Empire of Care: Nursing and Migration in Filipino American History

by Catherine Ceniza Choy

In western countries, including the United States, foreign-trained nurses constitute a crucial labor supply. Far and away the largest number of these nurses come from the Philippines. Why is it that a developing nation with a comparatively greater need for trained medical professionals sends so many of its nurses to work in wealthier countries? Catherine Ceniza Choy engages this question through an examination of the unique relationship between the professionalization of nursing and the twentieth-century migration of Filipinos to the United States. The first book-length study of the history of Filipino nurses in the United States, Empire of Care brings to the fore the complicated connections among nursing, American colonialism, and the racialization of Filipinos . Choy conducted extensive interviews with Filipino nurses in New York City and spoke with leading Filipino nurses across the United States. She combines their perspectives with various others—including those of Philippine and American government and health officials—to demonstrate how the desire of Filipino nurses to migrate abroad cannot be reduced to economic logic, but must instead be understood as a fundamentally transnational process. She argues that the origins of Filipino nurse migrations do not lie in the Philippines' independence in 1946 or the relaxation of U.S. immigration rules in 1965, but rather in the creation of an Americanized hospital training system during the period of early-twentieth-century colonial rule. Choy challenges celebratory narratives regarding professional migrants’ mobility by analyzing the scapegoating of Filipino nurses during difficult political times, the absence of professional solidarity between Filipino and American nurses, and the exploitation of foreign-trained nurses through temporary work visas. She shows how the culture of American imperialism persists today, continuing to shape the reception of Filipino nurses in the United States.

Genres: History, Nonfiction, Health, Race, Feminism, Labor, Asian American

272 pages, Paperback

First published January 10, 2003

About the author

Catherine Ceniza Choy's most recent book is Asian American Histories of the United States from Beacon Press in their ReVisioning History book series. The book features the themes of anti-Asian hate and violence, erasure of Asian American history, and Asian American resistance to what has been omitted in a nearly 200 year history of Asian migration, labor, and community formation in the US. Choy argues that Asian American experiences are essential to any understanding of US history and its existential crises of the early twenty-first century.

An engaged public scholar, Choy has been interviewed and had her research cited in many media outlets, including ABC 20/20, The Atlantic, CNN, Los Angeles Times, NBC News, New York Times, ProPublica, San Francisco Chronicle, and Vox, on anti-Asian, coronavirus-related hate and violence, the disproportionate toll of COVID-19 on Filipino nurses in the United States, and racism and misogyny in the March 16, 2021 Atlanta spa shootings.

The daughter of Filipino immigrants, Choy is Professor of Ethnic Studies at UC Berkeley. Her leadership experience includes having served as Associate Dean of Diversity, Equity, Inclusion, Belonging, and Justice in UC Berkeley’s Division of Computing, Data Science, and Society, Associate Dean of Undergraduate Studies Division, and Department Chair of Ethnic Studies. She received her Ph.D. in History from UCLA and her B.A. in History from Pomona College.

Reviews

[Mallory · Rating 5 out of 5]

Read this as part of a research project for my history of medicine class. Probably the most thorough and respected work on Filipino nursing migration to date. Choy does an incredible job connecting the Philippines’ colonial history to the healthcare labor crisis the nation is seeing today. An academic read that is digestible for any reader interested in the topic. I especially appreciated Choy’s detailed primary accounts from Filipino nurses of the time and how contemporary media portrayals affected their daily lives (i.e. the Speck murders). A great resource in cultural competency for those working in healthcare!

[Trish (readtmc) · Rating 5 out of 5]

I learned about this book when I saw the author at a Filipina networking conference a few years back. This is pretty much the only book around about the phenomena of Filipina nurses in America. Empire of Care gave me a historical context in which my mom came to the United States. For that reason alone, this is a standout. Also, Choy provides a transnational perspective, conducting research in the Philippines and the US, and examines the complex history of colonialism, imperialism, and immigration between the two nations.

[Tin · Rating 5 out of 5]

I see events that laid the groundwork for my existence detailed through the lens of policy and anecdotes and historical context. The threads of fact woven in my head with my mother’s story leaves a weird taste in my mouth.

