The Backstory: Aurora Almendral

Reporting on the Exploitation of Foreign Nurses

In the wake of the COVID-19 pandemic, hospitals in the U.S. and Europe rapidly accelerated hiring nurses from countries like the Philippines, India, and Nigeria, to bolster their workforces amidst staffing shortages. In “Merchants of Care,” a four-part series produced in partnership with Quartz and the Pulitzer Center, Aurora Almendral and Samanth Subramanian investigated the consequences of this global movement of nurses and spoke with dozens of nurses who left their home countries only to experience exploitation abroad. 

The series recently won the 2024 SEIU Award for Reporting on Racial and Economic Justice from the Sidney Hillman Foundation.

Following the award win, we spoke to Aurora about how she learned about the nursing crisis, how she got in contact with the nurses she spoke to for the series, and her advice for reporters who want to pursue ambitious investigative projects. This conversation has been lightly edited for length and clarity.

Paco Alvarez: Could you give us a brief rundown of the main findings of the investigation? 

Aurora Almendral: So for this investigation, we looked into foreign nurses being hired into the US in the wake of the pandemic after a huge amount of nurses left their jobs because of dangerous conditions and various other reasons. Hospitals were in a position where they were having to hire a lot of nurses, and they turned to foreign nurses. Foreign nurses who come into the US should be under the same kind of labor laws that U.S. citizen nurses are. But in practice, hospitals and the agencies who are the go-betweens the foreign nurses and the hospitals have a system of keeping the nurses in jobs that U.S. nurses would otherwise leave. And the way they do this is with high breach fees and threats of having their green cards taken away and other acts of intimidation that keep them in jobs that become increasingly dangerous. And because they don’t have this power of movement of labor that other U.S. nurses have or are restricted and intimidated into not moving jobs when the conditions are bad, they’re often faced with worse conditions than the U.S. nurses are. The proposition is often that Filipino nurses and nurses from other countries stay in their jobs longer and stay in these difficult, dangerous bedside positions longer than U.S. nurses. And the way they do that is through these abusive financial practices that prey on their vulnerabilities as people who are new to the country. 

Alvarez: What initially inspired the investigation or like, how did you begin the reporting process? 

Almendral: So during the pandemic, I covered migration around the world, kind of extensively. And during the pandemic, one of the stories that I did – I was looking very early on in April 2020 at these Filipino and foreign nurses working in the U.S. and the UK – places where they had explosions of Covid. In those early days, both in the US and the UK, international nurses were dying at higher rates. And so, I followed a Filipino family that had nurses all around the world. 

One of the tidbits that I came across in that reporting was from the head of the International Union of Nurses saying that these nurses have given a lot to these health care systems that they’ve immigrated into. But actually that international nursing migration is fraught with a lot of problems. Exploitation being one of them, but also the way that it drains the healthcare systems of the places that they leave, the abusive nature of foreign sort of richer countries like the US and the UK underfunding their own nursing nursing pipeline, knowing that they can just siphon off nurses from poorer countries whenever they need it. 

And so everyone in the system on both sides of the migration chain loses, because, you know, the nursing pipeline in the US and the UK is underfunded. They’re not paying people enough. They’re not providing good working conditions because they believe that if they need more nurses, they can pull them from countries like the Philippines and Nigeria. Which is what they do, even though for over 15 years, the World Health Organization has said that this can be when it’s not managed correctly, a very destructive practice, both for the healthcare systems,that the nurses go to and the ones that they leave for different reasons. 

So after I heard that, it sounded like something where you can pull the string. And it took a couple of years before I was able to return to it, but once I did, it’s was one of those stories where, okay, let’s look into this and then more and more, bits of information like problematic issues and government failure, and sort of exploitative business practices just kept coming out. 

Alvarez: You primarily focused on nurses from the Philippines, India and Nigeria. Why did you choose to look at those countries in particular? 

Almendral: So, the Philippines and India – they supply more international nurses to the global health system than anybody else. So in the UK, there are more Filipino nurses and Indian nurses than any other kind. I think they often switch places for who is number one in terms of providing nurses there. And in the U.S., about 4% of nurses are international. But of those, a third of them are Filipino nationals. A lot of nurses enter into the field in order to go overseas. There are a lot that go to the US and the UK and enormous numbers that go to the Middle East, Saudi Arabia, Qatar, as well as other European countries, Italy, Germany, Finland, countries like that. 

And then Nigeria – I looked at it because the country has one of the worst health systems in the world. Its outcomes are comparable to that of Somalia in terms of maternal health, in terms of child health, even though it’s the richest economy in Africa, it’s the biggest economy in Africa yet has among the worst health outcomes. And so for many years, Nigeria has been flagged as a country that you can’t recruit from, that you should not be recruiting from because they have such a dire health situation, not just because nurses are leaving, but because of various corruption issues in the country. Health care is always complex. It pulls in everything that the country has to offer. And for Nigeria, it’s particularly bad. 

