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Rapid Responses: Rapid Responses published:
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Brain Drain: a self inflicted malady
- Edeghonghon Olayemi (1 July 2005)
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Life8 - our response to Geldof?
- Dr Salehuddin Samsudin, Salehuddin Samsudin (1 July 2005)
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Brain drain: are the doctors blameless?
- MANI MARAN (1 July 2005)
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Blame lies with the professional politicians of Africa
- Rhett S Kahn (3 July 2005)
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An ethical recruitment policy
- William R. Podmore (3 July 2005)
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Not brain drain, brain circulation
- Paul E Shannon (3 July 2005)
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Global or local responsibility?
- Richard J Lyus (3 July 2005)
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Keeping doctors at home
- Leonard H Goldberg (3 July 2005)
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Re: Stopping African brain drain
- Akinseinde Osakuade, James Johnson (3 July 2005)
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Better than brain in the drain
- MK V Sathyamoorthy (4 July 2005)
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Ethics and the one way flow of intellectual property
- Amitava Banerjee (4 July 2005)
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Re: Brain Drain – The real issues
- Dr Emmanuel A. Okpo (5 July 2005)
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A way forward?
- Frank G. Njenga (5 July 2005)
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Skills Drain of Overseas Doctors - we should be paying "rent"
- John A Lourie (5 July 2005)
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Re:Timely article
- Himanshu Roy (5 July 2005)
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Instead of stopping the drain can we fill the gaps?
- Klara Tisocki (5 July 2005)
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Brain drain or brain gain
- Angel Magar, Nimesh Bhattarai, Amit Rauniyar (5 July 2005)
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The brain drain ...
- Emmanuel Agogo (6 July 2005)
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Reversing Brain Drain
- Thomas C. NCHINDA (7 July 2005)
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Fair trade = economy improvement=reducued migration.
- David Phiri (7 July 2005)
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No end in sight to the brain drain
- Richard A Rosin (8 July 2005)
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Struggling to Understand Mr Johnson's Anti-Immigration Stance
- Jay Ilangaratne (8 July 2005)
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Why should young doctors be in West?
- Matiram Pun (11 July 2005)
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Africa's Medical Brain Drain
- Andrew N Wilson (12 July 2005)
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Edeghonghon Olayemi, Lecturer Dept Of Haematology, Olabisi Onabanjo University, P.M.B 2022, Sagamu, Ogun State, Nigeria
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email:yemiede@yahoo.com It is a pity that a large percentage of health professionals trained by poor African countries at considerable expense end up in developed countries. However, rather than put all the blame on the 'final consumers of the finished product' I believe most African countries should take a hard look at their health policy and see if they don't need urgent changes. In the first place apart from the poor remuneration of these health workers who after qualification are expected to bear the financial burden of their immediate and extended families; there is simply no morden/ functional facilities to work with. While most African countries spend billions of dollars to host sporting events and political jamborees, the hospital wards, theatres, clinics etc continue to lie desolate. To add insult to injury, after qualification and going on to specialise, health workers especially doctors find it extremely difficult if not impossible to practice in some parts of their countries for ethnic or political reasons. So do you blame this same doctors when they decide to pick up lucrative offers from western countries where they are well paid and have adequate facilities to practice their profession? I can assure you that if the western countries make it more difficult or impossible for health workers to migrate to their countries, most of those 'stranded' in Afica would rather change their profession than continue to work under the current conditions which continue to deteriorate by the day. Competing interests: None declared |
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Dr Salehuddin Samsudin, SpR PICU Cambridge, Salehuddin Samsudin
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I read with great interest this debate which has been highlighted intermittently in recent years but is probably made more interesting in the wake of the G8 summit and Sir Bob Geldof's efforts to make poverty history. Doctors and nurses in many developing countries are also victims of poverty and this worldwide social injustice. Many are also here because of training needs which may be lacking because of the lack of funds, 'brain- drain' etc in their own countries. Most if not all UK colleges support trainees from these countries coming to the UK but not many provide training support for these doctors to train within their own countries. We may not be able to influence the outcome of the G8 summit but through our colleges and perhaps personal effort, just maybe, some of the inequalities in healthcare could be improved. Competing interests: None declared |
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MANI MARAN, PHYSICIAN MADRAS 600014
