The Globalization of US Healthcare

Eram Alam’s new book uncovers the ways that immigrant physicians have propped up the American medical system.

By Kim AdamsJanuary 6, 2026

• Science & Technology

• History

A PRESS RELEASE issued by the US Department of Homeland Security on August 27, 2025, described a new rule to “end foreign student visa abuse.” Past administrations, the release bemoaned, “have allowed foreign students and other visa holders to remain in the U.S. virtually indefinitely, posing safety risks, costing untold amount of taxpayer dollars, and disadvantaging U.S. citizens.” The rule, which proposed time limits and “regular assessments” for holders of F and J visas, joins a host of xenophobic immigration restrictions that target two contradictory visions of the foreigner: the educated liberal, labeled terrorist in a lingering haze of anti-communist sentiment, and the “illegal” migrant worker, an updated version of the 19th and early 20th century’s “coolies” and “dagos” whose poorly compensated labor has routinely fueled American immigration debates ever since the terms were coined. This two-pronged racialized threat matrix—allegedly “disadvantaging” US citizens from above and below—conveniently skips over the primary care provider you saw when you last visited a medical clinic.

The US medical system runs on immigrant labor. According to the New England Journal of Medicine, at least one in five healthcare providers currently working in the United States was born outside the country, including “29% of physicians, 17% of nurses, and 24% of direct care workers.” Eram Alam’s new book The Care of Foreigners: How Immigrant Physicians Changed US Healthcare historicizes this reliance on medical workers educated abroad. While recent anti-immigrant actions lump physicians with the rest of the educated elite, making examples of individuals like the transplant nephrologist Rasha Alawieh and delaying visas for an estimated 1,000 medical residents set to begin training this past July, the arrangement to retain foreign medical workers has largely remained in place. Alam, a historian of medicine at Harvard University, writes in her conclusion that, “even under a US administration obsessed with walls, indefinite detention, anti-immigrant executive orders, and references to SARS-CoV-2 as the ‘Chinese virus’ or ‘kung-flu,’ reliance on foreign healthcare workers [has] continued.”

¤

The United States’ doctor shortage began a century before postcolonial physicians, largely from South Asia, were summoned to fill the gaps in care. In the 19th century, there was no such shortage, in part because US medicine was not the highly regulated, prestigious, and expensive affair it is today but was instead a hot mess of liberty and quackery. In Alam’s words, it was “capacious and embraced a diversity of medical practitioners who espoused a range of healing practices and an assortment of credentials.” This changed dramatically at the turn of the 20th century when a group of “elite, white men who received medical training in Europe” orchestrated an “occupational closure” through education and licensure. The Flexner Report of 1910, commissioned by the Carnegie Foundation, established the scientific foundations of modern medical education and, just as importantly, shuttered medical schools for women and, by and large, for African Americans (two were left open). The process of whitening, masculinizing, and technologizing medicine produced a limited supply of elite modern men of science who became “the medical establishment.” That establishment was small by design—scarcity creates demand.

As modernity reshaped the nation, US doctors contributed to a reification of social hierarchies and the creation of a two-tiered system of healthcare riven by class and race. One tier was “technologically sophisticated and designed for a wealthy and middle-class, white consumer.” The other tier served poor nonwhite or immigrant populations in underresourced hospitals and clinics, which maintained the traditional charitable role of the Hôtel-Dieu. In general, by midcentury, medical treatment had moved from the home and family to the hospital and trained experts, a trend facilitated by the growth of employer-provided medical insurance. And, concomitantly, patient activists, associated with the Civil Rights and women’s movements, started lobbying for a new standard of care for poor and marginalized communities. They found some success. By 1965, the federal legislation of Medicare and Medicaid would conceptualize healthcare as a right rather than a privilege.

The Immigration and Nationality Act of 1965, also known as the Hart-Celler Act, was a Cold War solution to a new image problem. Domestic racism looked bad at a time when the nation needed to win an international ideological battle that equated capitalism with freedom. Because the medical establishment adamantly resisted internal change—and in particular resisted a national health system that would distribute doctors and resources equitably—the government had to find a solution as quickly as possible: it would solve doctor shortages in underserved areas by importing them from newly postcolonial nations. This relatively easy fix had the added benefit of looking virtuous. In Alam’s words, “extending an invitation to foreign physicians was strategic on two levels: it meant growth of the physician workforce in the United States with minimal cost and minimal delay, and it announced globally that the United States was committed to immigration, diversity, and economic openness.”

