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Eram Alam, "The Care of Foreigners: How Immigrant Physicians Changed US Healthcare" (JHU Press, 2025)
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- [00:00]
A
Hello, everybody. This is Marshall Po. I'm the founder and editor of the New Books Network. And if you're listening to this, you know that the NBN is the largest academic podcast network in the world. We reach a worldwide audience of 2 million people. You may have a podcast or you may be thinking about starting a podcast. As you probably know, there are challenges basically of two kinds. One is technical. There are things you have to know in order to get your podcast produced and distributed. And the second is, and this is the biggest problem, you need to get an audience. Building an audience in podcasting is the hardest thing to do today. With this in mind, we at the NBM have started a service called NBN Productions. What we do is help you create a podcast, produce your podcast, distribute your podcast, and we host your podcast. Most importantly, what we do is we distribute your podcast to the NBN audience. We've done this many times with many academic podcasts, and we would like to help you. If you would be interested in talking to us about how we can help you with your podcast, please contact us. Just go to the front page of the New Books Network and you will see a link to NBN Productions. Click that, fill out the form, and we can talk. Welcome to the New Books Network.
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B
Hello, everyone, and welcome to Academic Life. This is a podcast for your academic journey and beyond. I'm the producer and your host, Dr. Christina Gessler. And today I am so pleased to be joined by Dr. Aram Alam, who is the author of the Care of How immigrant physicians changed U.S. healthcare. Welcome to the show, doctor alumni.
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C
Thank you so much, Christina. I'm really happy to be here.
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B
I am so glad that you're here and that we get to go inside this book with you. Before we do that, will you please.
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C
Tell us about yourself? Sure. So, as you said, my name is Iram Alam. I am a historian of science and medicine. I grew up in Chicago and studied the natural sciences for my undergraduate career. And then life circumstances happen. People in my family fell ill, and this really shifted my interest in thinking about these topics, from the natural sciences to more of the social sciences. And so here I am today, trying to understand the organization of US Healthcare and trying to figure out how people are able to meet their basic needs.
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B
We're always curious at academic life about people's path through higher ed. You shared a bit about what shifted your interest specifically to this area. But when you were looking ahead to college, did you know you wanted to go to college? And did you know you wanted to go for so long that you would get a PhD.
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C
No, I had really no sense of what a PhD was. I knew that I wanted to go to college. That felt like the path that was available to me at that time. I grew up, you know, like I said, in Chicago. I went to public school, did well in there, and did well in the sciences. And so when I got to my undergraduate work, I became really interested, continued to study the sciences, and I thought at some point that I would actually go into medicine. But as you know, we'll talk about, I'm sure, with my book. One of the things that shifted me into a PhD was that medical school felt really cost prohibitive. I. I didn't grow up in a wealthy family at all, and the idea of taking on so much debt felt really burdensome and overwhelming, and I couldn't quite wrap my head around it. And so then after college, I actually became a high school biology teacher for three years in Chicago. And then again after that, I did a pivot into thinking about history and thinking about the other aspects of those things and learning that when one does a PhD, you receive a stipend. Granted, it's not some huge lottery amount of money, but it is something that, where I did my PhD at the University of Pennsylvania, allowed for a sustainable life during that period of time and became a really attractive option for me.
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B
And you talk about that in the acknowledgments that so many of the professors were so important to you that you have a list of names. And you also talk about the importance of getting financial funding to work on your book.
- [04:26]
C
Yeah, absolutely. All of this stuff is, you know, it is in some ways a privileged life to be able to sit and think and write about these things. And I, again, was able to go to a school where funding was secure, which is a huge, huge benefit. And so I could think about, you know, which archives can I go to, how can I travel to go to conferences to learn more about this profession? Because I come from a family where nobody does this kind of work. PhDs are not common at all. And so I needed that kind of infrastructure to help me understand what this thing was that I was getting into, because there was, like I said, no blueprints, really, in my life. So it made a huge difference that going to that school, understanding what the history of science was, understanding what this profession was. I really thought that it was something that was. I didn't understand a book was the product at the end of this thing at all. And of course, it's not always, but in history, that is a Common thing. And so I had to learn all of those steps along the way.
