by Aparna Alankar
Illustration: “Colors of Philadelphia” by Sorasicha Nithikasem
On January 27th, 2017, President Donald Trump issued an executive order known as the “Muslim Ban”. The order barred the entry of Syrian refugees into the United States indefinitely, and of all other refugees for 120 days. Both citizens and green-card holders of seven predominantly Muslim countries—Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen—were barred entry for 90 days2. Following the ban’s announcement, key parts of the executive order were temporarily blocked nation-wide by a federal district judge, allowing thousands to enter the country. The judge cited a lack of both evidence and necessity for the restrictions imposed by the order4. The ruling was later upheld in the U.S. Court of Appeals for the Ninth Circuit in San Francisco. President Trump immediately voiced his intention to take the case to the Supreme Court5. In a press conference held on February 16th, President Trump mentioned that a “new executive order is being tailored to the decision”6. He is expected to sign the revised order immediately, which senior officials from his administration say will include exemptions for green-card holders and dual U.S. citizens of the seven countries and lift the automatic ban of Syrian refugees7.
The new order will, however, continue to target citizens of Muslim-majority countries and label them as “terror-prone,” displaying a blatant disregard for what the United Nations has named the “worst migration crisis since World War II”7,8. Ultimately, both of these executive orders will have long-term effects for all that are involved extending beyond their direct ethical and political consequences. President Trump’s “Muslim Ban,” will wreak havoc on the world’s largest scientific and medical community, consisting of hundreds of thousands of international physicians and other health professionals, who play an critical role in graduate medical education and delivery of healthcare in the United States.
In 2015, the Educational Commission for Foreign Medical Graduates (ECFMG) published its annual report, recording that 24% of practicing physicians in the U.S. are international medical graduates (IMGs)13. They represented over 40% of applicants to residency programs in 201622. The act also threatens the roughly 200,000 IMGs currently practicing in the U.S. and the thousands more who applied to residency programs this fall, preventing them from being matched to residency programs this spring. In total, there were 2,101 applicants from predominantly Muslim countries, representing 17% of all IMG applicants 11. In addition to residency programs, highly competitive faculty positions at colleges and medical schools conduct their recruitment process in the months of January to February9. Additionally, doctoral and postdoctoral students will no longer hold valid credentials to work securely in their institutions, harming their applications and chances of placement. In many cases, these students have spent years contributing to research in their universities before applying.
Unless action is taken by individual institutions to ensure that all qualified IMGs can participate, these applicants face drastically reduced chances of acceptance into both residency and tenured positions. Moreover, even if IMGs are admitted, they will likely be unable to come to the U.S. under the standing regulations of the executive order9. Many of these applicants train on J-1 visas, which are non-immigrant visas issued with recommendation from the ECFMG. J-1 applicants are required to either return to their country of origin for 2 years or to obtain qualifying “J-1 waiver” clinical positions to remain in the U.S.16. The ban has caused widespread chaos and uncertainty amongst residents, fellows, and selection committees throughout the country, with many wondering how to treat applicants from the seven banned countries10.
In the week following the initial executive order, the Association of American Medical Colleges (AAMC) issued a statement in response, voicing their concern “that the January 27 executive order will disrupt education, research and have a damaging long-term impact on patients and health care”11. They also highlight that the growing physician shortage in the U.S. will be particularly exacerbated by the executive order. A physician workforce report published by the AAMC projects a total shortage of between 61,700 and 94,700 physicians by 2025, with a significant shortage amongst surgical specialities12. The shortage is attributed to a number of factors, mainly an increase in demand for health services from an aging population and the increasing accessibility of medical services and health insurance. According to AAMC President Darrel G. Kirch, MD, “these updated projections confirm that the physician shortage is real, it’s significant, and the nation must begin to train more doctors now if patients are going to be able to receive the care they need when they need it in the near future.”