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I have been reading quite a few article on the topic of brain drain occurring from African & Asian countries recently, thanks to the media hype created by Mr.Geldof's campaign. It's really ironic to watch the western media doing a lot of soul searching - with a bit of guilty consciousness!! But it is hardly surprising that the brain drain occurs and I am sure it will continue to occur irrespective of whatever the governments of developed countries do.Most of the doc's decide early on some even before entering medical school that on completion of their graduation they will go abroad for further training - an euphemism for earning good money and leading a comfortable life, with no plan of returning home.And all the while in medical school they hear of spectacular working atmosphere with great lifestyle and serials like ER seducing them on their journey. One of the main reason sited for emigrating by these doctors is the working atmosphere, but these very same people don't utter a word when they work in these same dirty hospitals as a PRHO and or a SHO, but once abroad boy how they can talk!! You might ask what is wrong if they want to make money, well only this for example a medical student in India for his 4 1/2 years of education spends approx. less than £1000 max towards tution fee, and gets a monthly salary of around 5000rupees. (approx £70), a miniscule amount in pounds but quite a decent amount in India.Who pays for all this? Yes it is offcourse the people more than 70% of whom are farmers and most of whom are uneducated, do these doctors ever think of them I wonder?? If only these poor people know what is happening to all their money, I suppose life is never fair,I might sound like a case of sour grapes which is not the case. Let me tell you how desperate some people are to go abroad, I once know a doctor who is a muslim and he wanted to go to USA very desperately but unluckily for him sept9/11 happened and his visa request was rejected twice, since his parents were well off, they hunted for a muslim bride in USA and made her come to India and they got married and he went to USA, he had always wanted to be a surgeon and he is very intelligent but alas today he is doing family medicine in a very backward province in USA, but he says as long as it's in USA he is happy...... what more can a person sacrifice? So it's high time people in developed countries stop blaming their system alone and start pointing the finger towards the doctors too and don't worry they won't mind......but truth does hurt. Competing interests: None declared |
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Rhett S Kahn, Private family doctor 77 Toronto Rd. St Helena Welkom 9466 South Africa
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Prof Gaddum said: " People may get better because of or despite of drugs'. Similarly with the health of sub-Saharan Africa; the health of the people is improving not because of the professional politicians but despite their interventions. If the developed world wishes to help, target the culprits viz. the professional politicians and not the doctors, who eventually give up and leave out of desperation. Insist that spending on weapons of war cease totally and with immediate effect and most defence budget moneys be transferred to health care. Insist that the professional politicians and their family members use the same State run medical facilities they expect their electorate to use. Insist that all support for developing Africa be in the form of training and the loan of human capital for health and educational services so obviating well intentioned money again ending up in greedy professional politician's pockets, whether it be directly or indirectly. Competing interests: None declared |
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William R. Podmore, Chief Librarian British School of Osteopathy, 275 Borough High St., London SE1 1JE
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Dear Sir, In his editorial Dr James Johnson calls on the Blair government “to commit the UK to training enough people to become self-sufficient in workforces of doctors and nurses”. We also need to adopt an ethical recruitment policy. This might involve making agreements that those trained here either have to work here in Britain or in a less developed country, rather than going to a more developed country (usually the USA) and that we would take from no country with a shortage of doctors and nurses. Presently the only country in the world with such an ethical policy is Cuba, which exports nurses to African and Latin American countries because it has created a genuine surplus at home. Yet the Blair government is still stripping many developing countries of their most precious asset, their skilled people. It cannot be right for a country with allegedly the fourth largest economy in the world, Britain, to dispossess some African nations of more than half their trained nurses. What is this but a new kind of colonialism, a variation on the theme of looting their resources? Yours sincerely, Will Podmore Competing interests: None declared |
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Paul E Shannon, Consultant Anaesthetist Doncaster royal Infirmary, DN2 5LT
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James Johnson's article, whilst no doubt, well-meaning is heavily one -sided. He fails to point out the positive aspects of medical migration. These are many. Firstly, doctors leaving poor countries do so of their own volition to better themselves. This is a noble sentiment. They send money back to families that they wouldn't be able to do otherwise, and this is spent on many things, including health care. Remittances to sending countries amounts to more than total aid from OECD countries. So, there is a marked economic benefit to offset the loss. Secondly, betterment abroad stimulates higher education back home, "...seeing highly trained people getting lucrative jobs abroad may persuade youngsters to train too, thus raising a developing country's skill levels" (1). Thirdly, migrants are often politically-active and motivated to bring about reform in their home countries, "the creation of new, trans-national communities may also bring opportunities for gain" (2). Next, is the benefit of those who return home. This doesn't always happen, but when it does it is highly beneficial. It should be encouraged in receiving countries, "international migration generally benefits developing countries, as long as host countries take steps to reduce harm—by, for instance, encouraging migrants to return" (1). Thus, a re- circulation of talent could occur permitting the sharing of resources for mutual benefit. This would also encourage doctors from developed countries to spend time overseas, perhaps in a volutary capacity, making a practical difference and hughly encouraging locals. But, there has been a worrying reduction in recent years of overseas volunteering, "many middle-class professionals feel they have to manage their time and money more carefully—and selfishly—than before" (3). Further, Mr Johnson seems to reserve special criticism for the US. (It's always easier to blame someone else). He states