The Potent Lever of Toil: Nursing Development and Exportation in the Postcolonial Philippines

Abstract

Although the colonial relationship between the Philippines and the United States precipitated nurse education and migration patterns that exist today, little is known about the factors that sustained them. During the first half of the twentieth century, for example, the Philippines trained its nurse workforce primarily for domestic use. After the country's independence in 1946, however, that practice reversed. Nurse education in the Philippines was driven largely by US market demand in tandem with local messages linking work and nationalism and explicit policies to send nurses abroad. As these ideologies and practices became firmly entrenched, nurse production not only exceeded the country's numerical requirements but focused largely on preparing practitioners for the health care needs of developed nations rather than the public health needs of the indigenous population. This historical trend has important present-day ramifications for the Philippines, whose continued exodus of nurses threatens its public health.

IN RECENT YEARS, THE migratory pull of nurses from poorer to richer nations has been a vexing problem, particularly as it relates to variations in state–labor relations and health workforce policies that in some instances threaten the public's health in those nations that send nurses abroad.¹ There have been numerous attempts to address migration of nurses and other health workers and to create guiding principles and voluntary international standards for the ethical recruitment of health workers.² Contemporary policies and codes of practice aimed at remedying global disparities in nursing care and the management of nurse migration streams, however, have been largely unsuccessful. Part of their failure is their inattention to the impact of social structures and historical precedents on present-day trends.

As it did throughout the twentieth century, the Philippines currently leads the world in exporting nurses to meet demand in the United States and other developed nations.³ It has been argued, moreover, that the country's persistent production of nurses for the global market is a state strategy to develop an export industry for economic development.⁴ Thus, unlike many other countries that lose nurses primarily through aggressive external recruitment, the Philippines has developed explicit internal policies and practices that encourage the production of nurses for export and operate in tandem with state-influenced policies in receiving countries (i.e., immigration services, nursing licensing authorities) to ease the process of emigration.

I examine the formation of state policies and practices in the Philippines that guided nurse professionalization, practice, and immigration over the past century. I argue that the Philippines’ state policy priorities were rooted in the imperialist relationship between the United States and the Philippines and that these dominant ideologies were accepted and reinforced over time. Work equated with nationalism, and working abroad and remitting salaries home demonstrated loyalty to the state while enhancing its economic security. These state-influenced messages eventually guided the export-oriented industrialization of nursing in the Philippines that prioritizes economic development over the public's health.

IMPERIALISM AND INFLUENCE

When Manuel Roxas assumed the presidency of the Republic of the Philippines on July 4, 1946, the end of colonialism between the United States and the Philippines was officially marked. As an independent nation, however, the Philippines now faced an economic challenge; the wealthiest 10% of the country's residents appropriated one third of the national income, with the poorest three quarters of the population claiming only 12.5%.⁵ Roxas clearly faced an uphill battle and one he knew quite well. As a result of his prior 3 years as the secretary of finance and chairman of the National Economic Council, the National Food Products Corporation, the Insular Sugar Refining Company, and the Philippine Charity Sweepstake Office, he was acutely aware of the nation's business, industrial, social, and economic needs and problems.⁶

Guided by his belief that work drove a successful economy and the development and maintenance of strong national pride, Roxas argued that the “potent lever of toil” was the main solution to the country's economic and social problems.⁷ In his estimation, a strong work ethic, supported by increased education to prepare individuals for the workforce, formed the foundation for building nationalism. Still, Roxas’ first attempts to balance the nation's budget included collecting unpaid taxes, reducing expenses, and promoting foreign trade. He also made clear to his constituents in the newly formed Filipino government that the country would still rely heavily on US financial support to reconstruct and rehabilitate its national economy.⁸ The alternative, he noted, was to “face demise.”⁹

FIGURE 1.

Philippines President Manuel Roxas and Mrs. Douglas MacArthur, July 1946.

Source. Life Magazine.

