The Immigrant Doctors Project

1. Why focus on doctors?

Doctors provide a fundamental service to all members of society—they care for our mental and physical health. The stated objective of the immigration ban executive order is to make Americans safer. However, our work shows that the executive order is likely to hurt the safety and health of millions of Americans who rely on these doctors.

These doctors are especially important in rural America, where there are long distances to travel between peoples' homes and the nearest physician and where there are often shortages of doctors. Until now, relatively little attention has been paid to the importance of immigrants in rural America and how rural Americans might be impacted by the new executive order.

It is certainly true that only a small share of the people in America from the targeted countries are working as doctors. Others are teachers, engineers, restaurant workers, etc. The large contributions that people from these countries make as doctors is simply the opening chapter in the larger story of how immigrants from these countries are contributing to American communities every day.

2. Are the 14 million doctors' appointments provided each year and the 7,000 doctors from the six targeted countries substantial?

Yes, these numbers represent important contributions to health care in America. One out of every 100 doctors in the US comes from the six banned countries. They are more concentrated in some areas than others, as can be seen on the interactive map. Those 7,000 doctors and the millions of appointments they provide are substantial for two reasons:

• Doctors provide highly specialized care and they work in local markets. For example, a neurologist in West Virginia is an important resource to a large number of patients spread over a wide area. Without that neurologist, many patients would need to travel longer distances for a consultation or in a medical emergency. Some will be forced to delay or forgo the medical care they need if it is too costly or time consuming to reach the nearest specialist.
• Many communities in the United States suffer from shortages of doctors. Nearly 20 percent of Americans live in areas without enough primary care doctors (source). Doctors from the seven banned countries work in these areas of need at the same rate as American-trained doctors, providing 2.3 million appointments to patients in areas with doctor shortages each year. These communities are already doing everything they can to attract more doctors: there are numerous incentives for newly trained American doctors and for doctors immigrating to America to work in underserved communities (links provide just two examples of the many incentives). Restrictions on the supply for foreign-trained doctors will result in more unmet medical needs in vulnerable communities that rely on their services.

3. What happens when there aren't enough doctors in an area?

Lack of easily accessible doctors is more than just an inconvenience.

• Cardiology and neurology are two of the three specialities with the highest share of doctors from the six targeted countries. Having cardiologists and neurologists nearby is crucial to the survival and recovery of patients suffering from heart attacks and strokes. In these emergencies, there is a short window in which immediate treatment can prevent permanent damage to the heart or the brain. Longer drives to the nearest specialist mean higher rates of permanent disability and death for Americans who have the misfortune of suffering from a heart attack or a stroke.
• A 2002 survey found that 30% of road-accident fatalities in rural areas arrived at a hospital more than an hour after the crash occurred compared to 8.3% of those in urban areas.
• Beyond emergency situations, such distances can also prevent patients from seeking routine, but essential care. For example, more than half of the women living in rural areas are more than 30 minutes away from the nearest source of prenatal care. And in mostly rural states, up to 20% of reproductive-age women live more than an hour away from the nearest prenatal provider (source). The lack of accessible medical care then contributes to the persistently higher rates of children born with low birth weight in rural areas (source).

4. Are current visa holders still affected, even though they are exempt from the new executive order?

Yes, even people from the targeted countries who already have visas in the United States may be impacted. The Cleveland Clinic and the Mayo Clinic, for example, are among the largest sponsors of H1-B visas in America (source). In 2016, applicants for H-1B visas represented 1.4% of the active physician workforce (Kahn and Gardin, JAMA 2017). Visas act as a document granting permission to enter the United States. But according to the reciprocity table for US H1-B visas, visa durations are very short for citizens of the targeted countries. Visas for citizens of Iran, Somalia, Sudan and Syria last for only 3 months with a single entry. Visa for citizens of Libya and Yemen last 12 months with multiple entries. Many current visa holders therefore have to reapply any time they leave the country, and may have difficulty in renewing their visas if they are granted visas at all.

The new Executive Order contains a lengthy list of people who may be eligible for exceptions from the visa ban from targeted countries, including those previously admitted to the United States for “a continuous period of work, study, or other long-term activity”; those with “significant business or professional obligations”; and those seeking to visit or live with family. At this time it is not known how this will be implemented and or how difficult it will be to qualify for the exceptions. Given the current uncertainty about being let back into the country where they live and work, many citizens of countries targeted by the visa ban are being advised to or choosing not to take the risk of leaving the United States.

Travel is very important for immigrant families, who often need to travel internationally to gather their families to celebrate weddings or mourn at funerals together. The travel ban hits especially hard for people with a dying loved one abroad, who have to weigh the risk of not being readmitted to their home in the U.S. against the possibility of not seeing the person they love—often their mother or father—before they pass.

5. Are the numbers presented here likely to underestimate or overestimate the total number of affected doctors?

We believe that our counts underestimate the total number of doctors who immigrated to the US from the six countries named in the executive order.

We identify doctors who are affected by the executive order as those who attended medical school in Iran, Libya, Somalia, Sudan, Syria and Yemen. But in practice, many citizens of those countries attend medical school in the United States or other non-targeted countries. Others are among the 18% of doctors excluded from our counts because we do not know their up-to-date ZIP code or the country they attended medical school. These factors would cause us to undercount the number of affected doctors. One factor that could cause us to overcount the number of affected doctors would be if a citizen of a non-targeted country (e.g. Egypt) attended medical school in a targeted country (e.g. Syria). Since we observe only the country in which the doctor attended medical school, we would be counting that person as targeted, even though, as an Egyptian citizen, they are not directly targeted by the Executive Order. We believe that this factor is likely to be smaller than the aforementioned reasons why we might undercount the number of doctors originally from the six affected countries. An analysis by Medicus using country of birth information contained in licensing data supports this conclusion.

Some fraction (though far from all) of the doctors we identify from these countries may have become American citizens, particularly those who have served American patients for decades. However, we think it is nonetheless reasonable to include these doctors in our count for multiple reasons. First, the Executive Order sends a direct message to these individuals and their families that people similar to them are not welcome in the United States. Second, the ban could reduce the ability of these Americans to have friends or family from their countries of origin visit them in the United States.

The immigration ban also cuts off the flows of future doctors from the targeted countries. According to the Association of American Medical Colleges, there are approximately 260 people from the six banned countries (and Iraq) applying to medical residency programs this year, and half of them would be likely to remain in the US after completing their residency. The doctors who remained would have provided over 200,000 doctors' appointments per year in future years in America. While the executive order stays in place, there will be a growing number of doctors who would have been working and seeing patients in America, but are now banned from the country.

6. Who can I contact if I have other questions about the study or the data?

Please email us at [email protected].