disdainfully that US nurses are the "most highly paid in the world". Well, UK doctors are the most highly paid in Europe. Following his own logic, Mr Johnson should be campaigning for a reduction in our salaries to make the UK less appealing to African doctors! Another effective barrier would be stringent medical screening, "a plan in Britain to introduce mandatory HIV tests for foreign nurses might also deter some South Africans from seeking work" (4). Erecting barriers looks like discrimination from some angles! Finally, the fatuous notion of "self-sufficiency" is pleaded. This sounds good but is, in fact, meaningless. When is enough, enough? The free movement of human capital is as important, if not more so, for developing countries as it is within the EU. And surely, Mr Johnson is not suggesting curtailing EU doctors' rights to work in each others' countries? To sum up, the benefits as well as the risks of migration must be considered coolly. Most of the evidence is that, with sensible policies, a healthy circulation of doctors and nurses around the world would be good for all of us! Refs: 1 The Economist, Oct 31st 2002. The view from afar. 2 The Economist, Sep 26th 2002. Outward bound. 3 The Economist, Jan 23rd 2003. Scared silly. 4 The Economist, May 15th 2003. Our country needs you. Competing interests: None declared |
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Richard J Lyus, Family Doctor Seattle, USA
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It is more convenient to attract foreign doctors to fill the jobs less desired by US graduates (for example) than to invest in expanding the numbers of places at medical schools. However, imagine a time when the US (or the UK, or wherever) became self-sufficient and no longer depended on the import of trained medical workers. This would remove the demand but would not address the fact that there would still be a lot of doctors in developing countries hoping to move to a better life. I would not find it a morally acceptable 'solution' to say thank you very much, we are fine now, and shut the door. I acknowledge that there is a certain amount of tacit local responsiblity with each medical degree gained. I have recently moved to the United States and feel guilty about leaving the NHS in which I trained, and the patients who trained me. However, I also believe that the broader issue of globalization is relevant and that all physicians should feel a degree of responsibility to address the needs of the developing world, regardless of the location of their training. How could such a sense of global service be inspired? I suppose this debate is irrelevant because no-one is going to encourage doctors to leave the UK or US while these countries have an inadequate supply for their own needs. However, the ideal to which we aspire should be a dynamic exchange where the number of doctors pulled in to the developed nations is equalled by the Western doctors who keenly follow the moral obligation to help those in more dire need in the developing world. This would certainly sit more easily on my conscience. Competing interests: None declared |
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Leonard H Goldberg, Dermatologist 7515 Main St. Houston, TX 77030, USA
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Rich countries do not actively loot doctors. Rather southern countries lose every opportunity to keep them at home. The solution to the problem does not necessarily lie at international conferences of national leaders. It lies in the determination and will of national governments to improve the quality of life of their populations and in particular of their professional members. Doctors, like all individuals want to live in safety (for themselves and their families) and be able to support a lifestyle which is compatible with their personal vision of life. They need the freedom to be able to practice their profession without too much governmental interference, and to take care of their patients to the best of their ability. It is up to local governments to improve working and living conditions in their own countries rather than creating barriers to the movement of doctors. Competing interests: None declared |
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Akinseinde Osakuade, GP trainee S75 2EP, James Johnson
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I read you editorial on the BMJ and i agree with most of your comments because you did highlight the problem but you did not make suggestions on possible solution to the problem. I am a Nigerian trained doctor, and at present i am training to be a GP. I worked in Nigeria for 2 years and inspite of working 80 hours a week, my salary was about 200 pounds amount , and i was always being owed 1-3 months salary at any given point in time. I got fed up with being paid low wages, being overworked and trying to provide medical service in a poorly equiped hospital and out of need for self preservation came to the UK to get training and a descent wage. At present i earn enough money here and i am responsible for schooling 4 of my siblings and catering for both of my parents that are retired because we have no social security.I give 50 percent of my earnings as 'aid' to help my people back home that are in need. The solution to the brain drain is not limiting outflow but basic problem of under production of doctors,corruption, poverty, and kleptocracy that at present predominates African country. I am yet to meet a Nigerian doctor who do not intend to return home once they are financially free and better euiped to survive in the present harsh economic climate that is present in NIgeria. The solution i feel that the western world could adopt. 1) Compulsory 2 year return programmes for African Doctors after completing training ro their country of origin. A tax incentive can be adopted to encourage people. 2) 2 Percent to be taxed from their salaries to be set up as a trust fund to reinvest in medical education in Africa. Countries where they are hired should be obliged to pay 5% of the income taxed from their earnings to this trust as well. This would also be enforced for UK graduates going to work in say America or Australia. 3)More interactions between African medical schools and similar institutions in the West. I would wish the BMA could organise a survey involving African Doctors enquiring on their perception of this problem. Yours sincerely. Akin Osakuade Competing interests: None declared |
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MK V Sathyamoorthy, SHO Wycombe Hospital, HP11 1FG.
