This was the question posed to me by a curious TV reporter on May 7, just three days after a stretch limousine traveling across the San Mateo Bridge carrying nine Filipino nurses to a bridal party suddenly burst into flames killing five of the occupants, including the bride.

When she interviewed me in my law office in San Francisco, Ann Notarangelo, the reporter who is the weekend anchor of CBS 5′s Eyewitness News, explained that she was only asking the question because it was on the minds of her viewers. She thought I might know the answer as I taught Filipino American History at San Francisco State University and I am the legal counsel of the Philippine Nurses Association of Northern California. Plus, I added, I am also married to a Filipino nurse.

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Ann said that she was frankly surprised to learn that 20% of all the registered nurses in California are Filipinos, a considerably large percentage since Filipinos number only 2.3 million (officially 1.2 million) out of a state population of 38 million.

“I never noticed it before,” Ann told me, “because I generally don’t see people in racial terms.” But, she said, in reflecting back on all the times she visited friends and relatives in hospitals all over California, she now recalls seeing Filipino nurses everywhere. Not just in California, I said.

There but not quite there

The seeming anonymity of Filipino nurses in the US – of being there but not being quite there – is likely no more. The video clip of the fire-engulfed limousine was the top story in the US over the weekend. The media reported that the fatalities included Neriza Fojas, 31, a newlywed bride who was planning to get married again in the Philippines in June; Michelle Estrera, 35, the bride’s Maid of Honor who worked with her at a Fresno medical facility; Jennifer Balon, 39, and Anna Alcantara, 46, of San Lorenzo, who both worked at the Fruitvale Healthcare Center; and Felomina Geronga, 43, who worked at the Kaiser Permanente Medical Center in Oakland.

Americans also learned about the nurses who escaped the fire and were treated for burns and smoke inhalation: Mary G. Guardiano, 42; Jasmine Desguia, 34; Nelia Arrellano, 36; and Amalia Loyola, 48. In a TV interview shown all over the US, an anguished Nelia Arellano blamed the limo driver for failing to stop immediately and for selfishly refusing to help them get out of the burning limo.

http://www.washingtonpost.com/national/limo-passenger-to-driver-after-fire-help-me/2013/05/07/d4dfd631-e67b-4b16-b01b-503c68b0e28f_video.html?tid=obnetwork

As the TV camera started rolling, Ann posed the question to me: “Why are there so many Filipino nurses in the US?”

There are push and pull factors that are at play, I explained. The main push factor is the poor Philippine economy where an average RN earns only about 5% of what an RN is paid in the US. The main pull factor is the nursing shortage in the US.

Americans should not to be too surprised at the large number of Filipinos in the US. After all, the Philippines was a US colony from 1899 until the Japanese occupation in 1942 and, some would argue, a “neo-colony” for many decades after the Philippines was granted independence by the US in 1946.

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It does not surprise the British to see many Indians and Pakistanis in England, nor does it surprise the French that there are many Algerians in France. They understand that people from the colonized countries generally tend to gravitate and immigrate to their “mother” countries, even after their native countries were granted independence.

Four waves of immigration

There are four waves of Filipino nurse immigration to the US.

The first wave came after the US began its colonization of the Philippines and needed local health care professionals to meet the health needs of the subject population which is why the US Army recruited Filipinos to work as Volunteer Auxiliary and Contract Nurses.

Under the Pensionado Act of 1903, Filipinos were sent to the US as government-funded scholars (pensionados) including those pursuing a nurse education. Some of those who stayed for employment as nurses in the US went on to form the Philippine Nurses Association of New York in 1928. The association’s first president was Marta Ubana, who completed her Bachelor of Science in Nursing degree at Teachers College, Columbia University.

Many other pensionado nurses returned back to the Philippines to help set up and manage the 17nursing schools that were established in the Philippines from 1903 until 1940.Large numbers of the graduates from these nursing schools thereafter immigrated to the US as, unlike with the Chinese and Japanese, there were no immigration restrictions against them since Filipinos were considered “US nationals” and even traveled with US passports.