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B
And the book is called the Care of How Immigrant Physicians Changed US Healthcare. And right away, you take us into why this book and why this problem that you want to dig into and address. But for listeners who haven't seen the book yet, how do you describe it?
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C
So I got very into this topic because this statistic really stuck out to me that one in four physicians in the United States are immigrant physicians, and they really, really provide the fundamental and foundational backbone of healthcare in this country. So these physicians often work in what are called shortage areas in urban and rural communities throughout the country. And I just felt this huge gap in knowledge about this extremely important cohort of healthcare workers in this country. And that's really what got me into this topic and trying to explore and understand what is it like to be an immigrant physician in this country. And, you know, what is the longer history of how that structure even came into be.
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B
You tell us that you accessed a number of materials and records, but you also did oral histories. And the people that you interviewed were part of the first cohort of foreign doctors who came to the US in the 1960s due to a change in legislation that was inviting a pipeline in. And you take us into your role as an interviewer that the people that you interviewed gave much of their interview in English, and then when they talked about their private life or personal things or their childhood, they switched languages. And as you were looking at this database of interviews that you amassed, you as the scholar, had an ethical dilemma of what really was private and what really could be shared and how to do. So. Can you take us into the process of figuring out how to ethically handle personal stories?
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C
Yeah, I mean, it's a. It's a really heavy question. And. And, you know, it's still one that I'm grappling with. And part of why I put it in the book as an open question still, you know, as we think about our practices and how best to do them, I wanted to be really transparent about my thought process in conducting and what to do when people's lives get turned into data. So, as you mentioned, I did a lot of oral histories for this project, and often it was through. Through personal connections, and then one person sent me to another person, et cetera. And these were physicians that arrived, as you mentioned, in this first cohort, so in post 1965, into this country. And often the ones that I spoke to were from India and Pakistan. And I am a immigrant of South Asian Descent. My parents came from India in 1970, and Urdu or Hindi is really the language of our household. So that's my language by heritage. And so that also was an immediate affinity with many of my interlocutors, where we shared that linguistic history. And so I would enter into these spaces, and often I would enter as somebody that they already had a kind of kindness towards and thought of as a child figure, and not in the infantilizing way, but as you're part of my family, welcome into my home. And so I'll say, you know, I was greeted with chai, and for whatever reason, there was always cantaloupe. I don't know if this is some South Asian immigrant thing to always offer cut cantaloupe, but it featured prominently in many of my. Many of my oral history sessions. And. And so then I would ask these physicians, and the way that I conduct oral histories was in a way maybe similar to how you conduct these podcasts, which is, I try to speak as little as possible and allow for the speakers to have as much space as possible. And so I would ask these physicians, you know, tell me just a little bit about your grandparents. And I would say, you know, I'd start there. So people can set up a kind of biographical lineage however they want to do it. And I say to my students sometimes that, you know, asking about parent relationships can sometimes be more fraught than asking about grandparent relationships. And so it can set people a little bit more at ease, potentially, in how they want to narrate themselves. So I would. I would just ask them that and ask them about their experience choosing to go to medical school, then making the decision to come to the United States, and then what their practice was like once they arrived here. And what I would get were these reflections about professional life that often were relayed to me in English, and then the ones that had to do with kind of the difficulties of displacement, of loss of transition, of kind of the shock of culture shock of coming to another country. And again, some of this stuff was very racially loaded as well, was relayed to me in Urdu or Hindi. And so I was struggling with just trying to figure out, because that stuff is juicy. And as an author, I want to put that in because it really animates a book. It animates the people that are in the book. You know, it's easy for people to take interest in that aspect as well. And so I just really had to think about, okay, well, what is this line? What am I being told? Because I'm considered to Be somebody who, you know, in a, in a loose way is, is a member of this community. And what am I being told as somebody who is a researcher and is going to convey this information to a much broader public in a different kind of register. And so I really struggled with that line and tried to think about, you know, what are the, what are the kinds of levels of, again, of affect or emotion or displacement that I felt comfortable putting on display for a larger audience. And again, it was a challenge because many of these physicians, especially in their first encounters of coming to this country, were in extremely vulnerable positions and really expressed that kind of vulnerability to me.
