The neocoloniality of who cares: US underinvestment in medical education exacerbates global inequitiesBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4293 (Published 17 November 2020) Cite this as: BMJ 2020;371:m4293
- Eric Reinhart, doctoral candidate, and candidate in adult psychoanalysis123,
- Eram Alam, assistant professor of the history of medicine4
- 1Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
- 2Department of Anthropology, Harvard University, Cambridge, MA, USA
- 3The Chicago Center for Psychoanalysis, Evanston, IL, USA
- 4Department of the History of Science, Harvard University, Cambridge, MA, USA
As covid-19 cases and deaths continue to accelerate beneath a mushrooming pandemic cloud, the United States and India have emerged as two nations experiencing the most acute crises. Although these countries have dramatically different health systems, both have proven inadequate to tackle the scale of the growing crisis. Since the early months of the pandemic, shortages—of hospital beds, equipment, and healthcare providers—have hampered both treatment and prevention, compounding the fallout of the virus.
In the face of limited resources, pandemic responses have channelled growing nationalist impulses, manifesting in the hoarding of protective equipment and concealment of scientific research, among other things. One of the starkest examples of this has been the retrenchment of geographic borders alongside a rise in xenophobic rhetoric and policy. Nonetheless, even under a US administration of wall building and anti-immigrant executive orders, the recruitment of foreign healthcare workers to cover deficiencies in healthcare investment has remained unchanged. In his proclamation on 22 June suspending entry to the US of immigrants who represent risk to the labor market, President Trump made a notable exception—healthcare professionals able to provide “medical care to individuals who have contracted covid-19 and are currently hospitalized” are welcome to enter the country. This authorized the state department to issue “mission critical” visas to foreign medical professionals.
This points to the longstanding structural connection between US and Indian healthcare systems that closely links the unfolding situations in both countries. The covid-19 crisis—itself an exacerbation of a much longer crisis of inequality and inadequate healthcare for poorer people—forces us to confront the ties between healthcare in developed and developing countries, their history, and their consequences for the world’s most vulnerable populations.
More than 25% of doctors and 15% of registered nurses providing care in the US today received their training abroad.1 The international healthcare labor market has drawn tens of thousands of doctors and nurses into US hospitals annually for over 50 years. The US currently has 26 doctors per 10 000 people. By comparison, India, which has sent more doctors to the US than any other foreign nation, has fewer than nine doctors per 10 000 residents to manage a much higher burden of disease with limited supportive resources.2
Indian states have been reporting for months that even when beds are made available for people who need them, treatment efforts are often frustrated by a lack of physicians, and doctors across the country are reporting exhaustion and a physical inability to keep up with rising caseloads.3 Physician shortages are reported in states ranging from Kerala, which has a robust healthcare system and exceeds the World Health Organization’s recommended 1:1000 doctor to population ratio, to poorer states such as Bihar, which falls well below this target.4
In response, Indian policy makers have proposed allowing medical trainees who have completed residency to bypass their final accreditation exam and immediately enter clinical practice. Other suggestions include permitting physicians trained in Russia and China who failed their Indian licensing exams entry into the profession if they provide care in covid-19 units for a year; cancelling final exams for nursing students so they can join the workforce immediately; and training local teachers as healthcare aides.3
We argue that the necessity of such measures is in part a consequence of the US government’s decades long strategic maintenance of a floating international labor force of foreign trained healthcare professionals—a system that, rather than being responsive to the greatest disease burden, siphons lifesaving workers to the US and away from much needier contexts.
Care from the postcolony: outsourcing medical education
The fact that the US spends far more per capita on healthcare than its peer nations obscures its long term underinvestment in medical education. Federal support for residency training, for example, which is largely financed through Medicare, was capped under the Balanced Budget Act of 1997 amid concerns of a potential future physician surplus.5 The physician surplus never arrived, and this decades old allocation scheme and its restrictive caps remain largely in place today even as they are failing to meet the healthcare system’s needs. In 2019, amid declarations of a physician shortage, lawmakers in both the US House of Representatives and the US Senate proposed the Resident Physician Shortage Reduction Act to tackle the restrictive caps and to increase funding for residency training positions. These efforts, however, have stalled. Without urgent attention to infrastructural expansion, the American Association of Medical Colleges again predicts a shortfall of 120 000 physicians by 2030, the impact of which will be most severe on poor urban and rural communities.6
Since at least the 1960s, the US has trained fewer doctors than it needs to care for its residents, relying instead on the more economically expedient option of employing, typically at lower wages, immigrant physicians trained at the expense of other countries.7 This dynamic owes much to the Hart-Celler Immigration and Nationality Act of 1965, passed in the same year that Congress established Medicare and Medicaid, which substantially expanded healthcare access and created a need for many more doctors and nurses. Under this new immigration policy that prioritized the recruitment of highly trained professionals, the US solicited immigrant physicians, mostly from postcolonial Asian nations, to fill doctor shortages in under-resourced communities across the country.
