Written by Andrea Eleazar

This past October marked the 30th annual Filipino American History Month (FAHM), recognizing the contributions and challenges of Filipinos in America since the landing of the first Filipinos in what is now California back in 1587. Over the centuries, waves of Filipinos have flocked across the ocean in pursuit of new opportunities while carrying their experiences and culture along with them. 

Fast-forward to 2022 – we live in the midst of a remorseless virus that infects and kills indiscriminately. But while the virus may not consciously choose its victims, we’ve seen that it thrives in a society whose systems are rooted in historical, persisting inequality. Certain communities have borne the brunt of the pandemic, exposing and exacerbating stark systemic health disparities. Nurses and healthcare workers are among those who have witnessed these grueling tolls firsthand – but some may not realize that they are concurrently falling victim themselves.

Ubiquitous in the American healthcare system, registered nurses from the Philippines make up 1 out of 20 RNs in the United States and remain the largest group of foreign trained nurses today. However, several media outlets have circulated some concerning data revealed in a report by National Nurses United, the largest nurses’ union and professional organization in the country: Filipino nurses make up only 4% of registered nurses nationwide, yet accounted for 31.5% – nearly a third – of all COVID-related deaths among RNs. Additionally, just under half (48.8%) of RNs of color who had died leading up to the study were Filipino. Some troubling statistics indeed, researchers have been investigating the possible factors behind this disproportionate toll – including a phenomenon that one study coins the “Filipino American health paradox” – and, in light of Filipino American History Month, what history can tell us about what needs to be done in reducing this burden moving forward.

The Filipino Nurse Diaspora – A Brief History

On the surface, the Filipino nursing trend may simply appear as a continuation of family legacies or perhaps even a widespread cultural inclination which few think twice to question. In more recent years, this may certainly be the case, especially among younger American-born Filipinos who wish to follow in the footsteps of their relatives and continue the medical lineage. But to understand what truly underlies the abundance of Filipino nurses in the first place, we must revisit the intertwined history between the Philippines and the U.S. Take a time trip back to the early 20th century and you’ll discover that these roots actually run deeper, sprouting from the American colonization of the Philippines.

The First Wave

A combination of American and Philippine policies set off migration waves of Filipino nurses to the U.S. throughout the 20th century. Following the Spanish-American War from which the U.S. emerged as victor in 1898, the Philippines came under U.S. colonial rule and President McKinley’s “Benevolent Assimilation Proclamation” for 48 years before gaining independence in 1946. During colonial rule, Filipino nurses were exposed to American education and westernized ideals both domestically and internationally. Along with the establishment of American-style nursing schools and programs in the country, President Taft signed the Pensionado Act of 1903 following the Philippine-American War, inaugurating a government-sponsored scholarship program that enabled Filipino students – including some nurses – to study at American colleges with the expectation that they would return to the Philippines to pioneer their respective fields and guide the country toward self-sufficiency. Among the early cohorts of pensionado nurses, some remained in the U.S. to pursue the American Dream; others returned home to expand the country’s network of nursing schools and train the fledgling nurses.

From Exportation…

The migration of Filipino nurses didn’t let up even after national independence was attained. Catherine Ceniza Choy, ethnic studies professor at UC Berkeley and author of Empire of Care, posits that although the intention of introducing American curricula was to prepare the Philippines for self-government, doing so “inadvertently prepared Filipino RNs to work in the U.S” (Nazareno). So, because they were trained under an Americanized curriculum, gained proficiency in English, and were “benevolently assimilated” to American culture, American hospitals viewed them as desirable and valuable hires. Thus began their active efforts to recruit Filipino nurses through advertisements and incentives. Mayette Calleja-Baglieri, an RN from the Philippines and member of the Philippine Nurses Association of Southern New Jersey and Philadelphia (PNASNJP), began her American nursing career in 1970 in the Medical Critical Care Unit of Montefiore Hospital in the Bronx, New York City. How did she get a hold of this opportunity? Through an advertisement in the Manila Times. 