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B
And there's more about the dilemma of the archive for listeners to find in the introduction. Questions about silences in the archives, what constitutes an archive, what we withhold and why and what should be made public. And it's very complicated, particularly with the silences having gone on for so long for one scholar such as yourself to decide, oh, now's the moment to say private things.
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C
Yeah, absolutely. And you know, I would add in addition to that, when you have what I call a living archive, when, when the person is in front of you also, how do you contend with, in terms of silences? You know, when we think about a paper trail, we think, okay, what's not here? But how do you think about the gestural? How do you think about the pauses? How do you. All of that are. Those are all huge sites of interpretation? I mean, is it 70% of communication is non verbal? And so I can put the positive speech that somebody conveys to me and that I can record, I can transcribe that. But how do I transcribe a shift in a seat that I, I interpret as maybe a sign of discomfort or, you know, an, an extended sigh that wasn't there when other questions were asked? You know, and what is, what do we do with that kind of, of material? Because those are all really, really rich sites of analysis. But should they always be sites of analysis?
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B
The book looks specifically at what you call the initial cohort of physicians who migrated to the U.S. you talk about how they, once they arrived, they were funneled to poorer areas, meaning they were resource poor. And you were interested in the structuring of the conditions. Why was it a crisis? Why. What created the position shortage? What created the disproportionate areas of under resourcing in the United States? And to dig into this, first, you take us into a key policy decision in, in chapter one called Importing a Solution. You open with President Johnson. It's 1965. And he's passing some really key legislation. Can you unpack that for listeners? Because it's really foundational of the before and after.
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C
Yeah. So that the 1965 moment is really, really a vitally important just moment in general in U.S. history. So we have civil rights legislation that has passed a year before. And In July of 1965, Medicare and Medicaid become law. So just as a reminder, Medicare is for people that are 65 and older and Medicaid is for people that are low income or disabled. So the federal government subsidizes their health care and is essentially their insurer. So when they go into hospitals, they, they have the government backed insurance. So this happens in July and overnight, approximately 20 million or more very high need users enter into the medical marketplace. And they're high need because older people and people who are poor generally have a greater burden of disease than people that are younger and wealthier. So this happens in July and then in October, and the 60 year anniversary is just coming up in a few weeks. In October of 1965, Johnson passes this Hart Cellar Immigration and Nationality Act. And he passes it for two really important reasons. The first is that it is a solution to this labor issue. So now that all of these people have entered into the medical marketplace that can access services, the US realizes that, well, there actually aren't enough physicians to be able to provide the requisite number of service hours essentially for this whole new set of people that have entered into this domain. So immigration becomes this really quick solution for if you write into the legislation that there's a special preference category for these skilled migrants, well then their entry can be expedited. That was one really important shift that happened with the 1965 immigration bill is that selective immigration based on labor categories became instituted in the United States. Secondly, part of what was happening was immigration required some kind of reform because the previous immigration bill, which was a 1924 comprehension act, was extremely restrictive and it had closed off immigration from African and Asian nations. So now imagine the US within its new place, as you know, the superpower in the world. And what it's trying to do is it's trying to convince these newly created post colonial nations in Africa, in Asia, that it is a friend and not a foe. And the fear is that if it persuades people that it is not welcoming, then they will lean over into the communist sphere of influence. So countries like India, et cetera, will veer more towards the communist spaces instead of the capitalist spaces. So immigration becomes this really important tool for foreign policy objectives. And people like Lyndon B. Johnson pushed it through and helped to push it through because they argued that this is sending a message to these other countries that the US Is an open, welcoming, democratic, liberal space that's welcoming now Asian and African people into its fold. So just to reiterate, so two really important things are happening with this legislation. One is on the geopolitical level where there is a signal to the world that, that the United States is now welcoming, it's no longer going to be closed and have this restrictive immigration system. And the second is that, well, there's also this labor shortage. So while we welcome people from certain countries, we also want them to have a certain skill set when they come. So that can help to alleviate this shortage of. At that time it was scientists, engineers and physicians within the country.