The 1965 act adopted a skills-based visa system in lieu of the national and racial quotas of the Johnson-Reed Act of 1924. Its aim, as much ideological as pragmatic, was to create a mobile class of elite human capital circulating freely with the flows of the global economy. The special provision for “skilled labor” and the official declaration of a doctor shortage by the Department of Labor in 1964 allowed legislators to implement the “short-term” solution of “inviting foreign physicians to staff shortage areas in exchange for legal status.” But what began as a short-term patch soon became a structural necessity. Foreign medical graduates (FMGs), now known as international medical graduates (IMGs), became integral to the system.

When the US changed its immigration policies to recruit educated workers, it may indeed have looked virtuous and forward-thinking. In fact, it was reproducing the structures of extractive colonialism, albeit now within an ideological framework of globalization that emphasized freedom of choice. Skilled medical labor became a movable commodity. Colonial education systems in India, Pakistan, and the Philippines duly trained medical professionals who then sought economic opportunity in the United States. When the new doctors arrived, however, the scene was far from what they expected. Ansar Aziz moved from Pakistan to Chicago in 1968 and began residency at Cook County Hospital less than a week after the assassination of Martin Luther King Jr. He expected to work at a “pristine state-of-the-art facility” and instead found “shards of glass, scorched buildings, and downed power lines surrounding the hospital.” As he told Alam, “I couldn’t believe that I was in America.”

The first patient that Arnab Singh, who had been educated in northern India, encountered in Birmingham, Alabama, was “an elderly, Mexican man experiencing intense stomach discomfort.” He started taking a standard patient history while performing a physical exam. The patient recoiled and asked, “Who are you? Wait for the real doctor. Too much pain.” Singh left the room. Anxious about having gathered no information to present to the attending physician, he sent in a co-resident to try again. This resident, from Northern Pakistan, happened to have “light brown hair and green eyes, like the Afghanis.” As Singh recalled decades later, his co-resident “went into the patient’s room and came out fifteen minutes later with all the information. I couldn’t believe it.”

Schooled in the US racial equation that correlates whiteness with “real doctor,” Singh learned to modify his technique. He would “ease into questions about family history, what the family was like, how the patient was feeling,” and then “ask permission to do a physical exam.” This approach took more time but served to “put the patient at ease.” Alam includes Singh’s strategy when describing a host of humanizing and feminizing strategies used by FMGs to negotiate the US system. These strategies “certainly improved patient care” but were “undertaken in response to critiques of competence.” Strategies included treating “the nurse as a respected colleague and collaborator” and inviting the patient to “stop me if you have any questions.” Not standard physician behaviors in 1968, they have since become de rigueur, which underscores just how much FMGs have shaped the culture of US medicine.

One could argue, as Alam does not, that such humanizing methods were precisely what the patient activist movements of the 1960s and ’70s were demanding. Our Bodies, Ourselves (1970) for instance, complained that doctors tended “to shut out human considerations” and “focus narrowly on technical, scientific, or pathological factors.” The Black Panther Party Program of 1972 called for “health education” as well as treatment and research programs “to give all Black and oppressed people access to advanced scientific and medical information.” The strategies described by Alam’s interviewees to survive racism in the clinic thus also responded—whether intentionally or not—to the demands of these revolutionary thinkers.

Scholars in “medical humanities” often see the Boston Women’s Health Book Collective and the Black Panther Party’s People’s Free Medical Clinics as points of origin for their field. Alam’s study suggests an alternative history. She argues, for instance, that doctors like Abraham Verghese, a renowned physician-writer of South Indian origin, became the poster children for the larger Indian immigrant community because they had the money, prestige, and moral authority that professionals like taxi drivers, motel owners, and engineers lacked. I would add that the medical humanities gained traction in tandem with the American figure of the Indian doctor because the field identified the same failures in the provision of care that FMGs remedied for purely structural reasons.

Changes in American medical education since 1965 have produced a paradoxical combination of shortage and oversupply. Or rather, what looked like a disastrous physician shortage during the political neurosis and economic abundance of the Cold War, looked like a crisis of oversupply during the fiscal conservatism of the 1980s, and today looks like a distribution problem: too many specialist doctors in the wealthy cities and suburbs of the coasts, and no doctors in the poor cities and rural towns that make up the rest of the nation. When I interviewed Alam for my podcast High Theory, she emphasized that shortage is always a political tool. Is medical labor defined by the number of doctors, their location, or the number of hours worked? How many specialists versus how many generalists should there be? How do nurse practitioners, physician assistants, and other allied health professionals affect the equation? Is demand counted simply by population, or does it include demographic factors that shape sickness and health? Do we assess demand in the present or try to imagine the needs of the future?

