerns before sending them for one test or another. This diminished time with patients gives doctors and nurses the feeling that they are mere cogs in a computerized system that cares little about people and their health problems.

This is not what most practitioners signed up for, and the mismatch between the ideals of medicine and the reality takes a high toll. Physicians in the U.S. have the highest suicide rate of any profession. That statistic may reflect the fact that physicians are stigmatized and sometimes punished for seeking mental healthcare.

Of course, the COVID-19 pandemic has reinforced the sense of purpose driving many medical professionals. But as they’re putting themselves in danger, and their mental health is suffering as they watch patients and even colleagues die. For many, including our friend in Queens and his colleagues, the crisis has already inflicted a devastating emotional impact.

In order to retain health professionals after this epidemic, we must do more than recognize their sacrifices, or address their current anger. We must answer their long-held concerns—and involve them in charting new policies and ways of keeping them healthy enough to tend the sick. Call it the GI Bill for Healthcare Professionals, if you will.

Some of these new policies should be financial. Nursing and medical students often leave school with thousands of dollars in debt, and the mental stress that accompanies it. Educational debt also adds pressure for doctors to choose a high-paying specialty rather than primary care and geriatrics, where the need for a larger workforce is most urgent. Steps can be taken to address that: Erase all health professionals’ school debt to help those already in the field. In addition, medical, nursing, and physician’s assistant training should be free for all low-income students, to encourage more people from disadvantaged neighborhoods and regions to pursue these necessary careers.

We also need to ease some of the burdens of daily work life. Electronic health records, as currently configured, are primarily tools for maximizing billing. Beyond the time required to fill them out, they create all kinds of headaches for doctors and nurses, who find them incredibly frustrating to use. These record systems need to be redesigned into one single, easy-to-use platform, with the primary purpose of improving care. A committee of healthcare workers should be the principal advisors in this endeavor.

We also need to adjust regulations to make it easier to deliver care to patients. In this state of emergency, the federal government has eased regulatory requirements to allow increased flexibility in where and how patients are treated. For example, Medicare is now paying clinicians for a wide range of telehealth services. We have heard from frontline clinicians that the reprieve from many regulatory and administrative burdens has reminded them of how much better it feels to devote time to caring for patients, rather than navigating paperwork and rules.

One primary care doctor told us that before COVID, she would have to see patients in person to determine that they did not need to see her for in-person visits. Now, she is encouraged to care for patients virtually whenever possible, without an unnecessary in-person visit beforehand. Common-sense policy changes like these should be made permanent if possible, with recommendations from healthcare workers helping to drive decisions.

Unfortunately, it isn’t enough to make health jobs easier and more patient-focused. After this pandemic, doctors, nurses, and other healthcare workers will need to recover from what they’ve recently experienced. Hospitals should expand access to counselors and other mental health services we need, and teaching hospitals must do the same for trainees. Health professional schools should follow the example of Weill Cornell Medicine in offering free mental health counseling for all students. Mental health services should be accompanied by safe and confidential screening services for depression, PTSD, and other mental health issues, to reduce barriers to access.

Finally, in the wake of COVID-19, the U.S. public health response to pandemics will have to be re-evaluated and overhauled. One priority must be to make sure healthcare workers are never forced to beg for masks and other basic protections again. To that end, we should establish a Clinician’s Affairs agency within the Department of Health and Human Services with representation from nurses and doctors. By putting clinician representation at HHS, and also at the Department of Homeland Security, it would position healthcare professionals to give direct input on national health and security policies.

For years, Americans have stood by as the healthcare system pushes our doctors and nurses to the breaking point. Now, our need for them is as great as it’s ever been, and we are pushing them further. World War II veterans got the GI Bill. Clinicians today deserve the same assurances. We need a Healthcare Professionals Bill that eases their educational debt and also includes them in redesigning multiple aspects of our broken system.

The post What Do We Owe Doctors and Nurses? appeared first on Zócalo Public Square.

It is now commonplace to be cared for at the bedside by a Filipino immigrant nurse. According to the 2016 Survey of California Registered Nurses, Filipinos make up the second largest group of the state’s active RN workforce, nearly 18 percent. Among younger nurses, they’re even more predominant, with Filipino nurses representing nearly a quarter of nurses between ages 35 to 44 years and more than one-fifth of RNs 45 to 54 years old.

In the process of becoming essential to California, Filipino nurses have changed the definition of what we describe as care by bringing their own cultural practices and sensibilities to the bedside. At the same time, they have contributed to the research, business, and politics of American health care as directors of research centers, as entrepreneurs of health care institutions, and as leaders of labor unions and professional organizations.

The presence of Filipino nurses in California is not new; indeed, the nurses are part of a larger and more complex story of a medical field where cultural ideas and practices are frequently exchanged.

