Roberta Boltz keeps her doors unlocked at night. The former coal mine worker says it is just one perk of living in the small Pennsylvania town of Hegins.
But last Christmas morning, she had her first epileptic seizure, and her only worry about rural life took center stage: access to health care. There is no hospital in her community of 812 residents, and she says she does not trust the one closest to her.
"I've heard people say they wouldn't send their dog to that hospital," Boltz said. "They're so understaffed."
Seated upright in a platinum nightgown, with gauze covering her thin forehead, Boltz recently made the one-hour commute to Danville, Pennsylvania's, eight-story, 559-bed Geisinger Medical Center to receive care, as she has done during several critical life moments. Geisinger treated her son's Crohn's disease when he was a child, and more recently, after her husband suffered a heart attack.
Located beside a 300-acre forest, Danville is not much more urban than Hegins. With a population of 4,631, it could not by itself support a hospital this size that serves all of central Pennsylvania and has grappled with its own issue of filling medical staff positions.
Geisinger has tried to solve its own staffing problem by hiring immigrants from Jamaica, India, the Philippines, South Korea, Kenya, Cameroon, Nigeria, Ghana and others — many of whom have come to live in a borough (town) that is 94% white.
In interviews with VOA, Geisinger staff referred to the nursing shortage crisis as one of its biggest supply-and-demand challenges. Despite being the region's "employer of choice," they say local talent recruitment alone has fallen short of their needs.
The entire United States faces a massive shortage of health care professionals over the next decade, including up to 120,000 physicians by 2030. One-third of currently active doctors in the country will reach retirement age during that span.
Unless the health care workforce gap is addressed, rural areas are likely to bear the brunt of its effects, says Andrew Lim, director of quantitative research at New American Economy, a bipartisan research organization.
"If you look at urban areas, there are over 200 doctors per 100,000 people. But if you look at rural counties, the number of doctors to go around is much less — something like 82 for every 100,000," Lim told VOA.
The population of Danville more than doubles when Geisinger — with its 6,200 employees — is fully staffed. Among the workers: 415 internationally trained physicians and 57 foreign-born registered nurses.
"Not only is Geisinger trying to recruit (international nurses), many other health systems are," Julene Campion, vice president of human resources at Geisinger, told VOA. "We could probably use another 100 easily (across the Geisinger network), but there aren't enough available."
"We've outgrown our ability to supply," added Crystal Muthler, Geisinger's vice president of nursing — a 30-year veteran.
The community's needs, combined with an aging workforce, she says, are ultimately what led Geisinger to reevaluate its staffing model and implement an international nurse initiative in 2018.
"We have to look at how we attract people to the area," Muthler said.
According to U.S. Bureau of Labor statistics, health care is projected to be the largest-growing sector of new job creation over the next decade, accounting for more than 1.3 million new jobs, roughly one-third of them for registered nurses.
But for those looking to find opportunity in the United States, while helping fill a critical shortage, obstacles remain.
It is unclear whether Trump's new immigration plan, announced on May 16, will help health care staffing. The merit-based system would favor immigrants who fall into broad "high-skill" categories, including "professional and specialized vocations," at the cost of family-based and humanitarian immigrant visas.
'Kindness is my language'
Even now, foreign-born health care professionals represent more than their share of the overall U.S. population; 14.7% of nurses and 22.7% of health aides are immigrants, according to NAE, compared to 13.7% of the population as a whole.
Thirty-five-year-old Hemoy Drummond, a recent Geisinger hire from Jamaica, has an EB-3 employment-based immigrant visa. She has 13 years of experience as a registered nurse.
"I was very nervous. It was a new setting, new expectations," Drummond said. "But when I got here, I realized that people are kind. ... I said, 'That's my language.'"
Danville, with its lush hillsides and nearby cornfields, reminds her of the sugar cane fields her father harvested in her native Clarkstown, Jamaica. Her community is safe. The mother of two can walk home alone after a late shift.
The nursing work is easier in Danville than in a short-staffed Montego Bay hospital.
"It's easier to care for four to six (patients at Geisinger) than 18 (in Jamaica)," Drummond said. "I love to talk with (patients) that extra minute."
Willing to stay
In town, locals generally welcome — or at least tolerate — their new international neighbors.
"They're magnificent!" remarked one woman on Danville's Mill Street. "We'd be stupid not to let them into our country."
Two hours southeast of Danville, along the Susquehanna River in Chambersburg, Pennsylvania, views are more mixed. A foreign-born doctor described Chambersburg as "where blue meets red."
Yet Chambersburg Hospital, too, has been trying to solve its health care staffing problems with immigrants.
In Chambersburg, population 20,878, VOA spoke with 10 foreign-born doctors from India, Pakistan, Bangladesh, Nigeria, Poland and Hungary. Nine of them expressed a willingness to remain in rural Pennsylvania long term, including Indian physicians affected by a per-country green card backlog that has placed their families' future in limbo.
U.S.-born physicians do not want to go to Chambersburg, much less stay, explained Dr. Golam Mostofa, chairman of the department of hospital medicine at Chambersburg Hospital.
"Fifty percent of our hospital medicine physicians are foreign graduates," Mostofa said. "If we interview 10 American graduates, maybe one shows up."
Dr. Muhammad Khokhar, a gastroenterologist from Lahore, Pakistan, has been in Chambersburg for 16 years. He remains committed to the town, even after his sixth grade daughter's classmates at a Montessori school accused her of making bombs.
"(When) you have invested so much in the community, and you have built up relationships with your partners and the practice, it's difficult," Khokhar said.
"I'm here," he added. "This is my retirement place."