Illustration by Salma Eldeeb
Article by William Borges
It was the early 2000s at the University of California-San Francisco (UCSF). In the first year of her graduate work in medical sociology, Jennifer Nazareno was summoned by her senior faculty advisor. He wanted to see her in his office. It was time to talk about Jennifer’s Ph.D. thesis topic selection. Nazareno recalls that her advisor was an older white gentleman, clearly learned with an aura and presentation screaming “Ivory Tower.” His bookshelf was filled with classics from the western tradition. Nazareno was nervous; this meeting could very well determine the rest of her career. If she didn’t end the meeting with a thesis topic she was genuinely interested in, that could mean disaster for her future.
However, the meeting surprised her. Rather than shutting her down, as Nazareno had feared he would do, her advisor was very open-minded. “He asked me: ‘What is the fire in your belly?’ and ‘Why is this important to you?'” Nazareno recalls.
She thought hard for a moment, she says, and then confidently answered.
“I think the story of immigrant labor in healthcare has never been told at the level of academia,” she said. “In the Ivies or the elite universities, we don’t hear the stories about how immigrants contribute to our US economy and our healthcare industry.”
Nazareno is the daughter of an immigrant Filipino nurse who became an entrepreneur and built long-term care businesses. She felt compelled to capitalize on this scholarly opportunity to tell her story and the story of many others like her. She says this kind of academic research matters because of the soft power that academia holds in society in determining right from wrong–what is acceptable and what is not. If societal groups are not properly represented within the discourse in these circles, it can perpetuate discrimination, resentment, and fear.
Since deciding on the focus of her dissertation, Nazareno has become recognized globally as a pioneer in the study of immigrants in healthcare entrepreneurship. In particular, she studies Filipino women immigrants who create and run long-term care businesses in the US. She is tenure-tracked at Brown in Public Health and is an innovator in the field: in April 2019, Nazareno founded the Filipino Health Institute at the Brown University School of Public Health, which supports research and advocacy for Filipino health and has a partnership with a university in the Philippines.
Working on the thesis
Nazareno chose to follow a path different from others in her class, who at the time mostly studied either Alzheimer’s or breast cancer because these were two well-funded areas at UCSF. She had rejected spending four or more years of her life studying something she wasn’t passionate about.
“I was taking a chance because nobody funds this kind of research; it’s not like the NIH [National Institute of Health] is funding immigrant labor research. It didn’t matter. I just said, ‘You know what? I’m just going to do it,’” says Nazareno. Like many Filipino women before her, Nazareno was now following an entrepreneurial path–only this time, it was in academia. Her Ph.D. thesis, the first of its kind, helped define an academic area of focus within immigrant studies.
At the time, Nazareno found the project both exciting and daunting. She first turned to a book by Catherine Ceniza Choy, one of Nazareno’s academic advisors, called Empire of Care. The book chronicles the colonization of the Philippines by the United States from the early 1900s.1 The U.S. built medical hospitals throughout the Philippines, which spurred the creation of a skilled Filipino nursing labor force. Over time, the U.S. recruited these trained nurses for use as cheap care labor in America, even creating special visa programs for registered Filipino healthcare workers called EB3 visas.2 According to the largest nursing union in the United States, National Nurses United, Filipinos make up approximately 4% of registered nurses in the United States.3
Nazareno decided to write about the inequities and history of these nurses that came as a cheap labor force during a time in the U.S. in the 1950s and 60s when the U.S. faced nursing shortages.4 With the medical industry booming, immigrants filled the gaps.
“What happens afterward?” Nazareno asks. Nazareno argued in her thesis that Filipino women have “gone on to build businesses in the healthcare industry, particularly in long-term care.” Filipino nurses, particularly in coastal areas like California, New York, and Texas, went on to build home healthcare spaces, nursing homes, and assisted living facilities because these women were disproportionately responsible for taking care of those in long-term care. This trend was mostly spurred by Filipino women’s experience in administering care, friendships in the long-term care industry, and passion for caring for those in long-term care settings.
“If you think about the hierarchy of healthcare, long-term care is like the step-sister of healthcare. You have the immediate healthcare system and long-term care is for aging adults and they’re not in serious need of healthcare; they’re not in the emergency room; the system is not as focused on these folks,” Nazareno said. Due to the unattractive nature of long-term care, an opportunity structure was created and immigrants stepped in and became entrepreneurs.4 In addition to this, healthcare policies in the United States at this time, including the passage of Medicare and Medicaid in 1965, created a deficit in long-term care funding.5 These conditions allowed small, private, immigrant-owned long-term care businesses to fill the gaps.