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When you have got the relevant knowledge, you have to put it into effective use. Or else it is gonna result in disuse atrophy. Similarly when you dont have facilties to work as a proper doctor, and people die not because of lack of doctors but because of lack of resources, I cant understand that why one has blame a doctor. When people die because of lack of proper sanitation, housing, safe drinking water how the doctor is going to change them all. How the doctor is going to save a life that is going to die due to dehydration without intravenous fluids when he has no facilities even to measure his patients electrolytes, leave alone outdated leaky manual BP equipments? Even when the doctor can prescribe a medication, but what is the point if in a free market economy if the patient is unable to buy the medication. Apart from all, the doctor is also an individual and he also has a family to look after. Developing countries dont have the lavish social support system because they cant afford to, because of the state of their economies. The only solution for stopping the so called brain drain, lies in improving the economy of the respective nation states. Competing interests: overseas graduate |
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Amitava Banerjee, SHO General Medicine (from August 2005) John Radcliffe Hospital, Oxford OX3 9DY
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It is great to see the "brain drain" being discussed by so many parties on the international stage with renewed vigour(1).There are many other problems within the health systems of developing countries(from under-funding to poor infrastructure), and “plugging the brain drain” will only address one of the many issues. There is a huge responsibility upon the governments of poorer nations to improve their internal working conditions and health systems, in order to train and retain their own health professionals. Two ethical principles stand in conflict when considering migration of doctors. Firstly, there is the principle of autonomy, the right of the individual nurses or doctors to freedom of choice. Secondly, the principle of distributive justice concerns the fair distribution of resources for the common good. Taking desperately needed health professionals from other countries appears to be unjust, but restricting their careers to their country of graduation denies those same professionals freedom of choice. Not just in the field of health, the developed nations (notably the US and the UK) continue to capitalise on the markets of the developing world, through patent law, as shown by TRIPS implementation for antiretroviral therapies in poorer countries. Africa's (and other developing country) health professionals need to be likened to intellectual property of developing countries, which they have trained and invested in. It is ironic that our governments do not entertain free global exchange of intellectual property with respect to drugs, but the greatest intellectual property (that of trained health professionals)is not respected. Is it not the equivalent of Malawi or Ghana coming to the USA, and taking drugs produced and developed by US pharmaceutical companies for free? At a government-to-government level, developed countries which recruit doctors from developing countries could pay compensation to that country for any doctors/nurses recruited. This could account for the training costs and the loss of service in the feeder nation. This was adopted as a resolution at the 4th World Rural Health Conference in Calgary, Canada in 2000(2). Secondly, governments, and their recruiting agencies, should restrict active nursing recruitment by stopping: (a) advertising in the journals of developing countries; and (b) visits to those countries in order to lure their health professionals. There is a responsibility for the G8 countries to lead developed countries in more ethical recruitment practices so that they do not compound the problems faced by poor country health systems. 1. Stopping Africa's medical brain drain.James Johnson. BMJ 2005; 331: 2-3 2. The Ethics of International Recruitment. Ian Couper and Paul Worley. International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy. April 2002. Competing interests: None declared |
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Dr Emmanuel A. Okpo, Public Health Medicine Dept of Public Health, Harrow Primary Care Trust, HA1 3EX
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Email emmaokpo@yahoo.co.uk I have read with great interest the debate triggered by James Johnson’s editorial “Stopping Africa’s Medical brain drain”. I must point out that African doctors migrate out of their own free will and it would be unfair to blame the developed countries for this. I think what we should be concerned about is to find out why so many doctors want to leave their countries. Coming from a similar background, I would think the most important reason is to get a better life. Doctor’s spend such long time training and when they graduate they have nothing to show for it. The remuneration is very poor (and mind you these people have families who sacrificed their all to train them through medical school), and the working conditions even poorer. To add to these, programmes for further professional development are none existent. Medicine is dynamic and no doctor wants to be left behind. The solution to this brain drain might be to standardise the pay of doctors worldwide and provide a mandatory yearly or six monthly training opportunities/exchange programme for African doctors to visit the UK or US. However, the onus lies with leaders of developing African nations to stamp out corruption and spend what little money they have on improving and strengthening their health care system rather than spending on overseas leisure trips and other unpromising agendas. Competing interests: None declared |
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Frank G. Njenga, Consultant Psychiatrist UpperHill Medical Centre, P.O. Box 73749 Nairobi 00200 Kenya