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B
And you tell us on page 48 that during the height of the Cold War, broadcasting a deficiency in the medical and scientific workforce had the potential to compromise a country's political and ideological authority. So we have the Cold War. We also have the AMA weighing in on this situation. And you have legislation happening. But you point out that this wasn't a surprise to the legislators that there was going to be a physician shortage, that sticking through the records, as historians say, we bring the receipts, this had been building for quite a long time. And you take us back to the 19th century and you show us pipelines that were being shut down from a variety of types of medical providers. And as you alluded to earlier in our discussion, the cost of medical school is prohibitive for so many people. And then the way medical school is structured, the schools that we have can only admit so many people because of the commitment they make to each student. It's a long time commitment.
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C
Yeah, that's right. So, you know, the AMA from the early 1900s was really invested in trying to cohere a professional identity. So prior to that there was a lot of what we, as historians of medicine, we call kind of the medical marketplace. And it was, there are many, many kinds of practitioners who are operating within that space. And so as the AMA became stronger, one of the things that they did was really invest in trying to cohere a professional identity. And a key aspect of that was to streamline medical education and make it something that was considered to be much more scientifically based. So this is when the introduction of, you know, all of my, my pre med students, all the courses that they have to take in order to enter medical school, the logic behind having to know these basic sciences as an Integral aspect to medical care became part of medical education in the early 1900s. And so as a consequence of those things coming together, a more scientific approach to medicine and just limiting the number of medical schools that could operate and meet that criteria of being able to provide a clinical education and a scientific education, a lab based education, just the numbers of schools were limited as a result. You have fewer schools, well, then you have more selective admissions into those schools. You have fewer people that are actually able to go to those schools. And through other kinds of complicated bureaucratic mechanisms as well, the AMA really limited who could enter into the profession. So women were disallowed for a long time from really entering fully into the profession. Minorities were disallowed from entering the profession. Again, we were talking about the cost. If you were poor, it was very difficult to become a physician. So all of these things came together to construct an image of a physician that was a white, wealthy, male figure, predominantly. And there were just far fewer medical schools that these people were going to. So this continued in this country for a very, very long period of time. And even as population increased, the number of slots in medical school and who could access them didn't change. And so you have this mismatch that's happening. And then again, when you have this population change, you have people that are demanding more medical care, but you have a limited supply consistently of physicians.
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B
Chapter two is called Documenting Difference. And this takes us into the bureaucratic landscape, the paperwork, and what it means for this initial cohort that came over who tried to access this pipeline. You look at their motivations to come to the US in the first place, and you look at people who were successful in having their paperwork processed and people who were not. And it's really eye opening for people who haven't had experience in dealing with the cumbersome nature of paperwork. Can you take us into chapter two, Documenting Differences?
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C
Yeah. So, you know, I say in there that the paper life is completely foundational for an immigrant's existence within another country. And part of why paperwork becomes so important is because the image of a foreigner is already one that causes some kind of discomfort. This question of who are you? Where are you from? And how do I know? And historically. So paperwork becomes this technique through which a person can become known. And in the case of an immigrant physician, not only does their identity have to get verified and confirmed and become something that's known, but also whether they have the requisite expertise to do this very complicated work, this very intimate work. I write, and this is a term that Charles Rosenberg is a historian of medicine, talks about, of the very complicated work of birth, death and illness. So how do you know that this practitioner who's in front of you, how do you know who they are and that they're not lying about who they are? And then how do you know that they actually have the skill set to be able to take care of you? And so paperwork becomes really this kind of foundational mode of recognition. And immigrant physicians, they get bombarded with the need to constantly produce themselves and their knowledge through these paper regimes. So in order to even enter into the country, an immigrant physician has to take what is called the ECFMG exam. And it's an exam that has two components, and one is a test of biomedical knowledge, and the other is English proficiency. So that's step one in the process. After they pass this exam, often they can come to the country and try to secure some kind of employment. Once they are able to do that, then the next step is to apply for licensure. In the United States, unlike in some other countries, we don't have a federal