BMJ  2005;331:2-3 (2 July), doi:10.1136/bmj.331.7507.2

Editorial

Stopping Africa's medical brain drain

The rich countries of the North must stop looting doctors and nurses from developing countries

Africa will be the major focus of the G8 summit in Gleneagles next week, and rightly so. Nearly 11 million children aged under 5 years are dying every year worldwide from treatable diseases. Most of them are living in developing countries, with more than four million of these deaths in sub-Saharan Africa.¹ Along with the disastrous effects of warfare, HIV/AIDS is wiping out young adults and leaving frail, malnourished children in the care of their siblings and grandparents.

It is difficult to see how the countries of sub-Saharan Africa can develop economically and politically when such large proportions of their adult populations are living with chronic diseases such as HIV/AIDS, tuberculosis, malaria, and other tropical diseases. Antiretroviral drugs could make a dramatic difference, and so could appropriate aid. Although the developed countries of the North are giving aid with one hand, they are robbing African countries with the other by siphoning off their most precious resource—trained doctors and nurses. The Commonwealth's developing countries are particularly hard hit because their health professionals speak English and are therefore a valuable commodity to plug manpower gaps in the United States, Canada, the United Kingdom, New Zealand, and Australia.

Large parts of sub-Saharan Africa have effectively no health care at all, with only 600 000 healthcare workers for a population of 682 million.² For example in Ghana, faced with a ratio of nine doctors to every 100 000 patients,³ is it any wonder that young, talented health professionals are burnt out and despairing, and that they leave for a better life in the North? Only 60 of the 500 doctors trained in Zambia since independence are still there.⁴ Mozambique has only 500 doctors for a population of 18 million.⁵

What can be done? We cannot and should not prevent completely the migration of doctors and nurses. Medicine has a strong tradition of international collaboration, with doctors moving around the globe to gain further training and different clinical experience. Indeed, we like to think that international exchange and diversity enrich us all. This is a romantic delusion. We gain in the North, but developing countries lose out by losing their doctors permanently.

Any number of incentives have been tried to persuade doctors to remain in or return to their countries of origin—enhanced salaries, better pensions, cars, and housing allowances. Ethical recruitment codes may make us feel that we occupy the moral high ground. But, as long as the rich countries have plenty of vacancies, the flow of healthcare professionals from South to North will continue.

The most important element of the solution is self sufficiency. The BMA and the Royal College of Nursing have urged the prime minister and the chancellor of the exchequer to commit the UK to training enough people to become self sufficient in workforces of doctors and nurses. This would not be a huge leap for the UK since we have been expanding the number of medical school places year on year since 1997. Over the same period, we could radically expand the number of exchanges, overseas elective periods, and twinning programmes that would help our very hard pressed colleagues to feel less isolated and overburdened.

But what of the US? Already, it employs half of all English speaking doctors in the world. And it wants more. By deadly coincidence, the US wants to employ one million more healthcare workers in the next 15 years⁶—exactly the extra number needed for sub-Saharan Africa to fulfil the millennium development goals.⁷ The US system regards healthcare professionals as a commodity to be purchased in the market and is making little provision currently to increase the number of doctors and nurses it trains at home. Nurses in the US, with an average salary of $65 000 (£36 000; 53 000),⁸ are the most highly paid in the world.

The US is a great place to live and work. Unless it can be persuaded to think and act differently, it will soak up skilled workforce from every available source, including the UK. We would find it difficult and irksome to spend UK taxpayers' money training doctors to care for American patients. But we are a rich country, and many of those doctors would eventually return home. Ghana is already contributing to an obscene reversal of the flow of aid: it spends around $9m each year on medical education⁹ only to lose its doctors to a voracious and insatiable health market in the North. The African initiative of the G8 countries will fail spectacularly if the richest nations of the world do not allow the poorest to maintain the bare essentials of healthcare provision.

BMA, BMA House, London WC1H 9JP
(jjohnson{at}bma.org.uk)

---

Competing interests: None declared.

References

1. Department for International Development. Millennium development goals. Child mortality. www.dfid.gov.uk/mdg/childmortalityfactsheet.asp (accessed 20 Jun 2005).
2. The 3 by 5 Initiative. Preventing and treating HIV/AIDS in poor countries will help deliver better health services through 2005 and beyond. 1 November 2004. www.who.int/3by5/mediacentre/news27/en/ (accessed 20 Jun 2005).
3. World Health Organization, Communicable Disease Surveillance and Response. Global atlas of infectious diseases. www.who.int/GlobalAtlas/DataQuery/browse.asp?catID=180100000000&lev=3 (accessed 20 Jun 2005).
4. Development Gateway. Capacity development for MDGs. Rising to the challenges: the millennium development goals for health. 12 November 2004. topics.developmentgateway.org/mdg/rc/ItemDetail.do~1024486 (accessed 20 Jun 2005).
5. Office of the United States Global AIDS Coordinator. Country profile. Mozambique. June 2004. www.usaid.gov/our_work/global_health/aids/Countries/africa/us_mozambique.pdf (accessed 20 Jun 2005).
6. Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med 2004;141: 705-14.[Abstract/Free Full Text]
7. Bull World Health Organ 2005;83(1): 1-80.
8. Orlovshy C. Survey says: nurse salaries on the rise. http://w3.rn.com/news_news.asp?articleID=13080 (accessed 20 Jun 2005).
9. Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart GL. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Res Health 2004. http://eprints.ouls.ox.ac.uk/archive/00000847/01/hagopian_2004.pdf (accessed 20 Jun 2005).

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