Stopping Africa's medical brain drain

BMJ 2005; 331 doi: (Published 30 June 2005)
Cite this as: BMJ 2005;331:2

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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.

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Competing interests: None declared

Andrew N Wilson, Radiation Oncologist

Cape Town South Africa 7800

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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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Matiram Pun, Medical Student

Institute of Medicine, Kathmandu, Nepal

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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.


[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.

Competing interests: None declared

Jay Ilangaratne, Founder

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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.

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Richard A Rosin, Consultant Psychiatrist, Mental Health Services

VA Medical Center Puget Sound, Seattle 98108

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The Chairman's editorial whilst probably well meaning does not provide viable 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.

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David Phiri, sho

Aintree hospital,liverpool

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7 July 2005

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:
1)provide very good training to them in the broad area of tropical diseases research (biomedical, epidemiological, clinical, social and behavioral sciences and health economics).
2)Adopting sandwitch training whereby part of their research particularly field research took place in the home countries of the trainees. In this way they did research on tropical diseases in its natural habitat and among sufferers of the disease
3)Providing them with re-entry grants to initiate research in their home institutions on completing their studies.
4) Helping them to master the art of writing research protocols to enable them apply for competitive research grants.
5)Providing institutional support whereby the home institution gradually acquired state-of-the-art but appropriate equipment and supplies to do research in their home countries where they will work. These institutions became good training ground for the 2rd generation scientists locally
6)Helping to provide internet connectivity so as to them with access to world scientific litterature and keep them researchers within the mainstream of scientific knowledge.

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.

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Thomas C. NCHINDA, Retired WHO professional, Epidemiologist and Public Health Physician


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6 July 2005

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)


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Emmanuel Agogo, SHO HIV medicine

North Middlesex Hospital, London

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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.

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Angel Magar, Doctor

Nimesh Bhattarai, Amit Rauniyar

Kathmandu Medical College, PO Box 21266, Ktm, Nepal

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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.

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Klara Tisocki, Assisstant professor

Faculty of Pharmacy, Kuwait University

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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

Competing interests: None declared

John A Lourie, Associate Postgraduate Dean

Oxford PGMDE, The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP

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