system of, you know, we don't have nationalized healthcare. And so as a result, all of this stuff is conducted on the state by state basis. So what happens is that a state can decide how they want to recognize a particular school, what additional kinds of information they can provide in an article that doesn't feature in this book. You know, I, I investigated some of this stuff in regards to a state, and people, people who are on the board to actually verify physicians credentials would do it based on things like, oh, I went on vacation to this country and I saw this medical school. And so this means that it's a real place, and I'm going to put it on the list of approved medical schools from overseas. So just to emphasize that this is a pretty haphazard process that's going on at this time based on what the states can ask. So some states would ask things like how many microscopes are, are in your laboratory? What is the kind of training that your medical professors received? And based on that kind of information, they would decide whether to grant a license. After that granting of a license, physicians then were additionally required to pass through different sets of exams, which changed over time. So every seven to 10 years, a new exam would be added, another one would be subtracted. But essentially what all of this is getting at was there was an inability to figure out how to actually know this practitioner. And so all of these different kinds of strategies were often deployed that, okay, maybe more tests will do It. Maybe more paper will do it, maybe more identification records from country of origin will do it. But ultimately, I think that the US Healthcare system, or just the US in general, that there. There was this unease with this figure who's claiming this expertise and this authority that has historically been reserved for rich white men in this country. And they're claiming that, and they're claiming it from a position of elsewhere, a position of outside.
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B
One example you give in the book is Dr. Nilesh, whose paperwork was ultimately denied over dispute about how his name was written.
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C
Yeah, you know, these are. This is what even actually primed me to start thinking about this in this way, is coming across these primary source materials and this exchange of letters between this physician who had been practicing in the United States already for seven years and wanted to transfer, so physically move with his family and. And work at a different hospital. So the way that physicians often work is if they have an independent practice, they need to apply to a hospital in order to get privileges so they can see patients in a clinic. But then if they need advanced screenings or another kind of. Of if they need X rays or something that the physician can't do in an office, they need to be attached to a hospital in order to take care of those kinds of things. So this physician was working in the United States, like I said, for seven or eight years and wanted to move. And so he applied to obtain privileges at a different hospital. And the hospital was said, okay, in order for you to get this, we need to get your medical transcripts, and we also need you to fill out these bureaucratic forms. So he filled out the forms, he sent the transcripts. He was having difficulty obtaining them because it had been so long since he actually was in medical school in India. And so he ended up having a family member get the transcript, a family member in India get the transcripts for him and mail them directly to him. And then he sent them to the hospital. And then his. His name was written in such a way that didn't fully align with the bureaucratic spaces on a form. And so he received a reply to his request to get permission in this hospital. And the director who grants these privileges said, well, your name is written in the wrong way, and we don't accept transcripts that are coming directly from you because we can't trust you, essentially, is the implicit part of that. And so they need to come directly from the medical school. And so he was irate. The next set of letters, and he wrote back saying, you know, I tried to explain to you that the way that my name is written is a, it is a remnant of a cultural history. And that, that is just the way that names are written in the place that I'm from. And he also attached additional evidence and articles that explain this. And then he also went on to elaborate about how difficult it was to actually get those medical records. And then he continues to say, you know, I've also sent you essentially recommendations and from your US Based colleagues that can vouch for the quality of the work that I've done in order to support my application process. And so, you know, here I think he's really trying to assemble all of these different aspects, all of these different ways of vouching for his identity and vouching for his expertise so that he can gain permission into this hospital and move with his family. And ultimately the director decides that he's, in my reading, untrustworthy and that he is going to be denied access to this hospital. And so he ends up not being able to move into practice over there. And, and I don't know what happens with his case after that. But these kinds of, what I call these bureaucratic roadblocks that have to do with not even necessarily the skill that somebody is able to exhibit, you know, based on the vouching and the fact that he's been working in this country for so long, but these, these bureaucratic mechanisms that of essentially misrecognition, of saying, we can't trust where your knowledge comes from. We can't even trust your name. And on that premise, we're going to deny you access to these places. Physicians often reported experiencing things of this nature as they tried to move through the country.