In the latter half of the 20th century, the Philippine Overseas Employment Administration (POEA) was created to facilitate labor exportation; today, they continue to oversee the affairs of nearly two million Overseas Filipino Workers (OFWs) deployed around the globe. Their staunch promotion of overseas work earned the country its current status as the largest exporter of nurses in the world – so much so that they had to institute a healthcare worker deployment ban during the COVID-19 pandemic (later lifted) because of a domestic shortage of nurses. This shortage, partly caused by poor working conditions and insufficient pay in the Philippine healthcare system that prompt nurses to seek employment overseas, is what some have called a “brain drain,” leaving Philippine hospitals chronically understaffed and under-resourced to deal with the pandemic’s ramifications. 

…To Exploitation: Patching Up America’s Public Health Crises

As it turns out, the COVID-19 pandemic isn’t the first time Filipino nurses have served on the frontlines of American medical and public health crises. In fact, it is these crises that drove many of them to the U.S. in the first place. Between the casualties of World War II and the 1980s HIV/AIDS epidemic, the resignation of American nurses and healthcare workers triggered influxes of Filipino nurses to come to the country’s aid to remedy the shortages. Beginning with 7,000 Filipino nurses in the U.S. in 1948, the number skyrocketed by 50,000 within 5 years and grew steadily to approximately 143,000 today.

Essential but Chronically Vulnerable: The Filipino American Health Paradox

Mayette, now based in New Jersey, took a travel contract in a Central Jersey medical center in an ICU “filled” with COVID patients. “I must say that my initial response [to the pandemic] was shock! I didn’t expect what I was seeing! I thought that I was in a war zone!” she recalled. “Our 26 bed medical ICU became a 42 bed COVID-ICU, with IV tubings strung from patients to IV pumps outside the rooms to allow nurses to manipulate rates and hang IVs without going in and out of rooms so frequently in order to maintain isolation integrity…”

Nurses are essential to an effective public health response, and it’s no question that they’ve shouldered a heavy burden throughout the COVID-19 pandemic. At the bedside, they wear many hats, toiling for long hours as they treat patients and fight against disease. As such, the nature of nursing often places them directly in the virus’ path, meaning that their heroic contributions have come at a damaging cost. In the case of Filipino nurses, according to one article, a published paper found that Filipino nurses are more likely than white nurses to work in intensive care units, heightening their occupational exposure and risk of COVID-19 infection. But perhaps more shockingly, many are actually more chronically susceptible to worse health outcomes themselves.

The Filipino American health paradox describes how Filipinos constitute a major force of healthcare provision for the U.S. population, yet suffer from underlying health conditions and comorbidities that put them at high risk for severe illness themselves. A health needs assessment of Filipinos living in the Greater Philadelphia region found that among the surveyed population, the top five most prevalent health conditions were hypertension (67.5%), high blood cholesterol (57.1%), arthritis (28.9%), diabetes (21.8%), and cancer (14.7%). This trend is echoed nationally as other studies have found that Filipino Americans are at higher risk for cardiometabolic diseases compared to other Asian American subgroups and non-Hispanic Whites. Additionally, a study funded by the NIH’s National Institute of Minority Health Disparities and Health Disparities (NIMHD) concluded that Filipino immigrants’ chances of obesity are higher the longer they live in the U.S. Such trends can be attributed to a plethora of factors like genetics, health behaviors and lifestyle, and the social determinants of health, but research on this topic proves challenging as current data are limited.

Literature has also shown that working on the frontlines has given rise to various psychological hardships like depression, anxiety, burnout, and stress. A major source of this anxiety and stress has stemmed from a fear of infection from patients and possibly transmitting the virus to other family members at home, especially elderly relatives. This issue hits home for many Filipino nurses as Filipinos are more likely to live in multigenerational households and care for adult dependents, who may also be at high risk due to age and the same comorbidities.

Filling the Gaps, Fanning the Flames

Just as we’ve seen throughout history, these paradox-plagued Filipino nurses continue to fill the gaps of our patchwork healthcare system in spite of occupational health concerns, discrimination, and racism. In the 21st century, Filipino healthcare workers have been the targets of wage discrimination and exploitative hiring patterns which place foreign nurses in hospitals with limited funding and resources, typically those in inner cities and rural areas. These hospitals often seek out foreign nurses to fill positions not taken by native-born nurses. Furthermore, the paradox is compounded by the typical trials and tribulations of being an immigrant or person of color, whether the emotional toll of being halfway around the world from family, acculturative stress, or outside discrimination. The spike in anti-Asian hate crimes and rhetoric in 2021 added fuel to the fire, piling on an extra layer of distress outside of the workplace.