The role of IMGs is especially important in areas of need, including underserved rural communities and inner-cities, where the majority of J-1 physicians practice.16 According to the American Academy of Family Physicians, 42% of office visits in rural America are with foreign-born physicians21. Foreign-born physicians are also more likely to go into “front-line” specialties like pediatrics, internal medicine, and general surgery, where they will see thousands of patients a year. Reducing the number of potential physicians to fill these spots significantly undercuts the amount of care that can be provided to domestic patients in these much needed areas. Ultimately, the executive order affects a significant portion of the U.S. healthcare workforce, and was signed without regard of its long term effects, including the growing physician shortage.
Restrictions on mobility affect international patients travelling to receive care in the U.S. and domestic physicians who provide services internationally. The United Nations issued a report on January 31st that showed that children who are most in need of emergency international aid are from five of the seven countries banned by Mr. Trump17. For international patients, the executive order blocks access to crucial U.S. medical care. Pamela Paulk, president of Johns Hopkins Medicine International, said the following in response to the executive order: “patients who travel from the Middle East to the United States for treatment generally have severe illnesses that cannot be treated in their home countries, and need complex treatments like neurosurgery, heart operations, or bone marrow transplants for cancer or blood diseases. Some cannot afford, medically, to wait”18. Unable to obtain necessary treatment, many patients are left in medical limbo without proper follow-up.
18-month old Sham Aldaher from Syria is an example of one such patient19. She was born without an eye and was in need of extensive reconstructive surgery. The family began looking for a hospital willing to perform the surgery, and found one in Barcelona. Sham and her family were granted temporary residence in Spain, where Sham received her initial surgery. Sham will require close monitoring as she grows because she will require further surgery to correct facial asymmetries and replace her eye prosthesis. Sham and her family were only granted residency in Spain until late December, and were planning to move to the U.S. so she could receive appropriate follow-up care. After undergoing an intensive vetting process, including multiple interviews and background checks, they learned that they would be denied entry because of the new executive order. Sham and her family, like so many refugees who hoped to resettle in the U.S., are stranded abroad, are unsure of what the future holds for them.
Another case concerns an Iranian-born professor of obstetrics and gynecology at Baylor College of Medicine, Dr. Alireza Shamshirsaz20. Dr. Shamshirsaz specializes in fetal surgery, and recently canceled a trip to Iran, where he performs life-saving surgeries that are normally unavailable. He was worried that he would be stranded in Iran and unable to return to his family and patients in the U.S. after the executive order was put into effect. Even though the ban was repealed, the Trump administration has made it clear they are willing to contest the ruling, and the order could very well be reinstated, albeit in a revised format. In the words of Dr. Shamshirsaz, “there’s just too much uncertainty right now to know what is the right thing to do20.”
International medical students and faculty, and especially those from the seven predominantly Muslim countries targeted in the executive order, are crucial to the success of the U.S. healthcare system. According to The Medicus Firm, more than 15,000 doctors across the U.S. are from the seven targeted countries, including about 9,000 from Iran, 3,500 from Syria, and more than 1,500 from Iran21. Dr. Hooman Parsi, an oncologist granted a special visa for “individuals with extraordinary ability or achievement,” is stuck in Iran, waiting for a delayed visa following the chaos of the executive order rollout. Even though he is being issued a new visa, Dr. Parsi cannot return to the U.S. because the new court ruling affects solely those who have current visa stamps on their passports. Dr. Naeem Moulki, a Syrian citizen and medical resident beginning a cardiology fellowship in Chicago this fall, asserts: “Everyone, including me, would like to keep the bad people out. But this is not the best way to do it. If I have to leave, it affects my patients”.
The spread of xenophobic rhetoric has led to heightened tensions in examining rooms, where patients are beginning to look at their doctors differently. Dr. El Rafei, practicing physician at the V.A. Hospital in Minneapolis, says that the ban saddened him— “I felt like I was back in Syria again. You feel hunted there, as if you did something wrong, even if you didn’t. Now I feel the same way here”21. When asked by one of his patients why “you people hate us,” Dr. Rafei replied, “We don’t hate you. The bad people you see on TV are the same people who make us suffer, too”. The ban is an example of systematic, unwarranted discrimination and fear-mongering, ultimately compromising the perception of a large number of foreign physicians and their ability to deliver quality care.