[Rainier Moreno-Lacalle · Rating 4 out of 5]

Choy's book gave voice to millions of nurses in the US and the rest of the world.

[Ananoelle]

intellectualizing my grief, very incredible to me that research happens

[maddy ruiz · Rating 4 out of 5]

read for my final essay

[a · Rating 4 out of 5]

deeply essential and informative text in filipino american nursing history

[Jason H · Rating 5 out of 5]

Recontextualizing the relationship between the “professionalization of nursing” (1) and the migration of Filipino Americans, Empire of Care, Catherine Ceniza Choy’s examination of U.S. imperialism and its role in the commodification of the Filipino citizenry, highlights the insidious nature of colonial subjugation as a system that perpetuates economic disparities through the “institutionalization of migration” (4). By underscoring the parallels between the United States’s use of Western medicine to justify it’s domination of the Philippines and those of other imperialist powers as well as the discrimination with which Filipino nurses were met in the United States, Choy systematically refutes the notion “that the United States has a national character distinct from other colonial powers” (21).
Dividing her work into three parts, each comprising of two chapters, Choy frames her exploration of nursing and migration in Filipino American history chronologically. Establishing the foundations of American discrimination against Filipinos, Choy uses the beginning of the book to highlight the “construction of Filipino bodies as weak, diseased, and therefore racially inferior” (21). As Empire of Care progresses, Choy illuminates the ways in which this early racialization continues to manifest itself in the treatment of Filipinos by American institutions. In her discourse on the regulation of Filipino bodies, Choy notes the instrumental role of American medicine as an extension of the paternalistic attitudes of the West. Choy writes, “American imperialism in the Philippines [...] utilized the ‘white man’s burden’ overseas, to create racialized hierarchies of peoples” (21). As she examines early attempts to introduce American nursing practices to the Philippines, Choy offers a deft, intersectional exploration of the role of American women in the racialization of Filipinos. Noting that “nursing education [...] provided white American women with a sense of purpose in the colony” (23), Choy acknowledges the dearth of occupational opportunities for all, even Western women at the time. Choy goes on, however, to illustrate that while the gender expectations for American women relegated them to a limited number of jobs, their race enabled them to exert power over Filipinos in their training of Filipino nurses, which “nurtured empire as it reinforced many of the racial functions and beliefs of Western medicine”(23). This is particularly apparent in the case of Lavinia Dock, a “passionate advocate for Social reforms in the Progressive Era and women’s suffrage” (24) whose writings “echoed imperial narratives that justified U.S. colonialism in the Philippines on the basis of Filipino’s poor health” (24). By coupling a reference to Dock’s participation in American reform movements with her writings that “echoed imperial narrative” (24), Choy offers a powerful indication of the severity of the American racialization of Filipinos. As she writes of American colonialism resulting in Filipinos following “trends of professional nursing in the United States” (56), Choy establishes the conditions that would allow for the mass migration of Filipino nurses to the United States during the Cold War.
Writing of the “thousands of Filipino nurses” (66) who eagerly participated in the U.S. Exchange Visitor Program, Choy calls back to her earlier discussion on colonialism by attributing their eagerness to “racialized hierarchies [and] and a prestige partly informed by the complex intersecting outcomes of Spanish and U.S. colonialism” (66). Moving seamlessly between her earlier discussion on colonialism and the eventual migration of Filipino nurses to the United States, Choy makes a compelling case for spectres of the colonial past informing the present. As Choy explores the Filipino American experience later in the century, she writes that the State Board Test Pool Examination was found to be “racially biased” (182) by the California Department of Consumer Affairs. Though Choy continues to note the struggle of Filipino nurses well into the second half of the twentieth century, she highlights their boldness as well. Writing of their organization into the “Foreign Nurse Defense Fund” (183), Choy underscores their increasing resilience to the forces of racial subjugation. Although the rise of Filipino nurses is marked by Western colonialism, Choy brings her book to a close by offering a Filipina’s fearless reaction against the imperialist past with “we are sick and tired of being subservient and culturally non-aggressive” (184).

