Stopping Africa's medical brain drain
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7507.2 (Published 30 June 2005) Cite this as: BMJ 2005;331:2All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Africa's Medical Brain Drain
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
Competing interests: No competing interests