But the country's economy was not its only problem. Ravaged in the aftermath of World War II, the Philippines was in a state of ruin. Thousands lacked food and shelter, and what available food there was could not find markets over impassable roads, rails, and bridges.¹⁰ Hospitals, clinics, and sanitation projects were destroyed, and many schools across the nation closed. Reports of contaminated water supplies and poor sewage systems, insufficient and inefficient basic health care and vaccination programs, and inept administration were linked to poor health among the country's residents.¹¹

The newly created Department of Health and Public Welfare, led by Antonio Villarama, and the National Advisory Health Council paid particular attention to preventing dangerous communicable diseases (cholera, plague, and smallpox); caring for people with malaria, tuberculosis, leprosy, and venereal disease; improving maternal and child welfare; and supervising hospital operations throughout the country.¹² As part of the effort to improve health services, hospitals damaged during World War II were reconstructed or expanded in size and services. Between May 1946 and October 1947, for example, the Philippine General Hospital increased its bed capacity from 450 to 502, admitted 13 927 patients, performed 6546 operations and 8449 lab examinations, and treated 58 952 individuals in its outpatient dispensary (averaging 452 per day).¹³

Nurses, crucial to the delivery of health services during this period, needed further preparation to more efficiently and effectively render care to the local populace. As part of the early stages of the “educational boom” in the Philippines at the time, nursing education moved to the university setting.¹⁴

During the early years of the republic, for example, the University of the Philippines in Manila opened its College of Nursing, admitting its first group of 38 female nursing students in June 1948. The college offered a four-year basic professional nursing curriculum that included 96 hours of both English and Spanish language in the student's first year, along with broad studies of the history of the United States; principles of teaching; psychology; social problems in nursing; education and clinical practice in pediatric, psychiatric, obstetric, and medical–surgical care; and communicable disease management.¹⁵ In a novel approach to addressing the country's major health concerns, students received public health instruction and practiced in rural communities in preparation for future leadership and planning roles.¹⁶

Two years later, the Rockefeller Foundation funded a national survey intended to determine the Philippines’ ability to produce enough nurses to meet the country's nursing needs.¹⁷ American nurse consultant and University of Michigan alumnae Lorena J. Murray was commissioned to examine the country's nurse education facilities and estimate its annual nurse production rate.¹⁸ Arriving in the Philippines in December 1950 and working with local Filipino nurse leaders, Murray compiled baseline statistics regarding nursing numbers and places of employment and found that, of the estimated 7700 nurses in the Philippines in 1951, 1639 worked in public health agencies and 1338 in hospitals. The remaining 4723 were students, army nurses, teachers, administrators, or midwives.¹⁹

Of particular concern to the survey team was the wide disparity in availability of the “right types” of nurses across Philippines communities, especially in the country's rural areas, where maternal and infant deaths and communicable diseases were more prevalent than in other areas.²⁰ The ratio of public health nurses to the country's population (which had reached 19.5 million) was 1:12 000.²¹

Amid concerns that too few nurses were prepared to meet the basic health needs of the Filipino people were arguments that the country's real issue was its inability to hire graduating nurses in the first place. Conchita Ruiz, editor of the Philippine Journal of Nursing, questioned whether there was a true “nursing shortage” at all or whether the combination of the country's rapid expansion of health programs and services, poor use of nurses’ time and skills, and loss of qualified nurses to other countries made it increasingly difficult for nurses to locate, secure, and retain employment in the Philippines.²²

Indeed, lacking employment opportunities, nurses were lured by invitations to study or work in the United States and other countries experiencing post–World War II nursing shortages. As early as 1948, for example, readers of The Filipino Nurse were encouraged to consider US learning and work opportunities and were provided information for doing so.²³ Particularly appealing to nurses were invitations to apply to the Exchange Visitor Program (EVP) to “reach the country of your dreams and improve your nursing skills.”²⁴