“When you do these interviews with women, there are spaces of agency. Even though these women were working late-night shifts at a hospital, they were thinking: ‘I want to become an owner and operator of something. I want to be able to use the education that I got in the Philippines from a westernized hospital to become a nurse,'” said Nazareno. The unique opportunity structure allowed these Filipino women to create businesses, which would lead to social mobility for themselves and their families. According to Nazareno, many of the women she interviewed felt they were following the “American Dream” to build businesses and help fix a fractured national system.
Picture this: an immigrant Filipino nurse is forced to work the night shift in an American long-term care facility. She keeps hearing about how people she knows have started businesses in the long-term care space. She asks around for help and soon she is on the path to starting her own long-term care business. According to Nazareno’s interviews, this was the story of countless immigrant Filipino nurses in the US.
In her dissertation, Nazareno identified fifty Filipino women who owned healthcare businesses around Southern California. Nazareno worked to build trust within the community she sought to study, finding subjects through word-of-mouth. She conducted in-depth interviews. The community came to trust that she would represent their stories in a way they would see as accurate.
“There was this ethnic economy of nurses sharing resources, helping each other to build businesses and healthcare organizations so they could better support their families,” Nazareno says. Instead of competing internally, members of the community embraced one another and built on the success of others to forge new opportunities. Together, they were able to overcome financial and social limitations and rise as an entrepreneurial class.
“It is not just a story of inequity and injustice and oppression. There is also space for opportunity, mobility, and this sense of pride in being an owner. I wanted to bring that to light,” Nazareno says. Through her experience interviewing these founders, Nazareno learned that the women were very proud of what they had managed to build. They did not want to be portrayed as people to be pitied.
The culmination of the thesis
Nazareno realized the impact of her work when she went to her first academic conference, the Asian American Studies national conference. She was a young Ph.D. student and presented one of her chapters on a panel. She was pretty nervous, she says.
“The moment I will never forget was when someone from the back came up to me and said: ‘This is my history. I have never heard someone talk about it and break it down the way you did. You brought to light the history of my family that I just have never read about. I have never really thought about it as complex as you have’,” Nazareno recalls.
She says she saw that her work was validating for some Asian-American students in the audience. Students mentioned that they had always known about Filipino healthcare entrepreneurship because of their mothers and aunts. But they’d never learned about it in academic settings.
“Even if I am speaking to that one person, I want to shed a light on this topic and say, ‘I see you. I am documenting the history that has brought us to this country and the contributions your family members have provided for this country. It is documented and talked about. I teach about it at Brown University, an Ivy League institution,’” Nazareno says.
Brown University
Nazareno is now the Barrett Hazeltine Assistant Professor of the Practice of Entrepreneurship and Associate Director of the Online Masters’ of Public Health Program at Brown University. Her journey has been an inspiration to many students and families who see her as a symbol that their stories matter in academia. Students randomly email her from all over the world, telling her “‘I read your paper and I want to build on it’ or ‘I quoted your work.’” “That always means a lot to me,” Nazareno says. At Brown, she teaches a class on immigrant entrepreneurship and classes in public health. Soon, she will teach a new class in healthcare entrepreneurship to highlight future issues in healthcare and how entrepreneurs can work to solve these issues.
“I’ve brought together researchers and grad students to talk about Filipino healthcare and immigrants. I am proud of that. We have a partnership with one of the universities in the Philippines,” Nazareno says, referring to the Filipino Health Institute that she helped build at the School of Public Health.
A nervous graduate student became an Ivy League professor and entrepreneur. In doing so, she told her community’s story and followed the “fire in her belly.” Her work has included immigrant entrepreneurs in the conversation within elite academic circles. She has highlighted the entrepreneurial hustle of Filipino founders in healthcare and provided a voice to generations of women who fought for their futures.
References:
- Choy Catherine Ceniza. Empire of Care: Nursing and Migration in Filipino American History. Duke University Press 2003.
- Tancinco, Lourdes S. “Visas Available for Filipino Registered Nurses, Physical Therapists & Other Healthcare Workers (Including Caregivers).” Tancinco Law, P.C. – Trusted. Established. Dependable., 26 Sept. 2020. https://www.tancinco.com/visas-available-for-filipino-registered-nurses-physical-therapists-other-healthcare-workers-including-caregivers/.
- Econar, Fruhlein Chrys. “For Generations, Filipino Nurses Have Been on America’s Front Lines.” CNN, Cable News Network. https://www.cnn.com/interactive/2021/10/health/filipino-nurses-cnnphotos/.
- Donzé, Pierre-Yves, and Paloma Fernández Pérez. “Health Industries in the Twentieth Century.” Business History, vol. 61, no. 3, 2019, pp. 385–403. https://doi.org/10.1080/00076791.2019.1572116.
- “Long-Term Care in the United States: A Timeline.” KFF, 11 Sept. 2015. https://www.kff.org/medicaid/timeline/long-term-care-in-the-united-states-a-timeline/.