The medical “brain drain” – a phenomenon in which well-trained clinicians leave poorer countries seeking better job opportunities in wealthier countries – has helped fuel a divide in the health-care workforce distribution around the world. Many international medical training programs work to close that divide, but could these programs actually be perpetuating the problem?
Michele Barry, MD, is the senior author on an article published this month in the American Medical Association Journal of Ethics that examines the ethical questions involved with the design of these training programs. There are no easy answers, but the piece certainly gives those of us working in global health a lot to chew on.
Take the case of a physician they call Dr. R, a Nigerian surgeon who is training in the United States:
About halfway through his two-month stay, Dr. R tells you in confidence that he does not believe the health care system in his country will improve; there is too much government corruption and an incapacitating lack of infrastructure. Instead of returning home, Dr. R hopes to obtain a better job through the United Nations or in Ghana so that he can earn more and provide for his family, including his two young children.
If you were in his place, wouldn't you want the same thing? But if every Dr. R leaves Nigeria, or Bangladesh, or Honduras, real problems ensue.
Barry, writing with colleagues from the Harvard T.H. Chan School of Public Health and the University of California, Los Angeles, breaks down these dilemmas. They write:
An ethical challenge with 'brain drain' is that the transfer of human capital from the source to the destination area occurs at great cost to the former, but with minimal cost — and appreciable benefit — to the latter... The relationships that dictate this phenomenon are highly complex; while the source and destination countries both contribute to workforce migration, individuals’ decisions are also significant and introduce their own moral uncertainty.
The authors point out that as of 2013, 80 countries worldwide fell short of the World Health Organization’s minimum recommended threshold of 23 health care workers per 10,000 people – the minimum ratio needed to maintain a health system. This disparity is most dramatic in sub-Saharan Africa, which is home to 14 percent of the world’s population but only 3 percent of its health-care professionals.
But who is to blame? No one, and everyone. They write:
Many factors contribute to workforce migration globally, including failed global health policies, destination country incentives, and the limited ability of source countries to retain physician talent. The ethical responsibility falls on all actors — the individual physician and the source and destination countries. But to ignore the systemic root causes for his decision — the roles that we in the United States play and that his own health care system has played — would be to miss an important opportunity to combat medical brain drain.
Previously: Ethics for medical students and researchers overseas: A talk by Michele Barry and Global health expert: Economic growth provides opportunity to close the "global health gap"
Photo by Anne Worner