In the first 10 years after the Hart-Celler Act, approximately 75 000 international physicians joined the US healthcare workforce.8 Overwhelmingly, these physicians hailed from states with struggling economies negotiating the wake of colonial extraction such that a job opportunity in the US represented a considerable advancement in both compensation and social status. Few lawmakers raised objections to this new practice. They either assumed it was a stopgap or supported the measure on ideological grounds, arguing for an unrestricted “international market of brains.”9 A young senator from Minnesota, Walter Mondale, however, condemned the strategy, pointing out its harmful effects on countries like India, and decried it as a “national disgrace.” In a 1967 article, he said that the USA’s reliance on doctors “from countries where thousands die daily of disease to relieve our shortage of medical manpower is inexcusable.”10
Mondale and others noted in congressional hearings that the dollar value to the US of the manpower being derived through immigration “approximately equals the total cost of all our medical aid, private and public, to foreign nations.”11 Revealingly, these US politicians inadvertently echoed Kwame Nkrumah’s foundational descriptions of neocolonialism, wherein aid “is merely a revolving credit, paid by the neocolonial master, passing through the neocolonial state, and returning to the neocolonial master in the form of increased profits.”12
Although these criticisms gained little traction in the US, they were shared by the Indian government, which deployed several strategies to curtail emigration of its much needed healthcare personnel. For a brief period in the 1970s, for example, the Indian government prevented the administration of the exam required for US immigration in hopes of retaining its doctors. More recently, Indian policy makers implemented a patchwork of bureaucratic strategies to deter, or at minimum regulate, healthcare emigration. Some of these measures include bond payment penalties issued to health professionals who bypass service in state run public hospitals, and the Ministry of Health and Family Welfare’s refusal to issue “no obligation to return to India” certificates for physicians who emigrate for training purposes, obliging them to return and serve Indian patients.
Despite these interventions, enforcement in India remains haphazard.13 The net effect of these policies is that India continues to be the world’s leading exporter of physicians, and the US the largest beneficiary. The consequences of this international marketization of healthcare labor has broad consequences for countries like India that are struggling to improve inadequate public health and clinical infrastructure.
A WHO study showed that, between the early 1960s and 2000, approximately 51% of graduates from the country’s top medical school, the All India Institute of Medical Science, left India, overwhelmingly to work in the US.14 The study reports similar dynamics at India’s other top tier medical schools, which unlike most of America’s best medical schools, are typically public and government funded such that the cost of training is borne largely by Indian taxpayers. This mass emigration of the best educated trainees raises concerns about the degree to which this trend has hindered high quality leadership in Indian healthcare and harmed Indian patients.
In 2010 WHO urged its member states to consider the ethics and effects of labor market dynamics and to adopt a Global Code of Practice on the International Recruitment of Health Personnel.15 This code was developed in response to a worldwide shortage of health personnel, and it recognises that unidirectional recruitment practices flowing from the developing to developed countries harms developing countries and exacerbates global health inequities. The code urged developed countries to coordinate recruitment strategies across health systems to mitigate the “negative effects” on the health systems of developing countries. It also recommended that developed countries provide technical and financial assistance to developing countries. Most importantly, the code advised that member states “strive to meet their health personnel needs with their own human resources” by “strengthening their educational institutions to scale up the training of health personnel.”15
WHO’s code of practice underlines the fact that the failure to properly invest in domestic healthcare infrastructure and education in the US and UK, for example, does not only harm the quality of healthcare in these wealthy nations: in a globalized postcolonial world of vastly unequal market power, these domestic policies perpetuate tens of thousands of unnecessary deaths daily among the world’s poorest people under our ordinary, non-pandemic reality.
Opportunity for change
As the US seeks to emerge from the pandemic, it has a unique opportunity to remake its healthcare system to improve both efficacy and equity—two terms that pandemic reality makes clear are necessarily tied together: the failure to provide good healthcare to all weakens public health everywhere and poses risks to even the wealthiest nations and patients.
To this end, US policy makers and healthcare educators must confront the need for major new investments in medical and nursing education, expanded healthcare access, and highest quality facilities. Population growth, an aging population, retiring physicians, and growing insurance coverage have contributed to rising demands for healthcare that cannot be satisfied without programmatic redress of current infrastructural deficiencies. Much of the funding for such health infrastructure projects could be mobilized through financial restructuring of the current US system, which already takes advantage of abundant resources but is plagued by inefficiencies, profiteering, and economic barriers to access.
Not since Mondale’s early criticisms have US policy makers confronted the harms that the American medical system imposes on the residents of other countries from which the US draws much of its healthcare workforce. Covid-19 has killed hundreds of thousands of people in the world’s richest nations. This should provoke urgent allocation of personnel, technology, and supplies to mitigate the long term devastation that this pandemic is now also beginning to inflict, both directly and indirectly, on poorer countries like India, Mexico, Brazil, and South Africa.16
Rather than divesting from international collaborations like WHO, the US should reverse its mode of engagement and increase its contribution to global health and to training a global healthcare workforce. If the current pandemic has provoked US politicians to emphasize the importance of domestic production of vital supplies, then dramatically increased investment in medical education should be a key piece of better pandemic preparedness, as well as a more responsible, ethical position in global health.
The US must end its routinized dependence on healthcare professionals from needier countries. It should instead overproduce doctors and nurses to exceed domestic needs and become a major source of well trained personnel to care for vulnerable populations around the world.
Eric Reinhart is a visiting research fellow at the Institut für die Wissenschaften vom Menschen in Vienna. He is a PhD candidate at the Harvard University Department of Anthropology, MD Candidate at the University of Chicago Pritzker School of Medicine, and candidate in adult psychoanalysis at the Chicago Center for Psychoanalysis.
Eram Alam is an assistant professor of the history of medicine at Harvard University. Her forthcoming book, The Care of Foreigners, is a history of the international healthcare labor market and of South Asian international medical graduates in the US since 1965.
Provenance and peer review: Commissioned; peer reviewed
Competing interests: Neither author has any competing interests to declare.