Tuesday, September 2, 2008

Ghana and the "Brain Drain"

Check out an article by a friend of mine from NU, Daniel Bohl, in the journal, Consilience: The Journal of Sustainable Development. It's titled, The Ethics of Physician Migration And the Implications for the United States, and he discusses the issue of the drain of medical talent from developing countries into wealthy countries such as the United States. In it he sites Ghana as a specific example:
"When, in a classroom of Ghanaian medical students in Accra, students were asked how many of them would like to go abroad for further study after graduation, virtually every hand went up. When they were asked how many thought they would later return home, half of the students’ hands went back down. A great number of the student-physicians in which Ghana invests do not intend ever to practice in Ghana; instead, they envision their futures in New York, London, and Chicago. A total of one half of Ghanaian physicians practice abroad, with 20% in the United States and another 10% in the United Kingdom."
This reminds me of a poignant conversation that I had with Dr. Eleeza, the Ho district health director of the Ghana Health Service. On one of our last nights in Ghana, over a dinner of Banku and tilapia, I asked him whether he had personally experienced the result of the "brain drain." Had he seen doctors, nurses, and health professionals pulled from the difficult job of serving patients in their developing nation to the possibility of more lucrative work in North America or Europe?

"Yes," he said, "many of my classmates are practicing abroad in the UK or the US." This fits with Daniel's observation that "one half of Ghanaian physicians practice abroad." And, as he spells out in the rest of his essay, it fits with a growing and disturbing trend across Africa and the developing world.
"... 70% of physicians trained by Zimbabwe in the 1990s have since left. 60% of Liberia’s physicians practice in the United States or the United Kingdom. 120,000 doctors currently address the needs of the 900 million people on continent of Africa, physician to population ratio of 13 to 100,000. The number of physicians in the United States, the United Kingdom, Canada, and Australia per 100,000 population are 293, 231, 220, and 271, respectively, approximately 20 times higher than the African physician population ratio."
Is it simply the prospect of more money that is drawing doctors to the developed world? Or, are there larger forces at play?

Dan makes a really interesting point: that we cannot only look at the forces "pushing" doctors from the developing world - forces including the lack of reliable infrastructure, equipment, and medicines necessary to do their job. He says we should also look at the forces pulling physicians and nurses to wealthy nations such as the United States and the UK.

He sites the dramatic and growing shortage - and thus demand - of doctors in the developed world as a necessary component of the "pull."
"This demand exists in developed nations including the United States, the United Kingdom, Canada, and Australia because these countries consistently train fewer physicians each year than their healthcare systems require. They do so because allowing already trained physicians to cross their borders is less expensive than training physicians domestically. The influx of already-trained physicians represents an influx of human capital with no monetary exchange. This induced shortage draws in physicians from less developed nations all over the world."
The fact is, there already is and will continue to be a growing shortage of doctors in the United States. Why? Because training home-grown doctors is expensive for all countries, and it is much less expensive than importing doctors from abroad. The crux of the problem is that the physician shortage has been created through a concerted effort by the government to correct for an anticipated physician surplus during the 1970's and 80's.
"The federal government responded by drastically cutting funding for medical education. Medical schools stopped growing their class sizes and the number of enrolled students entered a period of zero growth that would last for the next twenty years."
The problem is that the anticipated surplus of physicians never occurred, and instead, there has been a steady shortage of physicians in countries such as the US, Canada, and the UK. In order to meet the growing demand of the healthcare sectors of the wealthy world, doctors in the developing world not only feel the pressure of dealing with the difficulties of practicing medicine in their own countries, but are also faced with excellent job prospects abroad. You can't fault the physicians for wanting to improve their economic situation; we must look at the forces that structure their decision to stay or go.

Here is the ethical dilemma:
"No country wants to train doctors. For wealthy nations, it is cheaper to allow them in from poorer ones; for poorer nations, it is extremely costly to have them leave for wealthier ones. With demand for physicians high in both groups, the wealthier nations with the thicker pocketbooks receive a major influx. In contrast, developing nations are left to train a higher number each year in order to retain a suitable workforce....

While it may be ethical for developed nations to fill unanticipated physician shortages because of their right to self-service in a time of need, it is not ethical for them to use physician immigration as a long-term, cost-cutting solution....

The emigration of physicians, unlike that of other professionals, causes a direct and immediate harm to individuals. Physicians are direct caregivers. When a physician leaves, individuals who desperately need treatment go without the very services they need. The people of developing nations are directly and immediately harmed by the action of the free market."
It is unethical to intentionally import physicians on the free market because it directly harms the people from countries on the losing end.

The solution of course: for countries like the United States, Canada, and the UK to use their own abundant resources to train the physician they know they need. This is especially urgent as the baby-boomers continue to age and will put an even greater strain on our already strained medical system. It will take investment from the federal government in new universities as well as an increase in funding and class size at our existing institutions.

I see no reason why the United States cannot train its own physicians. And, after seeing Ghana's overburdened and understaffed medical system, it is easy to see how problematic it is to have to train twice as many doctors as it ends up with. With 50, even 20 more doctors per year, the GHS would be able to reach more and more patients in rural areas, perform more life saving surgeries, and diagnose and treat more infectious diseases such as HIV and tuberculosis.

For me, it comes down to an issue of rights. For my friends in the under served community of Ando, economically structured physician emigration to the wealthy world contributes to the violation of their human right to health.


Alex Cook said...

Very interesting. I wonder if there has been a microfinance effort in that part of the world?

jshaffer said...

Hey Alex,

Yeah, microfinance is actually a huge deal in Ghana. I actually saw a couple Opportunity International banks in Ho, where we were working, microfinance definitely has a presence in Ghana.

I do know however, that microfinance has taken off more slowly in Africa than it has in places such as India and Bangladesh. I'm not sure if you've read the book "Banker to the Poor," but its about Muhammad Yunus who basically invented microfinance. In it he talks about how quickly microfinance completely changed the lives of so many people in dire poverty in those countries.

I'm still searching for some explanations about why microfinance has been slow to grow in Africa. Perhaps overall lower population densities impedes the growth of small businesses? Cultural barriers to benefits of credit (although I doubt that explanation)?

If you find any research about that, I'd be very interested. Send it my way!

Hope UNC is awesome.