But the nurses are quite highly coveted, they’re well-educated, they speak English. And so when the US and the UK found that they had chronically underinvested in their nurse pipeline, they began pulling from Nigeria to the country’s potential detriment. And so that’s why sort of Nigeria kind of represents this particular slice of a source country that really endangers the health system that they leave behind. 

One of the distinctions to keep in mind here is that there are the individual choices that the nurses make, and they have the right to move for better opportunities, better pay. Particularly in the case of Nigeria, where their pay and conditions are so bad, like you don’t blame them for wanting to leave. But the cumulative effect and the way that that cumulative effect is, is driven by wider economic forces and failures by a government. That’s the thing that we’re looking at. SoI don’t think it’s right to blame the individual nurses, nor is the solution stopping their movement. It’s about improving the conditions both in the source country and destination countries. That’s what we’re trying to look at in the investigation. 

Alvarez: You spoke with a number of nurses about working conditions and the reasons for moving to the United States in the United Kingdom. How did you get in contact with your sources? Did you face any difficulties getting people to talk to you? 

Almendral: Yeah. I mean, it was strangely difficult. I often kind of go for difficult subjects, but this was among the more difficult to source. 

In the Philippines, that was fairly easy. Filipinos in general, they kind of respect the press and are very talkative. And so the story in the Philippines,I just reached out to a couple of nodes of the migration process and then started talking to people, hung around at a training program and started talking to people there, and then ended up following a woman from one of the island provinces to where she ended up in Schenectady, New York. That was fairly straightforward. And from there it got quite difficult. 

In Nigeria, the government is incredibly sensitive about its health care system. You know, for a number of reasons. But they retaliated pretty strongly against both doctors and especially nurses who have spoken out against the healthcare system. And, none of the nurses there were willing to use their name, understandably, because of government retaliation, because of retaliation from the people that they work for. And there are not that many jobs. So it’s not it’s not a great job, but it’s a job. And so they don’t want to be fired, of course. 

And so, I was working with a local investigative journalist there. His name was Ibanga Isine, and he’s very, very good. And, just through advocacy organizations, we made a lot of contacts. I think I spent a dozen days in Lagos and just kind of went from one person to the other, saying, okay, this person is willing to meet. That person is willing to meet. No one was willing to give their name in Nigeria. But the stories aligned and we protected the sources and eventually talked to enough people to get a picture of what was going on there among the nurses. And I also spoke to some Nigerian nurses who had moved to the UK that were more free to talk because they were already in the UK. That was plenty difficult. We were meeting in secret places and  making an effort to stay away from anybody who might be willing to make their lives harder, knowing that they were talking to me. 

But the hardest bit was the Filipino nurses in the US. As I mentioned, they’re the largest number. So they’re often the ones that end up, you know, filing class action lawsuits, who are the most active. To the degree that foreign nurses are trying to do something about this, like systemic exploitation that a lot of the agencies participate in, it’s Filipino nurses that have been doing that. Indian nurses and Nigerian nurses are also in the US, but in smaller numbers. And so they haven’t amassed the number of people that Filipino nurses have, so I focused on them in the US. 

I started in the Philippines. I sent a bunch of messages to sort of mixed results. And then there’s a Facebook group where people talk about – sometimes just how do you save money in the U.S. What do I do with taxes? You know, like really sort of nuts and bolts stuff as well as occasionally the exploitation and this always, in this Facebook group, aroused a lot of controversy. Some nurses, you know, were kind of on the side of just “be grateful. You’re lucky to be here. Don’t rock the boat. Just do what you’re told.” And on the other side, nurses are like, “we don’t deserve this kind of treatment. We should be treated like everybody else,” which is what U.S. law says. 

And so I started messaging people from that Facebook group, over 100 of them. Some of them had left their jobs, left their agencies 5 or 6 years before, but they still were very apprehensive about talking to me. And, it was one of those things where a lot of people didn’t respond. The vast majority, over 100 messages, didn’t respond. A lot of them did respond and they were worried. Is this too dangerous to talk to you? And then another group, you could tell that they wanted to say something and either they were still too afraid or they had signed NDAs, but felt sufficiently wronged that they wanted to get it out there. But, if somebody has signed an NDA, it makes it very difficult to talk to them. But it did indicate that there was, that it was both widespread and continued intimidation of nurses into silence. 

And, eventually, a nurse that I was talking to who had taken an advocacy role in the community sent me an audio recording of an agent who had gotten very angry, because one of his nurses had posted on this Facebook group, about a list of things that the agency was doing that that this person felt was exploitative in various different ways. It was a list of perceived or real wrongdoing by the agency towards the nurses.

The nurse who posted invited me to Tallahassee. So I fly to Tallahassee and they’re all working for this hospital, Tallahassee Memorial HealthCare, which is a beautiful facility. This is a legitimate hospital that people would be happy to be treated in. They had a wall of nurses who are being celebrated for their ethical treatment and things like that. So it’s a hospital that does everything right. But they were but they were working with this agent who had a $30,000 contract breach fee, was constantly threatening his nurses that if they don’t stay in the hospital, whether the conditions are right for them or not, conditions in pay are right for them or not, then he’s going to get their green card taken away, which is a violation of labor and human trafficking laws in the US. You can’t threaten to have it taken away and legally, international nurses can move jobs. Movement of labor is key to the U.S. labor system, it’s one of the few sources of power that workers have. And international nurses can move jobs if they want to. But because it was so hard to keep nurses after the pandemic, they’re supposed to stay at their jobs. This is the agents’ value proposition. Our nurses are going to stay, and the way that they get them to stay is with these high contract breach fees, these threats, and it preys on the nurses. 