Although Asian immigration restrictions under the 1952 Immigration and Nationality Act (McCarran–Walter Act; Pub L No. 414) limited employment for Filipino nurse migrants, the EVP's learn and earn option fit nicely with the needs of underemployed Filipino nurses who viewed their work as part of the plan for a strong Philippines economy.²⁵ Between 1956 and 1973, more than 12 000 Filipino nurses entered the United States through the EVP.²⁶ Most of these nurses applied for the program through the Filipino Nurses Association (whose name was changed to the Philippine Nurses Association [PNA] in 1966) and, after remaining in the United States for 18 to 24 months as exchange visitors, returned home to the Philippines.²⁷ Others, like Marvelito Unite (whose exchange rotation was at Chicago's St. Mary of Nazareth Hospital), were recruited for and remained in staff nurse positions in the hospitals where they trained.²⁸

By the mid-1960s, Filipino nurses were entering the United States by the thousands under the new occupational preference clause of the 1965 Immigration and Nationality Act (Pub L No. 89-236); this section of the act encouraged the migration of skilled laborers in areas of reported US labor shortages.²⁹ With catchy slogans such as “your cap is your passport,”³⁰ recruitment agencies and hospitals worked in tandem to recruit new Filipino nurse graduates and former exchange nurses even as the numbers of domestic nurses expanded.³¹

Nurses’ success stories in the United States as exchangees or employees were widely documented in Philippines nursing journals and elsewhere and were a source of national pride. Philippine ambassador Bartolome Umayan cited letters he received from “respectable Americans” attributing nurses’ success to the “good records and good images” of the Philippines nursing profession that made the Filipino nurse “the best in the U.S.A.”³² Frank C. Tui, research director of Manila's Chinese General Hospital Gastroenterology Center, praised the international reputation of Filipino nurses to newly licensed registered nurses at a reception and ball in their honor, asserting that “[Filipino nurses] are preferred to most local nurses in America, as many prominent American patients will testify.”³³

MIXED MESSAGES

The “good records and good images” of Filipino nurses, continued unemployment of nurses in the Philippines, and nurses’ enthusiasm for overseas learning and work opportunities led to the rapid development of travel and placement agencies cajoling nurses toward greener pastures.³⁴ Advertising in the January–February 1966 edition of the Philippine Journal of Nursing, the Manila Educational Exchange Placement and Travel Service asked nurses “Where in the world do you want to go?” and subsequently advised that they “take the easy way out and go someplace else.”³⁵

Philippine Air Lines guaranteed “cheerful, friendly care and personalized attention” to US-bound nurses in addition to a free placement service for hospital selection, living expenses, and wardrobe choices; Pan Am Airways offered cuisine by Maxims of Paris in a “fly now–pay later” plan.³⁶ Still another advertisement, depicting Chicago, Illinois, at the center of the United States with lines leading to New York City, New York; Miami, Florida; Dallas, Texas; San Francisco, California; Portland, Oregon; Seattle, Washington; and Toronto, Canada, offered nurses salaries from $600 to $845 per month if they would “get up and go to Cook County Hospital.”³⁷

As nurses availed themselves of educational and employment opportunities abroad, however, some, including two of the country's most prominent politicians, argued that there were too few remaining nurses to care for the Philippines’ population. For example, Pura Castrence, the country's ambassador to Germany, encouraged nurses to remain at home rather than emigrate abroad. Although admitting that nurses’ salaries in the Philippines were significantly lower than what could be earned in the United States, Castrence chastised nurses for placing economics above nationalism.³⁸

Congressman Epifamio Castillejos echoed Castrence's admonition. Publishing survey findings from his study of Filipino nurse exchangees working in the United States in 1966, Castillejos highlighted the negative consequences associated with nurses working overseas: “almost every Filipino nurse had problems which ran the gamut from discrimination in stipend, the nature and amount of work they are made to do, to the lack of in-service or specialized training in the hospitals they work in.”³⁹ Castillejos vowed to sponsor legislation at home to provide financial incentives to keep nurses in the Philippines, investigate the unscrupulous actions of travel agencies, and carefully scrutinize EVP policies and practices.⁴⁰ Despite his promises, however, migration of Filipino nurses to US hospitals increased fourfold between 1965 and 1972.⁴¹