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B
And you tell us in the chapter that this unpredictability that the physicians experienced was provoked by the difficulty in the US of reconciling what the US Saw as two different kinds of people. They saw the migrant as one sort of person and they saw the expert as the other. And in bringing in the foreign medical graduates for, for people here, it was seen as this novel configuration. It was a foreigner claiming expertise and demanding the status reserved for a physician. And that continued to plague the physicians who came over to serve, particularly, as you point out, marginalized communities who are hard hit by healthcare precarity and who have you gave a number of statistics and data in the book. But in many of these underserved communities, there is one medical expert for 3,500 people. And so they're part of this pipeline to bring in people to fill the physician shortage is that there's great need in these underserved communities. And yet there's great difficulty for the physicians in navigating this cumbersome and unpredictable paperwork process. Another complication that you point out that they have once they are here is outlined in detail in chapter three, which is called First Contact. And it takes us into the social dynamics of the clinics where these doctors are working. And you talk about how they are expected to perform normative expertise. And since there is no such thing, they have to study how the US Born doctors are doing this, and then they have to learn it and rehearse it, and they have to do this where they're sent to places in the country that it sounds like from reading this book, are a complete surprise to them. One example is we meet Dr. Aziz, who's in Chicago's Cook Hospital. Can you tell us about his experience?
- [36:24]
C
Yeah, absolutely. So he shows up in 1968 to Cook County Hospital in Chicago, which is the largest public hospital in the city. And it's located on the southwest side of the city. And just a few days prior to his arrival, Martin Luther King Jr. Was assassinated. This resulted in lots of rioting happening in major metropolitan areas all across the country. In Chicago, Detroit, these are really huge sites of protest. And so the southwest side of the city at that time is there are buildings that are, you know, glass is shattered all over the place. They're boarded up. It's not at all the image that Dr. Aziz thought was in his mind when he decided to embark on this journey. He was talking about the fact that, you know, he had only heard about America from his friends, and he had only seen images of America through Hollywood media, propaganda, kinds of things. And so this was not at all what he had anticipated. And in addition to that, you know, I think that it's really important to pay attention to the way that race is organized, that spaces are organized in the United States. So he entered into this space where the majority of the patients that are coming to Cook County Hospital are black and other minority patients. And he had never actually seen somebody who identified in that way. And so just even this entering into this space that was so different than what he had anticipated, and now working with patients that have a completely different social, political, economic history than he does. He talked about, you know, the need to really gain. This wasn't just about a biomedical knowledge that he had to gain in order to effectively serve his population. He had to understand what are the politics of civil rights that are happening in this space. You know, some of the people that he's trained that he's treating are people that are, you know, who were parts of protests and, and were injured because of, you know, certain kinds of antagonistic violence in those in that area that now he had to really understand something new and something different about what was going on there. And so this is what I try to emphasize in this chapter, that even once a physician had done great work in terms of being able to complete all of their, their paperwork, entering into this space was a whole different kind of education.
- [39:31]
B
Chapter four is called Political Branding and it looks at how after years of practicing medicine, foreign born physicians mobilized and harnessed their economic capital and their professional status. Chapter five is called Brand Placement and it's how and why the figure of the South Asian physician has become a ubiquitous and familiar one. Chapter, the final chapter is the epilogue. It starts on page 156 and it's called America's Solvable Crisis. We're starting to come to the close of our time together and I'd like to take a few moments to sit with this chapter. You talk about how the book starts with this declaration of shortage amid emergency and where we are when the book ends, we're still in that place. And you also talk about the consequences of this migratory regime for planetary health. And you point out in several places in the book about what this means for the countries who are sending the physicians over. You point out that in India, for example, 51% of the graduates from the top medical schools, they're top students who are really prepared to go forth and serve there, who come to the United States. As we look at America's solvable crisis, what would you like to share with listeners?