The predominance of Filipino nurses was catalyzed by three big changes in the United States during the 1960s. First, the establishment of Medicare and Medicaid resulted in an increased need for nurses, while, in a second major change, the women’s and civil rights movements resulted in new job opportunities for American women. At around the same time, a more equitable immigration law, called the Hart-Celler Act, was passed. As the increasing demand for nursing services became difficult to fill domestically, American hospital recruiters looked abroad.

Meanwhile, in the Philippines, high rates of domestic unemployment and political instability pushed Filipino nurses to emigrate overseas. The devaluation of the Philippine peso against the U.S. dollar made the United States a highly attractive destination. By the early 1970s, a Filipino nurse in the Philippines needed to work 12 years to earn what she could make in the United States in one year.

Some Philippine government officials initially criticized Filipino immigrant nurses for abandoning their home country. But, in the early 1970s, after observing the demand for Filipino nurses in the United States, then-President Ferdinand Marcos shifted the country’s development towards a labor export economy. The Philippine government began aggressively promoting the outmigration of Filipino nurses and other workers, eventually touting them as the new national heroes for the billions of dollars they remit annually in foreign currency.

There was another, more historic reason why the Philippines specifically became the leading exporter of professional nurses to the United States: U.S. colonization of the Philippines from 1898 to 1946 had led to the creation of Americanized professional nursing training in the archipelago. In the early twentieth century, American nurses trained Filipino students in courses such as practical nursing, the use of pharmaceuticals, and bacteriology. Philippine nursing licensure examinations included testing in the English language as well as in nursing-related subjects. Although intended to prepare Filipinos for Philippine self-government, these U.S. colonial policies inadvertently prepared Filipino nurses to work in the United States.

But change and influence don’t move in just one direction. Just as American nurses indelibly influenced Philippine nursing, so too have Filipino nurses changed the practice of health care in the United States.

In the U.S., Filipino nurses integrate Filipino cultural values and beliefs into their caregiving practices. Among these core values are a high regard for elders and authority, an emphasis on group harmony and interpersonal relationships, and the significance of modesty, sensitivity, and spirituality. Such values shape Filipino nurses’ renowned compassion and work ethic at the bedside. As one nurse stated: “I see my patients as my relatives and this influences the way I care for them. I feel that my upbringing helps me see people and care for them.”

Filipino immigrant nurses also bring experience with Philippine traditional therapies such as hilot, faith healing, and the use of medicinal plants. Hilot is a traditional form of massage therapy or chiropractic manipulation that relieves aches and pains. This knowledge of Philippine healing modalities is important not solely because the use of alternative therapies in the U.S. has become more mainstream, but also because a growing number of Americans are of Filipino heritage. Between 1980 and 2016, the Filipino immigrant population in the United States nearly quadrupled. California is home to the largest Filipino-American population in the nation with over 1.6 million of Filipino descent.

As educators and researchers, Filipino nurses are at the vanguard of creating new knowledge relevant to Filipino Americans who have been generally underrepresented in health care-related research. For example, Felicitas dela Cruz is a professor at Azusa Pacific University’s School of Nursing and the director of its Center for the Study of Health Disparities. In her research with Carmen Galang, Dr. dela Cruz has found that, like other ethnic groups, Filipino Americans avail themselves of folk medicine as well as Western medicine to address illness. In the case of high blood pressure, they have utilized hilot and religious activities to lower their blood pressure.

Filipino nurses’ experience in health care has led to their ownership of health care businesses. The research of Jennifer Nazareno spotlights the growing number of Filipino immigrant nurses in Southern California who have become private owners and operators of small government-subsidized businesses in the long-term care industry, providing care to some of the most impoverished—as well as cognitively and physically disabled—elderly populations. While
this group of Filipino immigrant nurse entrepreneurs has created an important safety net for the most vulnerable in the American health care system, they are under tremendous stress to provide quality care within limited or fixed government-subsidized budgets.

Filipino nurses in the U.S., out of deep commitment to their profession, have also changed health care by forming organizations that provide social outlets and build political power. In the 1960s, pioneering Filipino nurses in California created professional organizations that would become known as the Philippine Nurses Association of Southern California and the Philippine Nurses Association of Northern California. Their mission is to promote the welfare of their members through community building and networking, to further their nursing knowledge and skills through professional development programs, and to contribute to health care and society.
Immigrant nurses initially created these organizations in order to address their isolation, loneliness, and educational needs, but they have also played a part in making Filipino nurses visible within the larger system.

Photo courtesy of Philippine Nurses Association of Southern California.

As Filipino immigrant nurses have taken up positions of leadership in labor unions and professional organizations, they have addressed the politics of health care in the U.S. In 2015, Zenei Cortez was the first Filipino to be elected president of the California Nurses Association/National Nurse Organizing Committee, a labor union and professional association of registered nurses that has advocated for lower nurse-patient ratios and health coverage for all. Cortez is currently a president of National Nurses United, and a prominent advocate of Medicare for All.

