Like many of my fellow physicians, I suspect I’m two things: a child of immigrants and a child of a physician. That combination gave me a unique window into two fundamental systems, health care and global economics, long before I studied either formally. I saw the sacrifices and hard choices required to navigate both, often simultaneously, with no geographic boundary ever limiting our responsibilities.

Many vivid memories from childhood have stayed with me, but what stands out most is my mother’s tireless dedication, not just to her patients, but to family. Her energy seemed boundless. She juggled lab and hospital duties, handled after-hours calls, and still managed the logistics of caring for family across continents. She would fly back to Calcutta, India, one of the world’s largest exporters of physicians, with suitcases stuffed with American goods requested by relatives: lipstick, Ritz crackers, and Keebler’s Sandies, which my grandmother adored despite their dry, sawdust-like texture that I could never tolerate. These “care packages” weren’t trivial. They were part of a ritual, physical tokens of love and connection in a world where distance didn’t dull duty. Every trip back felt like Christmas via Air India, and every gift was a reminder that we hadn’t forgotten where we came from.

But far more important than the snacks and souvenirs were the remittances, money sent home regularly to cover everything from living expenses to emergency medical procedures. I vividly remember a late-night call my father received from his brother, explaining that their sister’s family in East Bengal, now Bangladesh, was in crisis. The house was falling apart. Health issues had gone untreated. A child needed surgery. Medications were unaffordable. The local hospitals required full cash payment up front, and there were no safety nets.

These calls always ended the same way, with hushed debates over tea in the kitchen about who needed help most and how much could be sent. My parents would weigh medical urgency against financial feasibility, juggle the bills, and somehow find a way. I was a small, silent observer, but I understood early on that money and medicine were inseparable, and both were transnational in our household.

The formal term for what my parents were doing is “remittances,” typically small cash flows from immigrants to their countries of origin. I didn’t even know the word until much later, when I read Basic Economics by Stanford professor Thomas Sowell. He described remittances as a “transfer of wealth,” and I laughed out loud. Those modest wire transfers, sent regularly and often with quiet urgency, never felt like “wealth.” But in aggregate, they are.

According to 2024 World Bank figures, India received over 129 billion dollars in remittances, followed by Mexico at 68.2 billion, China at 48 billion, and the Philippines at 40.2 billion. In countries like Tajikistan, Tonga, and Nicaragua, remittances make up more than a quarter of the entire GDP. Now, with a proposed 3.5 percent remittance tax on the table, the debate over what these transfers mean, for individuals, families, and nations, is more urgent than ever.

From a medical economics standpoint, remittances function as a form of decentralized, informal insurance. In many low- and middle-income countries where public health infrastructure is fragmented, remittances cover what governments and weak health systems cannot. They fund everything from dialysis to diagnostic imaging, maternal care to surgery, even routine medication refills. In India, it’s not uncommon for hospitals to require full payment before providing treatment or even admitting a patient. My mother often sent money to cover just such expenses for relatives, with no co-pays, no preauthorization, just the hard reality: No cash, no care.

In this way, remittances reduce strain on underfunded national health systems by serving as a parallel stream of health care financing. They prevent worse outcomes by funding early interventions, improve health literacy through access to private care, and sometimes even subsidize small, community-based clinics. From an economic perspective, this has a ripple effect, because healthier individuals are more economically productive and less reliant on their own governments for emergency services.

Meanwhile, my father’s transfers often supported both medical and entrepreneurial needs, funding a cousin’s trekking company in Darjeeling, or investing in a local hostel. These weren’t just business ventures, they were long-term strategies to foster stability and resilience in environments where both jobs and health care were insecure.

So when we talk about taxing remittances, we’re not discussing luxury expenditures. We’re talking about taxing people for supporting their families, often in ways that directly reduce public health burdens in both the sending and receiving countries. These funds fill the gaps left by broken or underfunded systems. And yet, the average cost to send just 200 dollars remains stubbornly high, 6.4 percent globally, and even higher in parts of sub-Saharan Africa. South Asia has fared better, with an average of 5 percent, thanks to the rise of digital platforms. But now we’re proposing to tack on an additional 3.5 percent? For many senders, especially those who are underbanked or paid in cash, this becomes a regressive tax on the poor, many of whom are already paying into local, state, and federal tax systems.

The issue isn’t just economic, it’s practical and ethical. People won’t stop sending money. They’ll simply resort to riskier, informal methods, handing off cash to couriers, mailing envelopes stuffed with bills, or trusting acquaintances to deliver money across oceans. These methods are unsafe and untraceable. History shows that when survival mechanisms are over-regulated, people adapt, often with dangerous consequences.

What’s most troubling is the message this tax sends. This country was built on the idea that we attract and support the best talent from around the world. Immigrants already give so much. They are often underpaid, under-credentialed, and yet still support two households, one here, and one back home. If we now penalize that generosity, are we not undermining the very spirit of inclusion, opportunity, and innovation that defines the American ideal?

In today’s mobile, globalized world, where remote work, digital entrepreneurship, and dual citizenship are increasingly common, young professionals are already questioning whether the United States is the best place to build a life. Burdens like this remittance tax could accelerate a slow but steady reverse brain drain. And that’s not a hypothetical concern, it’s a measurable shift already underway. Remittances are more than money. They are medical lifelines, emotional bridges, economic investments, and deeply symbolic acts of care. They are often used to buy someone more time, in a very literal sense. And they are a two-way street. We would be wise to keep that road open.

Dalia Saha is a nocturnist.