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By Dr. Frank Njenga, FRCPsych Dear Editor, I have read with much interest the debate regarding the brain drain from Africa to Europe and America and are concerned that the African voice remains relatively unheard. Recognising that no single solution will be found to this ever increasing problem, I would like to suggest that the fact that Europe and America find the African doctor attractive and useful is indeed a compliment to the training programs in English speaking Africa. Looked at this way, I would propose a situation that would be win -win for both Africa and Europe in which Europe and in particular the United Kingdom funded a scheme or schemes that afforded relatively inexpensive medical training in Africa enabling those who then wish to migrate to Europe to do so. Some of us who trained in Europe in the seventies and eighties did decide to come back while others stayed behind. Looked at this way doctors and nurses should be treated like any other commodity in a market driven economy where goods and services follow value attached to them. Rather than stare the problem in the face with apparent paralysis, Africa and the West have a unique opportunity for increasing the number of doctors and nurses for the two regions relatively inexpensively. Let us all therefore campaign for more funding and allocation of resources to medical schools in Africa rather than complain that the few brains available are being drained away. As an African practicing in Africa, I can confirm that there are large numbers of Africans who qualify to enter the best medical schools in the world but are unable to do so because of unavailability of opportunities. In this way rather than aid, Africa will “trade” with the west as equal partners, in this case capitalizing on its ability to train good doctors cheaper than the west. Kenya for example is able to train doctors in the clinical years for 2,500 Pounds per annum compared to approximately 25,000 Pounds (including fees and upkeep) per annum, for a foreign doctor training in the United Kingdom. In other words if the west was able to encourage Africa to train the doctors needed in Africa, they could get a bargain of ten doctors for the price of one. If half left and the rest stayed, both continents benefit. A good deal by any standards! No conflict of interests. The author is President of African Association of Psychiatrists and Allied Professions (AAPAP) and, Chairman, Kenya Psychiatric Association (KPA) UpperHill Medical Centre 3rd Floor, Suite 3C P.O. Box 73749 NAIROBI 00200 Email: fnjenga@africaonline.co.ke Competing interests: None declared |
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John A Lourie, Associate Postgraduate Dean Oxford PGMDE, The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP
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The editorial by Johnson (1), article by Ahmad (2), and correspondence in the same issue further highlight the massive and immoral skills drain of health professionals from developing countries to Britain, America, and other rich and well-provided nations. We have a pressing responsibility to consider how we can best maintain the healthcare services we have come to demand in rich Britain, while not unfairly stealing doctors and nurses who have been trained at considerable expense by some of the poorest countries in the world. Perhaps we should pay "rent" for the international medical graduates whom we "borrow" to provide services in the UK. NHS employers could be required to pay an annual fee directly to the Health Ministry of the country which trained the doctor (or nurse). If a "rent" contribution equivalent to the doctor's or nurse's salary in their own country were levied, relative salary levels would indicate a figure of around 10% of their UK salary. This could provide for the employment of replacement staff in their own country for those who have come to work and train in the UK. If no staff were available - a more than likely situation - the "rent" could contribute to a general improvement in salaries, working conditions and overall training facilities in the "donor" country, to the benefit of those health professionals who choose to remain at home. In this way we would at least be making a small contribution to alleviating the severe and tragic difficulties caused by the current and increasing transfer of medical skills from the world's poor to the world's rich. John A. Lourie Associate Postgraduate Dean (Overseas Doctors) and Consultant Orthopaedic Surgeon, Oxford PGMDE, The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP. (1) Johnson J. Stopping Africa's medical brain drain. BMJ 2005; 331: 2-3 (2 July) (2) Ahmad OB. Managing medical migration from poor countries. BMJ 2005: 331: 43-45. (2 July) Competing interests: JL runs induction courses to help overseas doctors familiarise themselves with the NHS |
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Himanshu Roy, Senior Medical Officer( Radiology) BHEL Main Hospital
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Dear Sir Your article on the brain drain from African and Asian countries is both timely and instructive.I agree with conclusions drawn from the article. However, I would like to point out another aspect of this phenomenon. The Persian Gulf states have routinely employed large number of expat medical professionals from both South Asia and Africa (especially Egypt). These medical professionals have provided yeoman services to the development of health care in that part of the world.There remittance has enhanced local economies of many South Indian states esp. Kerala and Tamil Nadu. This has led to development of the economy in these states.Kerala has had a moribund economy due to small industrial base. The remittance has allowed the econmy to flourish and a strong service sector in Toursim to develop. Moreover, in my recent visit I was pleasantly surprised by the level of sophistication of the Radiology equipment routinely availabel in private sector. On inquiring into the charges for the various examiantions, I found them to be quite competitive. I think sir, this would a positive example of " Brain Drain" Competing interests: None declared |
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Klara Tisocki, Assisstant professor Faculty of Pharmacy, Kuwait University
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The main challenge for many developing countries is to try to fill the enormous gap in competent health care providers and I think these countries also need to look for innovative solutions themselves for this problem. For example, Africa urgently needs armies of well-trained primary health care workers to deliver basic, essential health care, like distributing immunization, providing basic reproductive health care or giving basic treatments for common infections like malaria. Would these primary health care workers need five to six years of medical school training and an MRCP exam before they ready to practise? Could educational reforms and better allocation of resources between training of doctors, nurses and a new breed of “primary health care workers” can better serve the needs of a poor African country? While it is noble to maintain very high standards of physicians' training at African Universities (standards, that were frequently set up by European Universities along European models of medical education some 30-50 years ago), which makes the end-product a highly sought after