As the consequences of the ban continue to impact the lives of countless people, it is important to realize that the U.S. is a country built by and for immigrants. Immigrants have made a long list of contributions to the U.S. health care system and to science in general — achievements that transcend labels of religion, race, color, ethnic background, gender, and sexual orientation. Banning the entry into the country of international medical students and faculty disregards the talent, skills, and perspectives that international medical students and faculty contribute. In the few weeks that it has been in effect, President Trump’s “Muslim Ban” has already profoundly affected communities in the U.S. As Haxhir Rahmandad, an associate professor of System Dynamics at M.I.T. put it, “we are losing a lot of talent and potential collaborators, who cannot work with us because they cannot join our team and we can’t retain talent”9. The global perception of the U.S. is already changing in international medical and scientific communities following the executive order, and it is likely the country will suffer in the long-term.
1. “Full Executive Order Text: Trump’s Action Limiting Refugees Into the U.S.” The New York Times. The New York Times, 27 Jan. 2017.
2. Liptak, Adam. “President Trump’s Immigration Order, Annotated.” The New York Times. The New York Times, 28 Jan. 2017.
3. “Trump Says US Will Prioritize Christian Refugees.” CNN. Cable News Network, 27 Jan. 2017.
4. Nicholas Kulish, Caitlin Dickerson and Charlie Savage. “Court Temporarily Blocks Trump’s Travel Ban, and Airlines Are Told to Allow Passengers.” The New York Times. 03 Feb. 2017.
5. Liptak, Adam. “Court Refuses to Reinstate Travel Ban, Dealing Trump Another Legal Loss.” The New York Times. 09 Feb. 2017.
6. “Full Transcript: President Donald Trump’s News Conference.” CNN. Cable News Network, 02 Feb. 2017.
7. Mallin, Alexander, and Katherine Faulders. “Trump’s Revised Immigration Order Expected to Renew Ban on 7 Muslim-majority Countries.” ABC News. 25 Feb. 2017.
8. Pecanha, Patrick Boehler and Sergio. “The Global Refugee Crisis, Region by Region.” The New York Times. 08 June 2015.
9. Mohney, Gillian. “Medical and Science Communities Could Take a Blow From Trump’s Immigration Order.” ABC News. 25 Feb. 2017.
10. “Trump’s Executive Order on Immigration – Detrimental Effects on Medical Training and Health Care — NEJM.” New England Journal of Medicine. 25 Feb. 2017.
11. “AAMC Statement on President Trump’s Executive Order on Immigration.” AAMCNews. 30 Jan. 2017.
12. 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2025. Association of American Medical Colleges, 5 Apr. 2016.
13. 2015 Annual Report. Educational Commission for Foreign Medical Graduates.
14. Charting Outcomes in the Match for International Medical Graduates. National Resident Matching Program. September 2016.
15. Charting Outcomes in the Match for International Medical Graduates. National Resident Matching Program and ECFMG. 2014.
16. “Conrad 30 Waiver Program.” USCIS. 25 Feb. 2017.
17. UNICEF Humanitarian Action for Children 2017. UNICEF. January 2017.
18. Fountain, Henry. “Science Will Suffer Under Trump’s Travel Ban, Researchers Say.” The New York Times. 30 Jan. 2017.
19. Minder, Raphael. “For Syrian Girl in Need of Medical Care, Trump’s Travel Ban Adds to a Nomadic Tragedy.” The New York Times. 01 Feb. 2017.
20. “Trump Travel Ban Kills Surgeon’s Lifesaving Trip to Iran.” The New York Times. 10 February 2017.
21. Jr., Donald G. McNeil. “Trump’s Travel Ban, Aimed at Terrorists, Has Blocked Doctors.” The New York Times. 06 Feb. 2017.
22. A Census of Actively Licensed Physicians in the United States, 2014. Federation of State Medical Boards. 2016