I emailed DHS, Department of Homeland Security, I’d emailed the Department of Labor, I’d email the Philippine consulate that’s supposed to look after Filipino workers overseas. And everyone was just pointing their fingers at each other. And this was a fundamental issue with this kind of labor mistreatment. No one takes responsibility to enforce it. So DHS was like, you need to ask the Department of Labor Department. They said you need to ask DHS. Have you reached out to CBP? What about the State Department? Nobody. It’s no one’s job to worry about this. But the US laws already exist. You know, often, you know, the rare cases that these class actions are adjudicated. It’s because they’re found to be human trafficking or forced labor violations. And so, but because there’s not an agency to enforce, it continues to happen. And then when the economic forces make it all the more tantalizing to have a captive workforce as part of your nursing workforce come in like they did after the pandemic. Then it all sort of explodes again. 

Alvarez: What were your interactions with, both the agencies and government institutions like? Did you face any pushback from?

Almendral: I think that, via the US institutions, no one wants to take responsibility. And I think that that’s such a big part of it. But they weren’t even engaging in the issue. Just kind of endless finger pointing. And, the agency, I was kind of trying to lay low until we’d collected the information and the nurses were comfortable with me approaching them. A few of the nurses that I was talking to escaped the agency. They sort of took vacation days and then packed up all their stuff and had it shipped to another state. And once that happened, they felt a little bit more comfortable with me approaching the agency. 

Shortly before this was published, the nurses filed a class action lawsuit against the hospital, which was quite unusual. Often you file against the agency. But the lawyer felt that, that there was enough collusion or that the hospital was involved in a lot of the kind of abusive practices that the agency was carrying out to, to include them in this class action lawsuit. 

Alvarez: What was the most challenging part of the reporting process? 

Almendral: I think finding the right sourcing was challenging. I already talked about it, and I felt that the institutional and systemic problems were complex, but available to look up and talk to experts and things like that. But I thought that the story would really come alive with the right people. I wanted to find people who are going through it at the time that I was talking to them, as opposed to someone who has filed a class action lawsuit for something that happened a couple of years ago. I wanted to talk to people who were going through it, who felt the fears at the time, who felt that intimidation at the time, how they made the decisions. This was a very post-pandemic experience that they were having. Because, you know, that was the sort of economic linchpin for why things have exploded in terms of exploitation in the last couple of years. And so I really wanted to find the right people. And, and that took a while. I mean, there, as I mentioned, there are a lot of people who weren’t willing to talk to me, and there were a lot of people who had gone through in the past. One of them was incredibly good at collecting the contracts and receipts and things like that which bolster the reporting. She was both organized and willing to share all of this and it made an enormous difference in the impact of the story and, and it’s information that she was collecting essentially for her lawyer, but sharing with me as well. So, getting the people right, I think, was probably the hardest part. 

Alvarez: And since the series was published, have there been any updates or impact as a result? 

Almendral: I mean, the class action that they filed. I believe that was maybe April or June 2023. There have been a lot of lawyers that have been reaching out to me, as well as nurses and who are saying like, okay, this is, you know, we’re going through this to pass the information around. I think the article was referenced in another class action lawsuit there, unrelated to the nurses that I covered. I honestly wish I could say that now suddenly the State Department or Justice were cracking down on this because, I think they’re probably the ones that are in the best position to do it but unfortunately that hasn’t happened yet. 

Alvarez: My last question, this is obviously like a really complex, like, worldwide story. Do you have any advice for journalists who want to, like, tackle these big, interconnected issues or things that you wish you would have known before you had started it?
Almendral: I mean, I think my advice for this is a piece of advice I often give people is just take the big swing. You know, it’s a migration story. It was a global story. And I just felt like I needed to be able to tell it in a global way. I wanted all five countries represented, you know, for five continents. Like, I think that that’s because I thought that that’s what reflected the nature of, the nature of the issue. And, and I think that, and this is a question I get a lot, you know, like some version of it – how did you decide to do it this way? Why the scope? And I think that the story, the story kind of determines the scope. Figure out the best way to do it, try for that and then adjust accordingly. If you don’t have enough money, go in and try to get enough money. If not, take a country off your list. But I think just just go for the biggest swing that you can. And, and I’m, I’m so grateful that we were able to do this as expansively as I originally envisioned it. You know, like a migration story I think is always best told, from both sides of the migration stream. But, you know, you can’t always do that. Or maybe the story is, you know, it was more the passage or something, but, yeah, I think just try to figure out what the best version is and see how close you can get to that.

About the reporter