commodity all over the world, this might not be the current best use of resources of that country, if 90% of those graduates simply gets on the aeroplane a month after graduation to work overseas. I think, while maintaining these standards, it could also be important for these institutions to find new models of medical education and to train rigorously community health care providers for specific services who can deliver essential and often life-saving health care in places where no doctors or nurses will go. Cost of training and remuneration of these primary health care workers might be lower to the society than doctors’ training and salaries but benefits might be multiples of those gained from the services of, let say 10-15 physicians remaining in-country after graduation of 120 in a year (my experience from Zimbabwe). Governments, medical schools and training institutions in developing countries need to rise to this challenge of how to best serve the needs of their societies when educating health professionals and how to use available resources for medical education in the most cost-effective way. Competing interests: None declared |
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Angel Magar, Doctor Kathmandu Medical College, PO Box 21266, Ktm, Nepal, Nimesh Bhattarai, Amit Rauniyar
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It’s obvious that the human nature to pursue for better career & comfortable life in whatever profession s/he has in today’s world. If it wouldn’t have been it wouldn’t call modern age rather than Stone Age. US is not only the place where developing country’s doctor/nurse try for, UK, Canada, Australia are other place where it is very easy to get in as compare to US. USMLE is comparatively very tough than PLAB more expensive and took more than a year where as one can get through PLAB within 6 month of period. Though its different thing that doctors from developing countries work in the substandard area for their livelihood once they get through PLAB & couldn’t get the job in UK. Whereas in USA, most of them return back once they don’t get matched for that year and reapply next year. I have witnessed many stories throughout my days as a student and professional, I still remember the day I was excited when I got admission in KMC and went to then 2nd year medical student in Institute of Medicine (IOM) for his guidance for my medical education. I asked him what he wants to do after his graduation, “I will become a paediatrician and I will work in some courtyards” he said. He was a very good student so I used to meet him regularly after few year he said “I will join Cancer hospital in Bharatpur” for the same question. Then he said he will prepare for the USMLE when he was in intern, he worked for few months after internship and prepared for one year and went US and now he is doing residency in Internal Medicine (which he used to wish for) in a prestigious institute. As you see from this story, a medical student do not have enough information and future strategies and plan for his medical career in his early days of medical school as he complete his education, he has to bear the family responsibilities as mentioned by Edeghonghon. I have seen patients getting discharged because of lack of money from their family to support the treatment cost from the hospital. Sometime in Gyn/Wards a lady is left alone to deliver her baby as result of illegitimate relation. She doesn’t have even a single pie. There are more stories, by seeing all this I want to build a community hospital where I could provide them health service in minimum cost. But how can I afford this? First I have to earn money then I can make my dream come true. A newly graduate earns ~ £100 per month in Nepal. Do you think its sufficient for him/her for livelihood. In that case do you think they will remain silent and stay their country, where the government policy is so poor? Therefore I don’t blame developed country for recruiting developing countries man power. Yes, I would highly appreciate if developed countries initiate some projects to strengthen the health policy in developing country to prevent brain drain. Most of my colleagues are heading for abroad and so I might, not to settle down but to learn the modern scientific technology and to introduce in my country after getting specialization. Competing interests: None declared |
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Emmanuel Agogo, SHO HIV medicine North Middlesex Hospital, London
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The historical links between the countries of the Commonwealth and the United Kingdom extend far beyond the master servant relationship, it produced a generation of Anglophiles that wore three piece suits and bow ties in the boiling sun, full of nostalgia about their experiences abroad. All through Medical school we were regaled with stories of how Medicine is practiced in better climes and our teachers influenced our dreams. Furthermore, the promise of life in 'God's own Country' ensnares the mind of the hardiest patriot. We all want a good life at the end of the day. …Things didn't work and even when we tried to make them work, it was obvious that the task was daunting. The teachers we revered, upped and left suddenly to 'start all over' elsewhere. It became difficult to find role models to emulate. This crisis of brain drain will run its course and turn on its head if an effort is not made to reverse it. The quality of training will continue to deteriorate till the consumer countries realise the deficiencies of the new brand of 'product’. They will then develop new obstacles to stop all comers or become very selective and set even higher hurdles than those currently in force. While I appreciate the view of Professor Tisocki(1) on filling the gaps in health care delivery with well trained Primary care workers, it unfair to suggest that it is a ‘noble’ but unnecessary burden to maintain standards of medical education in Africa. Should the standard of training (what is left) fall so that the doctors are less competent and therefore less marketable worldwide? Would that make them less likely to jump on aeroplane and leave? I don’t think so. The creation of new cadres of medical staff may not be the solution. A similar model was instituted in Nigeria in the early 1990’s as part of a complicated Primary Health Care initiative with Traditional birth attendants, community health care workers and first AID boxes for each village but this elaborate programme has fallen by the way side. It is in the interest of humanity to ensure that reasonable level of quality of life and health care be available to we all that co-exist on this planet! It is obvious that different standards and accepted health practices already exist in developed and developing