One of the pioneer Filipino RNs was Isabel L. Mina who graduated with a nursing degree from the University of the Philippines in 1919 before working at the Mary Chiles Hospital in Manila. Together with two other Filipino nurses, Josefa Cariaga and Petra Aguinaldo, Isabel boarded a ship in 1921 to go to Hawaii where they worked in a hospital before moving to California. The three close friends then boarded a train and traveled to New York where they worked in a local hospital for several years before deciding to return back to Manila.

Information about Isabel Mina was obtained by her San Francisco-based granddaughter, Lissa Sobrepena, who found out about her grandmother’s exploits when she logged on to Ancestry.com. For a fee, the website showed her photos and documents of her grandmother including copies of the two passport applications Isabel Mina filled out when she lost her US passport while traveling in the US.

What stunned Lissa was learning that her grandmother’s best friend was Petra Aguinaldo, who quite coincidentally, just happened to be the grandmother of her husband, Robert Sobrepena. Neither Lissa nor Robert knew that their grandmothers – who died before they were born – were close friends and that they had traveled together across the US as RNs.

Second wave

The next big wave of nurses from the Philippines began in1948 when the US State Department set up an Exchange Visitor Program to “combat Soviet propaganda”. According to Catherine Ceniza Choy, associate professor of ethnic studies at the University of California, Berkeley, and author of Empire of Care: Nursing and Migration in Filipino American History (Duke University Press, 2003), owing to the “special relationship” between the mother country and its former colony, a large percentage of the exchange visitors came from the Philippines, and many of them were nurses or nursing students.

Among these nurses was Maria Guerrero Llapitan who came to the US in 1948 to take post-graduate nursing courses at Baylor University in Texas. Maria had served as the supervisor of the operating room of a hospital in Bataan before it fell to the Japanese invaders in 1942. After completing her postgraduate studies at Baylor, Maria moved to Chicago to work at the Cook County General Hospital where she met her fiance. She then went to Hunter College for Women in New York to get her nursing degree while working at Sloane-Kettering Memorial Hospital in New York.

Maria married her fiancé in San Francisco where they set up a family in 1951. She later was among the Filipino nurses who formed the Philippine Nurses Association of Northern California in 1961.

Third wave

The third wave of Filipino nurse immigration to the US came after 1965 when US Immigration laws were liberalized to allow Filipino nurses and other professionals to immigrate to the US. It also allowed Filipino nurses to come to the US on tourist visas without prearranged employment and to then adjust their status in the US.

During this period, the number of nursing schools in the Philippines soared from 17 in 1940 to 170 in 1990 to more than 429 at the present time. Many of these nursing schools were diploma mills exploiting the desire of many Filipinos to enter the nursing profession.

Unfortunately, as a result of the only 15-20% of the Filipino nurses who immigrated to the US after 1965could pass the state nursing board exams. This led to the establishment in 1977 of the Commission on Graduates of Foreign Nursing Schools (CGFNS) to help prevent the exploitation of graduates of foreign nursing schools who come to the United States to work as nurses but who can’t pass the nursing board exams here.

The CGFNS developed a pre-immigration certification program that consisted of: a credentials review; a test of nursing knowledge (CGFNS qualifying examination), and an English-language proficiency examination (TOEFL).

Since 1977, CGFNS has administered more than 350,000 tests to approximately 185,000 applicants in 43test sites worldwide. From 1978 to 2000, the data showed that 73% of CGFNS test takers came from the Philippines, followed by the United Kingdom (4%), India(3%), Nigeria (3%), and Ireland (3%).