NURSING IN THE “NEW SOCIETY”

By 1973, the Philippines and its 37.5 million people boasted one of the highest population growth rates in the world, nearly doubling over a 25-year span. The country also maintained the economic imbalance faced by Roxas in the early days of the Republic, with the wealthiest 8% of the population appropriating 37% of the national income and the poorest 61% claiming only 39%.⁴² With reports that the “poor were becoming poorer and the rich richer,” the country eagerly reelected President Ferdinand E. Marcos for a second term in 1969, accepting his promises of a “New Society.”⁴³ Echoing earlier messages from Roxas, Marcos offered the Philippines’ people hope for economic recovery provided that each individual worked for the country's “common good and general welfare.”⁴⁴

Marcos invited nurses to be an integral part of the New Society's social reform efforts. In his opening address at the 1972 PNA convention, he acknowledged nurses’ economic duress and sought their patience while he tried to increase their salary levels.⁴⁵ Concerned about “the piracy of trained nurses” abroad and the waning supply of nurses in the country's rural communities, however, Marcos also called for increased nurse production and the implementation of a mandatory four-month service rotation in a rural area as a prerequisite to licensure.

Unlike Castrence and Castillejos, however, Marcos hailed nursing as the Philippines’ new “international specialty” and nurse migrants as heroes whose remittance contributed to nation building, provided they adhere to four basic principles: maintaining their Filipino identity, returning home with new ideas and practices, participating in the dollar repatriation program, and joining the Balikbayan project, a public relations campaign designed to disseminate positive information about the Philippines around the globe.⁴⁶ “As members of the New Society,” Marcos told conference attendees, “your role is not only to alleviate the suffering to the despondent, but to help build a strong society, strong men, strong women, and strong children.”⁴⁷

In response to the “New Society” imperative and a rising market demand for nurses in the United States and other nations, the number of nursing schools in the Islands rose precipitously. For example, whereas 17 schools prepared nurses in the Philippines in 1946, 43 schools of nursing were operating in Manila alone by 1977, with an estimated annual production of nearly 12 000 new graduate nurses.⁴⁸

Because most of the nurse training programs and hospitals preparing nurses were located in urban communities, 80% of the nurses working in the Philippines remained employed in city hospitals. Private hospitals, which accounted for more than half of the available beds in the country, and nonprofit hospitals, with 15% of the country's beds, suffered from chronically low numbers of patients because most of the population was unable to pay for hospital care. Instead, between 60% and 90% of the population used government facilities, which accounted for 35% of the nation's available hospital beds. The maldistribution of nurses in urban communities and in private hospitals that could pay more marketable wages created the perception of a national nursing shortage even as nurse production reached astronomical proportions.

But as was true in the 1940s, the Philippines fledgling economy in the 1970s was unable to absorb the rising cadre of registered nurses with marketable Western nursing skills.⁴⁹ Tens of thousands of nurses, essentially trained to immigrate over the 21 years of Marcos’ rule (1965–1986), were drawn to overseas work opportunities in an unprecedented “brain drain” wave.⁵⁰ Comparing the loss of nurses with the loss of archaeological treasures, Filipino nurse Pura Santillan-Castrenci opined,

What do we do with them? We sell them to foreigners, we give them as gifts, we make a good impression to our overseas friends … but we impoverish the country of historical items which would otherwise enrich our museum.⁵¹

Nurses who chose to remain at home expressed confusion about their identities and roles in the New Society. Ruminating about the “unsung heroes” who worked “long and thankless hours” at “starvation rates,” one nurse referred to the members of her profession as a

fragmented lot, a voiceless group herded by the whims of both government and the public, lost souls still seeking their identity under the sun.⁵²