[Jensen · Rating 5 out of 5]

“Empire of Care: Nursing and Migration in Filipino American History” is a book that brings together key themes in Filipino American history through oral histories and primary sources. Catherine Choy divides her books into three parts: the first part is about the circumstances back in the Philippines and the factors associated with why nurses chose to go abroad, the second part discusses the methods in which Filipinos went to the US and how their experiences were, the last part of the book discusses the reasons why Filipinos stayed and the problems associated with living in the US. One of the crucial points Choy makes with respect to Asian American history is: “the significance of Filipino migration in…Asian American historiographical discourses about the mid-twentieth century, debates that have focused mainly on Japanese American relocation and internment, restrictive immigration legislation in the McCarran-Walter Act, and the repeal of the Chinese exclusion Act” (63). Choy argues that the immigration of a skilled and educated class is significant not only because of the difference in labor force but also because of the consequences of coming to the US.

One thing Choy does very well is how she divides the book. The events and oral history are organized well chronologically throughout the whole book. However, she cleverly uses different pieces of the oral histories to emphasize certain themes and points. Choy also utilizes many different information sources outside the oral histories including: newspapers, posters, texts from other institutions and in different languages, and photographs. To me, her presentation of the history made the information very tangible especially with visuals such as posters and pictures. Understand her four main arguments throughout the text were easier.

I want to highlight one particular troubling aspect of the book. One of the weaker arguments of Choy is her second argument: “the desire of Filipino nurses to migrate abroad cannot be reduced to an economic logic, but rather reflects individual and collective desire for a unique form of social, cultural, and economic success obtainable only outside the national borders of Philippines” (7). Already there’s a small problem in that she says economics is not the sole reason yet she mentions “economic success” later in her argument. Furthermore, Choy dedicates an entire chapter how economic conditions were greater in the US than they were in the Philippines. “They compared salaries, nursing facilities, equipment, and research in the United States with that of the Philippines and became frustrated and disappointed with the latter” (86). Later in the chapter, Choy even find information about the working conditions of Filipino nurses in Europe. Let’s just say that it was even more favorable there. (92) My point is that I agree that economics is not the sole reason that Filipino nurses went abroad. However, Choy doesn’t seem to give me another other reason to think otherwise.

Choy is constantly emphasizing the fact that while this book falls within the umbrella of Asian American studies; the Filipino nurse experience differs greatly from that of other Asian Americans. First, unlike the waves of Chinese and Japanese immigration, Filipino nurses were actually, to some extent, invited to the US to fill a severe labor shortage. Unlike other Asian immigrants, many Filipino nurses had some sort of college education or training in order to enter the US. One of the points I find most interesting is how Choy argues that for some nurses, the conditions (and pay) in the US were much better than in the Philippines. All of these points are very different that other Asian American immigrants.

Overall, I was very pleased with the book and research. Choy presents her research in a very accessible way for the reader and also supports most of her arguments. At points, there are weak spots. However, I argue that it is the fault of the limitation of language rather than lack of research. The structure and organization of the book is excellent. I highly recommend this book to anyone interested in an unique immigrant group.

[Vernice · Rating 5 out of 5]

With Empire of Care, Catherine Ceniza Choy presents a historical narrative and framework for the migration to and settlement in America of Filipina nurses, a phenomenon, while recognized largely after 1965, has been going on since the late 19th century. In doing so, Choy offers another perspective of the immigration of Asian women to the US that is different from the notion of subjected prostitutes or picture brides dependent on their husbands.

Choy places the stories of Filipina nurses within in a transnational framework that reflects, in the women’s individual experiences, the larger social, political and economic dynamics at play between America and the Philippines. One such example that Choy highlights is the historical and legal connotations that help prepare and accelerate the mass migration of Filipina nurses to the US. In terms of preparation, Choy highlights the strong moves by the American government to help establish formalized nursing education and curriculums in the Philippines in the wake of the Spanish-American and Philippine American Wars. It was through such curriculum, emphasizing western practice and studying abroad to complete one’s education, that Filipina nurses were first able to come to America, although in small numbers. Later, in the wake of World War II and the Cold War, the migration of these women is (unknowingly) accelerated by the introduction of the Exchange Visitors Program, followed by the Immigration Act of 1965 which gave preference to “necessary” labor professionals, such as nurses.