Role model

Menchu Sanchez immigrated to the US in 1980s and has worked as an RN for more than 25 years, the last three years at the New York University Langone Medical Center. When Superstorm Sandy battered New York last October, Menchu was taking care of 20 at-risk infants in the Intensive Care Unit of her hospital.Sandy knocked out the electric power to the hospital causing Menchu to organize the nurses and doctors to carry the babies in warming pads down 8 flights of stairs to safety. Menchu was invited to sit beside First Lady Michelle Obama at the State of the Nation address of US President Barack Obama on February 12, 2013.

In his speech, Pres. Obama cited Menchu as a role model: “We should follow the example of a New York City nurse named Menchu Sanchez. When Hurricane Sandy plunged her hospital into darkness, she wasn’t thinking about how her own home was faring. Her mind was on the 20 precious newborns in her care and the rescue plan she devised that kept them all safe.”

Many Filipino nurses who entered the US on H-1work visas after passing the CGFNS tests benefited from the passage of the Nursing Relief Act of 1989 which provided for their adjustment to permanent resident status if they had H-1 non-immigrant status as registered nurses and had been employed in that capacity for at least 3 years.

But the “sunsetting” of this law in 1995 effectively decreased Filipino nurse immigration to the United States.The passage of the Illegal Immigration Reform and Immigrant Responsibility Act of 1998 (IIRIIRA) further discouraged nurse immigration to the US.

Grow your own

The passage of restrictive legislation was fueled by nativist fears of foreign nurses taking American jobs as was expressed in July of 2009, when former Washington DC Mayor Marion Barry complained to the press: “In fact, it’s so bad, that if you go to the hospital now, you find a number of immigrants who are nurses, particularly from the Philippines,” Barry told the Examiner. “And no offense, but let’s grow our own teachers, let’s grow our own nurses — and so that we don’t have to be scrounging around in our community clinics and other kinds of places — having to hire people from somewhere else.”

Grow your own nurses the US did. According to the National Council of State Boards of Nursing, US nursing schools produced close to a million nurses from 2006 to 2011.

While the demand for Filipino nurses may have waned in the US, the demand for Filipino nurses in the rest of the world did not diminish. Filipino nurses working for the National Health System (NHS) in England drew international attention last February when Britain’s 91-year-old Prince Philip, while on a tour of a new cardiac centre in Bedfordshire, England, turned to a Filipino nurse and said: “The Philippines must be half-empty – you’re all here running the NHS.”

Not quite, not by a long shot, your majesty.

According to Reuben Seguritan, general counsel of the Philippine Nurses Association of America (PNAA), the Philippines is the world’s largest supplier of foreign-trained nurses with 429 nursing schools and 80,000 nursing students. To place this number in perspective, City College of San Francisco, with 89,000 students, does not have the resources to accept more than 75 students into its nursing program. The nursing students are chosen by lottery from a list of about 500 students who otherwise qualify for acceptance, a selective system practiced by community colleges all over California.

Is there a fourth wave of Filipino nurse immigration to the US?

Yes, but it hasn’t arrived yet. According to recent CNN report, “Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage will reemerge in the United States.”

The CNN report adds: “We’ve been really worried about the future workforce because we’ve got almost 900,000 nurses over the age of 50 who will probably retire this decade, and we’ll have to replace them,” [economist and nurse Peter] Buerhaus said.”

The fourth wave may come as early as 2014 when the US Patient Protection and Affordable Care Act, otherwise known as Obamacare, comes into effect and about 30-40 million Americans without any health insurance will finally be covered by health care insurance

LPG Marketer’s Association party-list Rep. Arnel Ty believes that Obamacare will “stimulate” the US hiring of foreign nurses. “This will hopefully spur US demand for new foreign nurses and other health practitioners such as pharmacists, physical therapists, medical technologists, radiologists, and speech pathologists,” Ty said.

To another question posed by the TV reporter, I answered that do not know the exact number of Filipino nurses in the US. All I know is that number, whatever it is, was significantly reduced by 5 on the evening of May 4, 2013.

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