While research has suggested that Filipino cultural values may contribute to Filipino nurses’ reticence and submissiveness, their encounters with discrimination have motivated them to fight for justice in California workplaces. Earlier this decade, a group of Filipino nurses—who claimed that they suffered from harassment and humiliation when they spoke Filipino dialects in break rooms and in the cafeteria, and that they were ordered to speak “English only”—won a landmark settlement against a Central California hospital. Although officials at Delano Regional Medical Center insisted they did nothing wrong, the hospital had to conduct staff training on diversity as part of the settlement.

And for all the power of Filipino immigrant nurses today, the story we’ve seen so far may prove to be just a small beginning. The American population is rapidly aging. Forecasts show dire shortages in the U.S. health care workforce by 2025. As important as Filipinos have been to developing the health care system today, their contributions will become even more critical in the decades ahead.

The post Why Are There So Many Filipino Nurses in California? appeared first on Zócalo Public Square.

But the waiter who turned Elinor away wasn’t moved by her patriotism. All he saw was her brown skin. It probably never occurred to him that the woman in uniform was from a family that served its country, as Elinor’s father had in the First World War, as well as another relative who had been part of the Union Army during the Civil War. The only thing that counted at that moment—and in that place, where Jim Crow laws remained in force—was the waiter’s perception of a black army nurse as not standing on equal footing with his white customers.

Infuriated and humiliated, Elinor left Woolworth’s and returned to POW Camp Florence, in the Arizona desert. She was stationed there to look after German prisoners of war, who had been captured in Europe and Northern Africa and then sent across the Atlantic Ocean, for detainment in the United States during World War II.

Elinor, like many other black nurses in the Army Nurse Corps, was tasked with caring for German POWs—men who represented Hitler’s racist regime of white supremacy. Though their presence is rarely discussed in American history, from 1942 to 1946, there were 371,683 German POWs scattered across the country in more than 600 camps. Some POWs remained until 1948.

And these POWs were kept busy. Prisoners of war, under rules set by the Geneva Convention, could be made to work for the detaining power. And, with millions of American men away serving in the military, there was a significant labor shortage in the United States. Farms, plants, canneries, and other industries needed workers.

For black nurses, the assignment to take care of German POWs—to tend to Nazis—was deeply unwelcome. To the African-American women who had endured the arduous process of being admitted into the U.S. Army Nurse Corps, this assignment felt like a betrayal. They volunteered to serve to help wounded American soldiers, not the enemy.

Long before World War II, black nurses had been struggling to serve their country. After the United States declared war on Germany in 1917, black nurses tried to enroll in the Red Cross, which was then the procurement agency for the Army Nurse Corps. The Red Cross rejected them, because they didn’t have the required membership in the American Nurses Association (ANA), which didn’t allow blacks to join at the time. A few black nurses eventually served in the First World War, but not because they were finally admitted into the Army Nurse Corps. The 1918 flu epidemic wiped out so many thousands of people that a handful of black nurses were called to assist.

More than two decades later, after Hitler invaded Poland, the United States began an aggressive war preparedness program, and the Army Nurse Corps expanded its recruiting process. Wanting to serve their country and receive a steady military income, thousands of black nurses filled out applications to enlist. They received the following letter:

“Your application to the Army Nurse Corps cannot be given favorable consideration as there are no provisions in Army regulations for the appointment of colored nurses in the Corps.”

The rejection letter was a crushing blow, but also an honest appraisal of how the country regarded black nurses: They weren’t valued as American citizens or seen as fit to wear a military uniform.

The National Association of Colored Graduate Nurses, (NACGN)—an organization founded in 1908 for black registered nurses as an alternative to the ANA, which still hadn’t extended its membership to black nurses—challenged the letter. And with political pressure from civil rights groups and the black press, 56 black nurses were finally admitted into the U.S. Army Nurse Corps in 1941. Some went to Fort Livingston in Louisiana and others to Fort Bragg, in North Carolina, both segregated bases.

When Elinor Powell entered the army in 1944, she completed her basic training an hour outside of Tucson, Arizona, at Fort Huachuca, which had become the largest military installation for black soldiers and nurses. The army had a strict quota for black nurses, and only 300 of them served in the entire Army Nurse Corps, which had 40,000 white nurses. It was evident the military didn’t really want black women to serve at all, and they made this clear.

German POWs in Camp Florence, Arizona, circa 1944-1946. Photo courtesy of Chris Albert.

Elinor’s cohort of newly trained Army nurses soon received shocking news: There had been too much fraternization between white nurses and German POWs at Camp Florence. So the Army was bringing in black nurses as replacements.