Such efforts and legal actions allowed Filipina women to enter rather differently from their Chinese and Japanese counterparts of the past eras, as they entered as “welcomed” professionals, whose livelihoods and statuses were not dependent on that of a man. In such ways, Filipina women are shown to have more agency, able to shape more freely their experiences and circumstances, although still entering as a form of desired labor. This agency is shown in, for example, the ways in which the Filipina nurses organize themselves together, while not all united, to form nursing associations that advocate for better standards for recruitment and licensure. The formations of the Philippine Nurses Association of America or the Foreign Nurse Defend Fund show these women taking charge for themselves on a national scale. This, in turn, reflects the one of the ways in which Asian American women have come together and fought for their standing as dynamic figures within the American society, essentially shaping their own histories.

While Choy tries to provide a comprehensive effort to historicize the lives of Filipina nurses, there are some details that would best be elaborated on. Namely, in emphasizing Filipina nurses as individual and dynamic figures, she seems to only highlight the experiences of “bachelorette” women or women who come and establish themselves on their own, while the rest of the family may be in the Philippines. Choy seems to neglect the idea of the establishment of a recreated family structure in the US, suggesting the immigration of the Filipina nurses’ whole families or the formation of a family through marriage to others. As a result, Choy seems to miss out on the opportunity to connect the mass migration of the Filipina nurses during the 19th and 20th centuries to the status of the Filipino and Filipino American community in the 21st century. The implications of this mass migration for future generations are left out, possibly, as pushed forward by Choy, to be for future study.

At end, Empire of Care presents a compelling historical context for a contemporarily recognized phenomenon of Filipina nurses that reflects agency in the dynamic story of one class of Asian American women. While presented to a larger academic audience, this book seems to be most suitable for those who wish to learn about the ranges of women’s immigration to the US and the establishment of Asian American organizations and communities.

[gmg86 · Rating 4 out of 5]

Catherine Ceniza Choy’s “Empire of Care: Nursing and migration in Filipino American History” offers an insight into the migration of Filipina nurses to America during the twentieth century. She effectively pairs a historical narrative with oral histories, producing a work that is both informative and accessible. Choy argues that this major migration is rooted in the lasting effects of American imperialism in the Philippines, a statement she supports with a complex and interesting argument.
According to Choy, the move many Filipina women made to the United States as nurses occurred due to much more than simple economic ambition—they were motivated by something deeper than a chase for economic opportunity. America’s imperial relationship with the Philippines drove the migration on a cultural level, as it served to romanticize American work and educational conditions, to “Americanize” both the professional training nurses received in the Philippines and the general culture of work on the archipelago, and to increase the prevalence of English. These factors, which came out of the largely one-way power relationship characteristic of imperialism, all served to make America seem very attractive.
Choy’s argument appears complete and effective because it is honest. She consults the situation from a diverse range of perspectives, including those of Filipina nurses, American nurses, Filipino leadership and its counterpart in the United States, and several others. Allowing the reader to consider the phenomenon from so many perspectives strengthens her overall argument because in understanding each party’s rationale, we can ourselves identify the imperialist tendencies she posits are present.
An example of her effective use of diverse perspectives is in explaining the motivation of American travel agencies’ distinct effort to lure Filipina nurses to the United States through “pay later” arrangements. These arrangements were paired with advertisements in which the nurses were guaranteed to “meet interesting people, and come back, a more interesting you” (67). It is not difficult to understand how American travel agencies’ benefited from a notable wave of immigration that involved an intricate network of paperwork and administrative permission. In highlighting what the agencies stood to gain, however, Choy allows us to see the imperialism in their promise. These advertisements implied that time abroad would allow the women to become “more interesting,” supporting her argument that American imperialism affected Filipino culture in that it idealized a life spent in the United States.
The picture she paints is not only accessible to her readership because she consults many perspectives, but also because she establishes its relevance. Through illuminating the dynamism of the interplay between Filipina nurses and the hospitals for which the worked, other American nurses, and the unions both Filipina and American nurses formed, the mark this migration left on American health care is clear. Female nurses from the Philippines filled a significant hole in America’s ability to provide for its citizens, and did not accept injustice without a fight. Because of Choy’s demonstration of the nurses’ prevalence across America and their efforts, though sometimes unsuccessful, to make their voices heard through formal organization, it is impossible to close this book thinking the effect of Filipinas to American healthcare has ever been negligible.
Catherine Ceniza Choy’s “Empire of Care” is valuable as an engaging source of information about the migration of Filipina nurses to the United States as a result of American imperialism in the Philippines. Though her argument can in fact be repetitive at times, I finished the last chapter of this text feeling enlightened to a decidedly notable phenomenon in American history.