Nurses thus struggled with which decision more aligned with the good of the nation: stay home and care for the local populace or serve as export products building a stronger Philippines economy.⁵³ Citing understaffing and rapid staff turnover, low salaries incommensurate with the standard of living, and physically and emotionally demanding work conditions as contributing factors to a nationwide shortage of nurses fueled by ongoing migration, the PNA petitioned President Marcos for assistance.⁵⁴

Despite such efforts at home, Filipino nurses working in the United States during the late 1960s and 1970s made clear choices to leave the country on the basis of economic incentives. In a study of 147 Filipino nurses working in Illinois, Minnesota, New York, Ohio, Pennsylvania, and Montreal, Canada, in the early 1970s, for example, Maria Pablico found that the nurses’ main reasons for migration were “economic security” and “remuneration.”⁵⁵ The nurses, all with prior hospital staff nursing experience in Philippines hospitals, reported that although they viewed nursing in the Philippines as “prestigious work” with a “significant impact” on the nation's health, they would have been unable to realize their potential for earnings and acquisition of material possessions had they remained at home.⁵⁶

Nurses interviewed in Chicago hospitals in the mid-1970s reported that they could send home double the expected earnings they could make in the Philippines each month.⁵⁷ Reflecting on her experience as a foreign-trained nurse in a South Chicago hospital some 25 years later, Elsie Dumlao noted,

I was an ambitious girl and I always sought out things. And of course, the dream of every nurse in the Philippines is to come to the U.S. Every opportunity is here. A lot of people there feel like the U.S. is paradise.⁵⁸

Nurses such as Lolita Campos typified many of the new immigrants to US hospitals during this period. Joining the nursing staff at New York City's Cabrini Medical Center in 1969, 18 months after graduating from St. Paul College in Manila, Campos entered the ranks of nurses supporting their families at home. Campos’ older sister, a nursing graduate from the University of the Philippines and an exchange visitor in 1960, was a hospital staff nurse in Long Beach, California, when she arrived. “Because we are a big family [11 children],” Campos shared in 1993, “financially my sisters helped the rest because that's how we did it … the first one who finished college helped my parents support the rest … it became a tradition.”⁵⁹ Campos found the “family-oriented” environment at Cabrini Medical Center an easier transition than other institutions may have been. Its Catholic affiliation and the presence of large numbers of Filipino nursing staff, housekeepers, and dietary workers provided social and religious comfort for new nurse migrants.⁶⁰

An exchange visitor in Galveston, Texas, between 1967 and 1969, 36-year-old L. A. (who, in an interview I conducted with her in 1993, asked to remain anonymous) was recruited in 1971 by the Manila-based North American Placement Service to Mahasset Medical Center in Nassau County, New York, leaving her husband and two young children aged seven and nine years behind to earn money to send home.⁶¹ When she arrived in New York City on the TWA flight from the Philippines, she described traveling with hundreds of other nurses, many of whom were former exchange visitors “going to Philadelphia, Chicago, New York … some were even bound for Michigan.”⁶²

L. A. worked for 1 year at Manhasset Medical Center on Long Island, New York, and commuted more than an hour by public transportation (bus) from Flushing before petitioning for an H-1 visa responsorship to Brooklyn's Downstate Medical Center and living in her cousin's apartment four blocks away from the hospital. When L. A. was assigned to the night shift, her cousin escorted her to work each evening until, a few months later and deeming Brooklyn “too dangerous,” she applied, was hired, and began working the evening shift in Cabrini Medical Center's intensive care unit. In 1975, rather than return home at the end of her contract, L. A. received her green card and sent for her family.

CRITICISMS AND COMMUNICATION

As Filipino nurses integrated into US hospitals, however, they were routinely criticized by American nurses as “too passive, working too many hours, and being too difficult to understand.”⁶³ Filipino nurses, likewise, reported that communicating with patients, families, and other nursing personnel presented their greatest challenge, both in expressing themselves and in understanding others.⁶⁴ Enhancing communication, in its many forms, became a central objective in the development and organization of PNA chapters during this period.