POW camps would become an ongoing assignment for the majority of African-American nurses. The remainder were stationed at segregated bases with black soldiers, who mostly performed maintenance and menial jobs during the war, and understood what it meant to wear a U.S. military uniform and still be treated like a second-class citizen.

Life for a black army nurse at a POW camp could be lonely and isolated. The camps in the South and Southwest, in particular, strictly enforced Jim Crow. The list of complaints from black nurses included being routinely left out of officer meetings and social functions, and being forced to eat in segregated dining halls. The trips to nearby towns were also degrading because of establishments that either relegated blacks to subpar seating and service or barred them from entering altogether.

At the hospitals in the POW camps, black nurses weren’t that fulfilled either. A great many of the prisoners were in good health, which had been a requirement to make the trans-Atlantic journey in the first place, so the black nurses weren’t utilized to full capacity. There were typical bedside nursing duties and occasional appendectomies performed, but rarely were there critical cases.

In some ways, from a social standpoint, the German POWs fared better than the black nurses. Local white residents, U.S. Army guards and officers were friendly toward them—a level of respect that black laborers, soldiers, and nurses did not experience with any regularity.

When German prisoners first arrived in the United States, many were shocked by the racial hierarchy entrenched in American culture. They saw the segregated bathrooms and restricted dining halls at train stations, and during their days-long journeys to their respective POW camps had black train attendants bringing them food and drinks and calling them “sir.” It was clear that in the United States, there was an inherent expectation of subservience to whites, even to those from Hitler’s army.

Once at camp, life for German POWs, for the most part, was comfortable. From the clean accommodations and regular meals, to the congeniality of Americans, some POWs were relieved to have been captured. And the interactions with black nurses were largely civilized.

But there were occasions when black nurses found themselves humiliated by German POWs and not backed up by the U.S. Army. At Camp Papago Park, outside of Phoenix, a German POW said he hated “niggers” in front of a black nurse. She reported the incident to the commanding officer, expecting a swift reprimand. The nurse later discovered the commanding officer didn’t think any punishment was necessary. She complained about the incident in a letter to the National Association of Colored Graduate Nurses:

“That is the worst insult an army officer should ever have to take. I think it is insult enough to be here taking care of them when we volunteered to come into the army to nurse military personnel…All of this is making us very bitter.”

Meanwhile, even though black nurses were underutilized, there was an urgent need for more nurses to care for the returning American soldiers, wounded in battle. Nevertheless, white nurses were tasked to tend to Americans almost exclusively. Yes, thousands of white nurses also had POW camp assignments—there were very few black women in Army Nurse Corps. But if a black unit could replace a white one at a camp, the swap was made.

As the war entered its final year, the numbers of wounded men rose exponentially. President Roosevelt made the alarming announcement of legislation to establish a nursing draft in his State of the Union Address on January 6, 1945. Radio announcements said the draft would be instituted unless 18,000 additional nurses volunteered.

At the time of the president’s address, there were 9,000 applications from black nurses hoping to enlist in the Army Nurse Corps. But those nurses didn’t count toward the goal, or dissuade FDR’s announcement—to the dismay of NACGN, the black press and civil rights organizations.

Congressman Adam Clayton Powell Jr., the esteemed minister from Harlem, famously denounced the decision: “It is absolutely unbelievable that in times like these, when the world is going forward, that there are leaders in our American life who are going backward. It is further unbelievable that these leaders have become so blindly and unreasonably un-American that they have forced our wounded men to face the tragedy of death rather than allow trained nurses to aid because these nurses’ skins happen to be of a different color.”

Elinor and Frederick, summer 1947. Photo courtesy of Chris Albert.

The draft legislation stalled in the Senate and the conscription of nurses never occurred. But with morale among black army nurses reaching record lows, the NACGN approached First Lady Eleanor Roosevelt for help, given her commitment to equal rights. And the meeting was a success.

In the final year of the war, black nurses were no longer assigned exclusively to POW camps. After a few months they were transferred to army hospitals for wounded American soldiers.

Elinor remained at POW Camp Florence for the duration of the war, and fell in love with a German prisoner, Frederick Albert. While fellow Americans humiliated her with segregation, a German, of all people, uplifted her. The two shunned the racist policies of Jim Crow and Nazism, seeking solace in a forbidden romance. They would spend their lives together in constant search of a community that accepted them, more than 20 years before laws banning interracial marriage were struck down in the 1967 Loving v. Virginia decision.

By war’s end, only about 500 black nurses had served in the U.S. Army Nurse Corps during WWII, even though thousands had applied. Despite the discrimination they faced, black army nurses demonstrated a persistent will to be a part of the U.S. Army Nurse Corp and serve their country. Their efforts paid off when President Truman issued an executive order to desegregate the entire military in 1948.

And by 1951, the National Association of Colored Graduate Nurses dissolved into the American Nurses Association, which had extended its membership to all nurses regardless of race.

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