The processes of colonization and migration of the 20th century and the unjust pandemic circumstances of the 21st century collectively lend itself to trauma and a traumatogenic culture. After weeks, months, years of exposure to stress brought on by these events, we are tipped into allostatic load – the cumulative wear and tear on the body – from which there could be long-term, even intergenerational health consequences. Ultimately, as long as social justice and human rights are compromised, the cycle of inequity – and disparate health outcomes – persists.

Disparities in Disguise: Disaggregating the Data

As widespread as Filipino nurses are in the American healthcare system, their struggles and health issues have gone largely unnoticed and unaddressed by administrators, policymakers, and the public health literature. This is partly due to the aggregation of COVID-19 case and mortality data by race and ethnicity. Essentially, Filipinos, along with other Asian subgroups, are generalized under the “Asian” category and treated as a monolith in data reports. 

For instance, an analysis of aggregated national health data showed that Asians only account for about 3% of COVID-19 cases and 4% of deaths, suggesting that they are not disproportionately affected by COVID-19. Compare this to an analysis of disaggregated Asian health data in California extracted by the same authors in 2021 – Filipinos accounted for nearly half (42%) of COVID-19 deaths statewide. Currently, California and Hawaii are the only two states to break down the “Asian” label.

The insights derived from aggregated data are reflective of the long-standing model minority myth placed on Asian Americans, which has generated the problematic notion that all Asian Americans are wealthier and healthier despite evidence suggesting otherwise. As we know, the Asian continent is large, encompassing a diverse and heterogeneous population with varied needs. With these disparities hidden beneath the surface, most data paint an inaccurate picture of Asian health needs and consequently misinform research, interventions, and policy. Lumping Asian American subgroups, including Filipinos, under such a broad umbrella is evidently harmful from a public health standpoint as it perpetuates the model minority myth and therefore the health disparities affecting the population. To ensure proper resource allocation and health equity in public health efforts, states and health systems should refine their data collection standards, especially in other Filipino-populous states like New York, New Jersey, Illinois, Texas, and Nevada. In short: one size does not fit all.

“Resilience” and Caring for the Caregivers

For some nurses like Mayette, a combination of optimism, self-care, immune-strengthening practices, and a sense of community has enabled her to see herself through adversity and draw out positives from the situation, which is certainly an achievement to be celebrated. 

“I resorted to acknowledging all positive thoughts and blessings from God.”

Another feat to be appreciated is the dedication and commitment of Filipino nurses to serving the sick and upholding the healthcare system in times of strain, despite all odds against them. “I wanted to help out during the pandemic,” Mayette explained. “Hospitals were very short of nurses.” 

This begs the question, at what cost? Unfortunately, many other Filipino frontliners cannot resonate with such positive sentiments, especially those who have found themselves caught in the paradox. The often-romanticized narrative of “Filipino resilience” that emerged from the onslaught of natural disasters and hardships repeatedly slamming the Philippines seems to have translated into the American context, doing more harm by undermining individual-level difficulties. One socio-ecological study even suggests that in the Philippine context, individual resilience may be a protective mechanism against psychological and mental health issues and contributes to further distress during the pandemic. On a greater population scale, resilience alone is not enough for post-pandemic recovery – the human body can only withstand so much. But if we frame resilience in the context of community empowerment, public health can be instrumental in the healing process.

 Of course, nothing can be achieved without greater collective action. While nurses are often regarded as the “unsung” heroes of our healthcare system, Filipino nurses fall under another layer of invisibility. As we begin to recover from the pandemic, leaders, policymakers, researchers, and advocates alike must adopt an interdisciplinary, intersectoral, intersectional approach to bring them out of such invisibility. We must turn our attention to the environments in which they work and live, ensure that their experiences transcend the numbers on a report, and draw accurate insights to properly attend to their physical and psychosocial health needs.In this endeavor, social vulnerability and the complex interplay of sociocultural categories and identities must be considered; inevitably, the stories of the past will be uncovered. By doing so, we are able to see how past events have structurally shaped the lives of Filipino nurses in this country. Above all, we can utilize this knowledge to provide for current and future generations of Filipino American nurses. While history is our retrospective lens into the past, it is also a magnifying glass for the present and a telescope into the future.