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C
Yeah, I think that the pandemic really also helped me think through this book and this question of planetary health because we realize that geographic borders are no, you know, can't contend with a virus. And so we have to rethink how our worlds are connected, how our communities are connected. And healthcare workers are essential to thinking about that equation and trying to figure out how do we, as not just as nations, but as a person planet, come up with some kind of preparedness plan to confront the next thing that is likely on the horizon. And this way of thinking through the problem of, okay, well, immigration is going to solve it and we should just have more people come, well, then we end up having a deficit in countries like India, the Philippines and Pakistan, which are the largest senders of physicians to the United States. So I try to think about how do we solve this imbalance, because there are ways of thinking about this problem that don't just have to do with, well, let's just get more physicians from elsewhere to deal with it. That we need to expand our scope of how we're thinking about health. And some of the things that I think about are, well, how do we encourage and grow a domestic labor force? And you know, some of the ways and tying into how we started our conversation is how do we recruit and incentivize people in this country to actually enter into this profession. So numerous studies have shown that people who come from, who are, who become physicians from low income communities are much more likely to go back and work in those communities than people who are coming from elsewhere or people who are from outside of those communities. So how can we harness the sense of belonging and place and social responsibility that people feel towards the places that they're from and encourage local production of physicians from those places? How do we do that in a, you know, much in a systematic kind of way? So that in this communities, in rural communities, for example, where, you know, now we're, we're just decimating the healthcare infrastructure, the public education is also suffering as a result. And so the result, the consequence of that is going to be, well, immigrant physicians are going to come and have to do that kind of work. Well, how do we shift that, that narrative to think about really, really investing in local talent, really trying to have them, you know, who feel a connection to place and to the people of that place and have them continue to work in those communities. So I think that's one possible way of thinking about this. Another one is to just shift the cost of medical education. It is so prohibitive for people to. It's not that easy to take on hundreds and thousands of dollars worth of debt. And what happens as a result is that in order to pay that off, there is an incentive to enter into specializations that are more lucrative than others. So, for example, things like surgery, dermatology, anesthesia, these get paid very, very well. Other specialties like internal medicine, family medicine, pediatrics, there they get paid less. Well, and that is really huge. A lot of shortages exist within those specialties. And those specialties are on the forefront of managing population health on a large scale. So how do we think about the cost structures of medical education such that more people are inclined also to go into those specialties that are not considered. And I put all of this in air quotes for your radio listeners that are not as prestigious and not as lucrative as others. Because part of what we're starting to see in this country is that we're having shortages that exist alongside surplus. So in certain communities, for example, I'm in Boston, there's no shortage. Here we have an abundance of physicians. It's not always easy to get in to see them, but they do exist. So how do we think about redistributing such that we don't have these kinds of models where there's a concentration of certain specialties in one area versus a complete dearth of them in another. And then how do we incentivize those specialties that are considered not as prestigious as other ones and not as lucrative as other ones, because those are on the forefront of actually doing the work of caring for people on a day to day basis, finding, you know, being able to identify illness before it gets to a state where it requires extreme and costly intervention. We need to really start shoring up those kinds of professionals and I also think to really think capaciously about who is able to provide healthcare in this country. So in the 1960s, there was a moment where community health workers were thought to be, you know, there was a desire to incorporate this kind of structure within the broader healthcare landscape. And very soon after, funding for these kinds of things was dried up and it essentially went away. So how do we also bring back public health? How do we bring back community healthcare workers that have so much knowledge and so much information that they can disseminate in ways that don't require a fully trained medical doctor to do, but are doing vital work for the life and the health of communities? How can we think about using physicians assistants and nurses and nurses aides and, you know, these really important allied health professionals in different kinds of organizational models so that the physician doesn't become the prime figure that's needed in order to do this kind of frontline healthcare? And so those are just some of the ideas that I have for rethinking the way that the US has structured this, the whole healthcare workforce?
- [47:47]
B
And finally, what do you hope this episode sparks for listeners?
- [47:51]
C
I just really would like people to remember that how important immigrants writ large are to the functioning and the foundation of the everyday. And that while there is this heightened shift towards these kind of xenophobic measures, that in fact the US Is highly, highly dependent on immigrant labor and they are not disposable. They're absolutely essential to the functioning of this country.
- [48:28]
B
Thank you so much for being here today, Dr. Alam, and sharing from your book, the Care of How immigrant physicians changed U.S. healthcare. I'm Dr. Christina Gessler. You've been listening to the Academic Life. Please join us again.
- [48:50]
C
Sam.