[David · Rating 4 out of 5]

In her extensive exploration of the plight and conditions faced by Filipino nurses in the 20th century, Catherine Choy embarks on an analytical voyage through American Imperialism, international connection, cultural implications, and gender identity. Indeed, Empire of Care represents a triumph in gender-centered transnational study.
Within a span of 20 years in the mid 20th century, the Philippines supplied the United States with over 25,000 nurses. In some places, Filipino nurses comprised of nearly 60% of the nurses employed. How did this come to be? Choy argues that institutions set into motion by American Imperialism are to blame. Under the guise of civilizing the Philippines by disseminating Western ideals of hygiene and medicine, thus validating their imperial presence, the United States set up several nursing schools in the Philippines. Yet these schools were not merely wellsprings of medical knowledge. Rather, they sought to prepare Filipino women to work in America, ultimately teaching them American culture and English in addition to basic medical practice. It is clear, then, that these for-profit institutions were ultimately aimed at the systematic export of nurses to America rather than the proliferation of Western medicinal knowledge.
Choy is privy to the role that economic considerations may have played in Filipino women’s decision to immigrate to the United States as nurses. She does not fail to mention that such women often earned salaries up to twenty times the amount that they could have expected in the Philippines. But Choy also convincingly argues that other factors, namely cultural ones, exerted significant influence. Some Filipina women simply wanted to travel, to explore the world. Some immigrated with an eye on social mobility. Others came to believe the dogma dished out in nursing school, and so have an overly romanticized mental image of what it was to work in America.
The fallacy of this image was likely rapidly discovered by those who immigrated. Even in the face of a significant nurse shortage, the ANA sought to bar the entry of more Filipino nurses. Filipino nurses could also expect unequal pay, strong racial hierarchy, and other strong forms of discrimination. Such discrimination is perhaps most evident in the case of Filipina Narciso and Leonora Perez were charged with poisoning patients. Though ultimately acquitted, this episode was used to illustrate how Filipino nurses were listed as the ‘other’ by mainstream American society, thus underscoring its unwillingness to accept such nurses as true citizens.
Overall, Choy presents a convincing, well-researched argument. Her use of an extensive body of oral histories is augmented by intensive review of newspapers and archived government documents from both the United States and the Philippines. This combination is especially potent because it served to both provide the context and significance of the oral histories, rather than allowing them to stand in isolation. One flaw was the monolithic approach to transnational imperial medical institutions. Choy’s argument may have been more compelling if she had provided data on another ethnic group involved in the medical field, or even looked at today’s exceptional prevalence of Indian immigrants in medicine. However, Choy’s book still represents a significant contribution to the understanding of transnational imperial medical institutions, and would thus be of great interest to scholars passionate about the history or medicine, migration patterns, or even imperial institutions.

[Paul Ocampo · Rating 4 out of 5]

i could never understand why my parents kept pushing me into the medical field (even after i quit premed, they egged me to be a nurse instead) until i read empire of care. this book allowed me to understand the deep impression the profession has in filipino culture. it's a comprehensive study that includes my own family's migration history to the united states (as my aunt, the first in our family to come to the u.s., is a respondent/informant).

should be read by the whole cast of desperate housewives.

[Becca · Rating 4 out of 5]

Great introduction to the history of Filipino nurses' experiences and reasons for migrating to the U.S., United States' immigration laws, and Philippine government rhetoric about national duty. I felt there was too little focus on political situations that influenced the in laws regarding immigration, though, as well as economic shifts that would have influenced perceptions of immigrants.

[Mimi]

I really loved this book.