By 1976, PNA chapters in Chicago; Detroit, Michigan; Honolulu, Hawaii; Galveston, Texas; New York City; Jersey City, New Jersey; and Northridge, California, shared the aim “to unite Philippine nurses and strengthen their common bond as a professional group in a foreign land.”⁶⁵ The Chicago-based PNA promoted cooperation and effective communication between nurses, members of other health disciplines, and other Philippine organizations while preserving nurses’ precious national heritage and unique identity as professionals in the United States.⁶⁶

The newly organized PNA of New Jersey focused its efforts on the “professional improvement” of its members through the establishment of continuing education programs, licensure examination refresher courses, and surveys of work-related issues.⁶⁷

Although they worked toward common aims, the US-based PNA chapters operated independently of one another and focused on local needs, interests, and agendas. Similar to state chapters of the American Nurses Association, each PNA chapter elected its own officers and executive board, and chapters rarely worked in direct collaboration with each other or their mother PNA association in Manila.

Despite the localized nature of the PNA chapters, the national assimilation of Filipino nurses into American culture and nursing loomed large. Michigan PNA president Rose Tutay argued that Filipino nurses needed to move away from their stereotypic image as the “white-clad, brown-skinned, slit-eyed Oriental with long black hair who talks ‘foreign,’ who works quietly and [who] is ever-willing to ‘work a double’ if the floor needs her” to a “better image of one who loves her profession, has leadership abilities, and can and does her share for the improvement and betterment of patient care and better health care in this part of the world.”⁶⁸

Concerned with creating positive images and collegiality with their American peers and the public under their care, Filipino nurses suffered a setback in 1976 with the arrest and indictment of Filipino nurses Filipina Narciso and Leonora Perez on five counts of first-degree murder, 10 counts of poisoning patients, and one count of conspiracy to commit murder while working at the Veterans Administration hospital in Ann Arbor, Michigan.⁶⁹ Already struggling with accusations by the Michigan State Board of Nursing of potentially “unsafe care practices” and fighting the board's recommendation that Filipino nurses be examined upon arrival to determine their clinical competency before practicing in Michigan hospitals, Michigan-based Filipino nurses saw the Narciso–Perez trial as tantamount to protecting their good records and good images.⁷⁰

The Michigan PNA chapter formed the “Narciso-Perez Legal Defense Committee,” soliciting money and support from other PNA chapters and the Filipino community at large.⁷¹ The PNA in Manila alone contributed more than $85 000 to the defense fund. Despite these efforts, however, Narciso and Perez were found guilty in July 1977.

THE CONTINUED EXODUS

Although briefly cast in a negative limelight, Filipino nurses continued to be heavily recruited by US hospitals and were aided in the immigration process at home by the newly formed (1974), state-sponsored Overseas Employment Development Board. Renamed the Philippine Overseas Employment Administration in 1982, its explicit role was to facilitate and regulate the deployment of workers for export abroad.⁷²

With a highly institutionalized system for labor exportation in place, the Philippines stepped up nurse production and exportation again between 1975 and 2000, supplying nurse labor to the United States in addition to the Middle East, other Asian nations, and many European Union countries. Those who stayed home rather than emigrate abroad faced circumstances similar to their predecessors decades earlier. Surveying more than 11 000 nurses working in the Philippines in 1987 (representing 23.2% of the estimated 50 000 nurses in the country at the time), the PNA reported that hospital staff vacancies and nurse turnover rates in the country prevailed.⁷³ Ninety-one percent of those surveyed earned between 400 and 2000 pesos (approximately $95) per month, although the legal standardized starting monthly salary for nurses in the Philippines was 3102 pesos ($142).