countries but theses inequalities should not encouraged further. The global trend, which has empowered nurses and brought nurse-led care in general practice and specialist areas, needs to be evaluated in the African context. Perhaps training nurses and midwives should become a priority for African countries. In the face of the distressing projections of the National Intelligence council of the USA and the scenarios projected by UNAIDS, it is difficult to be optimistic(2). The problems of Africa cannot be magically solved by the eight wise men of G8. The Aid or trade argument is futile without action. Unfotunately, the health needs are set to escalate as the HIV/AIDS epidemic peaks in West Africa and who knows what other natural or man-made disasters are lurking? It is important that research and training be encouraged in these health institutions across Africa. The current practice where the Multinational Pharmaceutical companies use Africa only as testing ground for new drugs (and only sponsor clinical trials for drugs that are not realistically affordable to those who need them) should be revised. Collaboration with local academics will improve their sense of self worth eliminating the current practice where no real research is being done. For all intents and purpose evidence based medicine is an alien concept in most parts of Africa. Countries like Cuba have led the way by developing health systems that adapts to the needs of the population.African Governments need to identify the more pressing needs of their peoples and tackle them. The emphasis on specialised care should be changed and a more general approach should be adopted. The hypocrisy of the richer countries who are selling weapons and guns to countries filled with hungry, sick and despairing people will only fuel more man-made crises, social instability and further brain drain. 1)Instead of stopping the drain can we fill the gaps? Klara Tisocki BMJ Rapid response (5 July 2005) 2)http://www.cia.gov/nic/special_globaltrends2010.html#contents Competing interests: None declared |
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Thomas C. NCHINDA, Retired WHO professional, Epidemiologist and Public Health Physician Consultant,
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The responses to this broad issue of "brain drain" have been as varied and broad as the issue of brain drain itself. Movement of trained professionals particularly doctors and healtlh researchers accross national borders goes beyond movements from poor to richer countries. This is a phenomenon that is healthy and cannot be stopped. The painful facts in this case concern poor countries whose doctors have to leave their countries where their services are most needed to service hospitals in the developed countries particularly UK and the US. My contribution concerns the issue of reducing brain drain or should I say furthering the return of researchers to their home countrires after training abroad. One should borrow from what was done in the area of Tropical Diseases Research by the World Health Organization and some bilateral research funding bodies who wanted tropical diseases research done in the tropics and by researchers in those countries. This they reasoned would get trained developing country researchers back to their home countries. They carried out a series of steps the most important of which were: These 5, among many other incentives too many to be described here, helped to get these scientists to return to their home countries and initiate research. From their re-entry grants they won many other grants that kept them highly performant and competitive. Many of these scientists are doing good research in malaria, for example, accross Africa, their institutions are strong and attracting scientists from UK and US who wish to do competitive research with them. Many of them will present their research research findings at the Malaria Research Conference in Cameroon in Novenber 2005. Evidently the clinical disciples present a different landscape but one can borrow some of these methods and a similar or suitably adapted treatment to keep the doctors working in their countries - high level clicical training in the important disciples needed in the country, good and well-equiped hospitals, good diagnostic services, availability of essential drugs, salaries that are commensurate with the national norms and a system of allowances commensurate with their responsibilities, qualifications, long hours of work and good service conditions. It is clear that the overall socio-economic development of the country is a key factor underlying brain drain in many of these poor countries and so efforts to improve this is one of the key factors to be emphasized that may slow down but not prevent brain drain. There are no quick fixes to solving or improving or reversing the brain drain and ALL of the solution must not be expected to come from abroad. The national administration of the poor countries have to be encouraged and helped to be part of the solution. This is what was done for tropical diseases research and should be encouraged in clinical services. Competing interests: None declared |
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David Phiri, sho Aintree hospital,liverpool
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The Chairman's editorial whilst probably well meaning does not provide viable solutions..it only offers an option that says to the African healthcare worker ' because you African we will not hire you'..this ofcourse will not solve Africas problems.. Africas problems will be only solved by the G8 not pointing fingers at each other or dictating terms to Africa but firstly treating African as equals and not patronising, prejudicing them but by treating them as equals and co-partners.. And if really the West wants to genuinely help they actively engage all Africans across the board and not just the corrupt gorvernments but civil society as a whole to to identify the problems and the probable solutions.. Coming back to the topic at hand the best way to is engage African expatriate health professionals by way of surveys and not just the well known gorvenments higher officials. Competing interests: None declared |
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Richard A Rosin, Consultant Psychiatrist, Mental Health Services VA Medical Center Puget Sound, Seattle 98108
