Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad

We sat down to talk with Dr. Kate Tulenko about her new book, Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad.

The outsourcing of American jobs to other countries makes headlines in the United States (US) on a regular basis, with opponents of outsourcing complaining that it destroys American job creation—and the economy. Although Americans, as a whole, are aware of more foreign-born health workers being employed by health care institutions in the US, few probably realize the impact of the importation of these health workers both in the US and in low-resource countries. In her latest book, Tulenko describes the problems and proposes ideas about expanding American health worker education and improving health care in the developing world.

“I felt the issue was like the elephant in the room that no one was talking about because it makes people a little squeamish,” Tulenko said. “It’s uncomfortable to think that one of the wealthiest countries in the world might be aggravating the health problems of some of the poorest. At the same time, we are underinvesting in our own underserved communities in the US.”

Tulenko believes that the US needs to train more Americans to become health workers—a statement laden with implications: "This can be a really divisive issue," she said in an interview with Minnesota Public Radio on the premise of her book. "It's a jobs issue, it's an immigration issue, it's a quality of care issue, and it's an economic issue." In Insourced, she shares how she arrived at that conclusion and proposes a way forward.

The US is increasingly relying on foreign-born health workers to fill health care gaps, particularly in providing primary care. In the short term, it is cheaper to import foreign health workers than train new ones, but Tulenko argues that this practice has dire economic and social consequences. It threatens the quality of medical care in both source countries and the US and allows the health worker training system in the US to continue down the path that has led to a shortage of health workers in the first place.

Underinvesting in the Health Needs of US Communities

Somewhere along the way, the US stopped producing sufficient numbers of health workers to meet its own needs. Tulenko identifies the lack of coordination among different health professions as a contributing factor to this underproduction.

“There is no one looking at the entire system from a public health perspective,” Tulenko said. “No one saying, how many nurses do we actually need? What is the nursing skill set we actually need? How many physicians do we need? What is the real role of a physician?” 

Actual health care needs are not driving the production or training of health workers: the various self-regulated health professions are. In the name of quality, students and faculty are compelled to meet ever-increasing requirements to practice or teach with no evidence that these requirements make better health workers or faculty. In fact, these requirements may be doing more harm than good.

“To be a medical school professor, you just need to be a physician, but for a lot of the other professions, including nursing, you need to have a PhD, which, by definition, contributes to a shortage of nursing professors,” said Tulenko.

Compounding that, “medical education has become more expensive. Tuition has increased for students—and the overall cost of training both nurses and physicians has soared. America has priced itself out of higher education.” Because the government subsidizes the cost of medical education, both taxpayers and students bear the burden of rising costs. And for students, high levels of personal debt may also be a contributing factor driving medical students to pursue lucrative specializations over primary care.

“But the high cost of health worker education is also a reflection of the fact that the US values research over care. Our medical and nursing education leaders have lost track of the true purpose of clinicians—to serve,” said Tulenko. “We need to focus on building students’ clinical skills rather than focusing so heavily on research. For many cadres, we need to reverse the ‘credential creep’ which has further driven up the cost of education, reduced the output of students, and put this type of education out of reach for most.”

Aggravating the Problems of Developing Countries

“There are more Ethiopian physicians practicing in Chicago today than in all of Ethiopia, a country of 80 million,” Tulenko wrote in a Foreign Policy column. For developing countries, losing health workers impairs their ability to fight against life- and economy-destroying diseases, including HIV/AIDS, malaria, and tuberculosis, as well as the common scourges of diarrhea, pneumonia, vaccine-preventable diseases, and access to reproductive health services such as family planning.

“Because the number of health workers per capita is directly related to the population’s health, migration of health workers has been branded as ‘fatal flows,’” Tulenko said. In Foreign Policy, she mentioned a Gates Foundation study that found the number one cause of loss of professors from African medical schools was migration. “Not surprisingly,” she wrote “the same study also revealed that lack of professors was one of the main barriers to training more health workers in Africa.

“Not only are we taking the water, we’re smashing the pump.”

Continue reading: 1 | 2all on one page


A physician and global health specialist, Dr. Kate Tulenko has worked at the highest levels of health workforce, health financing, and health policy development with institutions around the world. She currently serves as IntraHealth International’s senior director of health systems innovation. She joined IntraHealth from the World Bank, where she coordinated the Bank’s Africa Health Workforce Program.

Tulenko has been an advisor to national governments on health policy and reform. She has served on expert panels for the World Bank, World Health Organization, American Public Health Association, Global Health Workforce Alliance, and American Hospital Association, and she currently serves on the National Physicians Alliance board of directors. She also holds academic appointments at the Johns Hopkins School of Public Health and the George Mason College of Health and Human Services. Tulenko holds an MD and MPH from Johns Hopkins University, and an MPhil from the University of Cambridge, Emmanuel College. Tulenko has published on a wide array of topics.