In our conversation and in her book, Alam argued that US medical aid abroad amounts to outsourcing medical education. Global health initiatives supported state-funded medical education that supplied American hospitals with the labor they lacked. This argument may no longer hold water, however: USAID has been gutted, and education across the globe is an increasingly privatized commodity. The public education system that created Indian doctors during the Cold War is now under threat. Even so, medical migration continues to perpetuate domestic and global legacies of health inequality. Not only does the neocolonial “brain drain” siphon trained physicians from the Global South to the Global North, but domestic economic structures also concentrate US medical graduates in affluent regions and higher-paid specialties, leaving IMGs to treat the poorest and sickest Americans. We might compare the work of IMGs to that of adjunct teachers in American higher education. Although they’re sometimes better qualified than their tenure-track colleagues, the playing field is tilted against them.

I am the child and grandchild of two FMGs who are outliers in the larger story of postcolonial physician migration. My grandfather was among the cohort of Jewish refugee physicians who arrived in the United States during and after World War II. That cohort provides an early counterexample to Alam’s argument. I have my doubts about the “medical establishment’s sympathetic disposition” but agree that the material support of existing Jewish communities, especially in cities like New York, and “the ability to relocate to white suburban communities […] provided Jewish refugees a proximate relationship with whiteness that worked to their advantage.” In other words, Jewish doctors had the resources to pass as white within a changing racial imaginary dominated by a black-white binary. The model minority discourse applied to and claimed by South Asian physicians in recent decades attempts a similar positioning within the dominant social order.

My father is an American citizen who attended medical school in Mexico and met my mother during their residency at Brookdale Hospital in New York City, a hospital that continues to rely extensively on IMGs. Located in one of the less glamorous neighborhoods of Brooklyn, it is plagued by financial woes and staffing shortages, exemplifying the two-tiered medical system of our present. Patients with means avoid it and instead seek routine care in the well-known academic medical centers of Manhattan. This summer, the new rule from DHS mentioned in my opening stalled visas for its incoming class of residents. As for my father, after leaving Brookdale in 1989, he went on to spend his career in a small community hospital in Windham, Connecticut, a rural town that has recently become exurban. By contrast, my uncle is an American-trained doctor who left New York in the 1970s for London, joining a small but significant outmigration of doctors, including 125,000 who left for Canada between 1966 and 1976. Another such exodus seems imminent, given the actions of the US government. Between November and April 2024, the number of US medical graduates who signed up for the centralized service used by physicians to apply for employment in Canada increased 718 percent over the same period the previous year. In many cases, this outmigration reflects a desperate desire to escape the American scene.

¤

Alam proposes an alternative and more positive vision of this outflow, brightly seeing it as a way to solve systemic and inequitable global shortages of medical care. Following the model of Cuba’s Latin American School of Medicine, she calls for “medical internationalism.” By training more doctors and nurses than are needed domestically, the United States could turn over a new leaf and face the uncertain future of “pandemics, famines, and the effects of climate change” with the reparative aim of “planetary health.”

This dream aligns with the views expressed in a recent opinion piece in The New York Times by Alam’s colleague at Harvard, Stephen Greenblatt. That piece celebrated the National Defense Education Act of 1958 (NDEA) as “one of the most consequential federal interventions in education in the nation’s history.” This “huge influx of tax dollars” funded the research that transformed American universities into “global cultural icons.” Recent federal cuts have, however, put “the whole enterprise […] in serious trouble.” American medicine is deeply intertwined with higher education, and these cuts have hit academic medical centers just as hard as the universities to which they are attached. A return to Cold War models of public funding, Greenblatt argues, could save the institutions that once “made America into the world’s undisputed leader in science and technology.”

The combination of money and moral purpose is rare in the United States, however, and especially so in this century. Even the tech bros of Silicon Valley have soured on digital utopianism. And yet, there is no shortage of American undergraduates hoping to save the world and secure lucrative and respectable careers in medicine. Were the US to seriously undertake a project of medical internationalism, federal tax dollars would have to be infused into higher education on a level comparable to the NDEA (but without the incentivizing Cold War framework). In some hypothetical post-Trumpian future, medical internationalism could indeed do a world of good: it could mend the two-tiered global medical system and restore American universities to their educational mission. But in our isolationist moment, this is just a pipe dream.