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The need to attract doctors from other countries will continue as long as medicine's popularity remains diminished. And what was once a popular career will remain unattractive as long as doctors tend to be regarded as corrupt, incompetent fraudsters and even potential mass murderers who require increased scrutiny and regulation to ensure that they do not give in to any of these inherent inclinations. Many smart young people in Western societies no longer see medicine as a great profession with the possibility of service to humanity, intellectual challenge and excellent remuneration as a bonus. There are many well-paid jobs that come with far less hassle and stress. Despite this, society needs doctors and there is always somewhere where conditions are worse. Given these factors there is no end in sight to the brain drain under discussion. Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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No doctor is brought to the UK against his/her will.The reality is, surely, the opposite.Hence, using words such as 'rape'[1], 'looting'[2] and 'romantic delusion'[2]to hype an argument against migration of doctors, is unjust.Attacking medical- migration with impunity[1],[2] will not alleviate extreme poverty in Africa or elsewhere.The biggest barrier against reducing poverty is corruption;a Google search for words 'poverty','corruption' produced over three million cogent search threads. Large scale corruption of public funds in African and south Asian countries, is something that an average sixth-former is likely to know.Johnson does not refer to corruption in his editorial[2].Brain-drain,whether be doctors or other professionals,is largely an effect of poverty, and not a cause of it.We must not forget the benefit to poor countries from the money sent by doctors who are earning in richer nations. Launching attacks against global migration of doctors is not a duty of a UK trade union for doctors.Nor such attacks from Johnson[1],[2] can be construed as a fair reflection of the view of BMA's majority membership.Johnson also needs reminding that a large proportion of BMA members are from the very countries he is referring to; and without their subscriptions, the BMA accounts might not be as good as it is now. So let us hope he will show some sensitivity to his own members, perhaps next time.In any event, neither the BMA nor Johnson is in any sense a specialist source on global poverty issues or immigation--so they lack proper clout.Therefore, it would have been far better if Johnson's anti- immigartion protestations were secluded in a 'personal view' column of the BMJ. Perhaps, sending part of the BMA-subscriptions taken from overseas doctors in UK, to Africa, would be a more practical step which might be admired by many. By the way,Aliens Act 1905 (in relation to UK immigartion) was repealed a long time ago; hope that would reassure some who are already here, and those doctors who intend coming to the UK. References [1]Zosia Kmietowicz. BMA Annual representative meeting, Manchester, 27 - 30 June: UK hospitals must be staffed without "rape" of the developing world, says BMA chairman BMJ 2005; 331: 12-d. [2]Johnson J.Stoppin Africa's medical brain drain.BMJ 2005;331:2-3 (2 July), doi:10.1136/bmj.331.7507.2. Competing interests: Fee-paying BMA member and immigrant doctor. |
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Matiram Pun, Medical Student Institute of Medicine, Kathmandu, Nepal
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The cream manpower of the developing world has been constantly wheeling to the Developed world. Be it USA or European countries, the qualified people have preferred to be there after they get qualified from the Government Budget of the third world. They get scholarship from the Government and then fight for higher and better opportunities in the west. This is their choice. The western countries have policy of remaining quiet and keep the doors open. This policy might have been coined as “Looting of Doctors” in this article. But this, I think, is result of faulty policy of both sides and whim among the doctors to be in the west. The flocking of doctors in the west from the developed countries is driven by very few but genuine reasons: 1. Doctors get handsome salaries in the west. That is enough to be lifelong earning from their native country if they just stay there in west a decade or more. 2. They get the degree that is recognized in every part of the world. They will never ever be questioned about their competency. And they will be paid with that high qualification even if they resort to the developing countries in comparison to their counterparts of the developing countries. 3. The western world is the most, technologically, advanced world in the modern era of so far development goes. Every person has an ambition to be with the latest advancement of knowledge. So they get in touch with this there. 4. Another factor is the security one. Every individual has no any intention to betray one’s own land but the security matters e. g. in case of Nepal, a landlocked Himalayan country, jeopardized by the Maoist insurgency. There none can go to the villages. Young Doctors get frustrated and leave country. 5. Nothing has been done from the side of Government to promote these young doctors to stay in the country. Government invests to train them and goes to sleep. The political biasness has also contributed to flee young and competitive doctors. Actually, it is the Government’s policy to cash their talent and competitiveness. Unfortunately, the dead corrupt leaders body language is that they want every knowledgeable citizen flee so that they will go on ruling poor and innocent and illiterate people. There many other reasons that drive them there but abovementioned ones are the exclusive ones. Competing interests: None declared |
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Andrew N Wilson, Radiation Oncologist Cape Town South Africa 7800
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The editor should be ashamed of this illiberal editorial. The real question is why do qualified people (of all professions/trades) seek to leave Africa? Simply put, it is for a better future for them, and especially their children. It is their basic human right to do so. Your editorial is sadly quite typical of the UK's chattering classes, people who demand freedom and rights for themselves, and yet will happily aquiesce to the effective enslavement of others in some grand social engineering scheme. You clearly have no clue about the situation on the ground for health professionals in Africa. Africa is a continent ruined by a succession of ruthless political elites who rule by a mix of patronage and thuggery (including murder) and don't care a whit for ordinary citizens and especially not for their healthcare. It is axiomatic in modern ethics that any system you design you must be prepared to live under - I look forward to the BMJ medical editorial staff working in Africa - to set an example. Put up or shut up please. Competing interests: None declared |
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