With limited financial incentive to stay home, nurses such as Marlene Velasco, who immigrated to the United States with her family in the mid-1980s, continued to migrate abroad.⁷⁴ In 2004, the Philippine Overseas Employment Administration reported that between 1992 and 2003, nearly 88 000 nurses left the Philippines, with roughly half that number emigrating between 2000 and 2003 alone.⁷⁵

NATIONALISM AT WHAT PRICE?

The early messages linking the “potent lever of toil” to nationalism and economic security in the Philippines have been deeply ingrained and steadfastly maintained, creating a culture of migration that exists today. Nurses play an important role in this agenda, especially as the education of nurses, modeled after US standards, created a ready pipeline that carried hard-working and well-trained Filipino nurse professionals to short-staffed hospitals in the United States and other developed nations.

Indeed, fueled by rhetoric that congratulated their labor and remuneration and an economy that could not support them at home, nurses by the thousands moved abroad with the help of explicit policies and organizational structures (i.e., the PNA and the Philippine Overseas Employment Administration) that facilitated their international mobility and adaptation to new surroundings. At times, nurses received conflicting messages that simultaneously directed them abroad and chastised them for doing so, trends that continue today as nurse-starved countries around the globe look to the Philippines to fill their nurse shortfall.

The Philippines continues to lead the world in exporting nurses and has stepped up production to meet higher global demand, particularly in the past 5 years. Nurses’ reasons for leaving the Philippines have also held steady over 6 decades. Nurses’ average monthly wage of $170 in the Philippines ($2040 annually), for example, can hardly compete with the $3000 to $4000 monthly salaries ($36 000–$48 000 yearly) offered abroad; nurses in rural areas in the Philippines can expect only about half the national average, or $75 to $95 per month ($900–$1140 annually).⁷⁶ This translates into enormous earning potential; nurses working overseas can make in a single year what it would take more than 20 years to earn at home.

Also, low salaries among Filipino physicians ($300–$800 per month) have been a driving force in the nascent trend of doctors entering nursing programs to join waves of emigrating nurses.⁷⁷ This trend has been most noticeable in rural areas of the country, where it is estimated that 80% of doctors are studying to become nurses.⁷⁸ As more doctors leave medicine for nursing, so too have the number of medical school applicants dropped in favor of enrollment in nursing programs. Between 2000 and 2004, a reported 3500 Filipino physicians retrained and were exported as nurses, with 4000 more enrolled in nursing programs across the country.⁷⁹

Inadequate wages and high patient-to-nurse ratios, along with reports that the top graduates of Philippines nursing programs, the country's most seasoned nurses, and physicians are migrating abroad, create anxiety that care rendered to the local populace, especially those in rural communities, is in the hands of lesser experienced, lesser qualified personnel.⁸⁰ The loss of the country's most experienced health service professionals, including nursing faculty, has created noticeable divergence between local supply and demand.⁸¹ Thus, although Filipino nurses working abroad remit wages that may improve the Philippines’ economic health, there is a potential cost to the nation's public health.

CONCLUSIONS

Historical examinations of state–profession relationships can provide an instructive lens through which to view nurses’ migratory patterns and the local consequences and global implications of these patterns. Particularly relevant are the economic, social, and political factors that predicate nurse migration from developing to developed nations and the roles of local and global stakeholders in influencing migratory patterns and their consequences for nurses and the public in their care. The Philippines nurse case study, as a historical “constant” in the phenomenon of nurse migration, illuminates the complex and shifting nature of nurses’ global mobility and how local ideologies and economic conditions, aggressive international recruitment, and persistent shortages of nurses in developed nations converged to create the nurse pipeline that prevails to date.

Although not generalizable to all countries exporting nurses abroad, the roots of nurse industrialization in the Philippines foreground a broader understanding of the role of the state in the management or mismanagement of nurse migration, the production of nurses for local and global economies, the assurance of a quality product for the marketplace, and the public health consequences that may occur. As other countries market their nurses for export abroad, they would be wise to heed the lessons learned. n