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How to halt the brain drain

BMJ 2006; 332 doi: (Published 13 April 2006) Cite this as: BMJ 2006;332:921

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You can't write in the chimney with charcoal.

Dear Editor,

Those who wish to know the holistic picture of physician emigration,
the so called brain drain, should read the following article by Fitzhugh
Mullan, a professor of Paediatrics at the George Washington University in
Washington DC, who recently had a grant to travel all over India to study
this problem.(1) India contributes the largest émigré physicians’
workforce to the world. 60,000 Indian physicians work in the US, UK,
Canada, and Australia to name a few. That is about 10% of the Indian
physician count.

India is a continent occupying 2.4% of the land mass with 15% of the
world population. Eighty per cent of the latter are in the far flung
villages where medical care is hardly existent. Of the 592,215 doctors
registered in the Medical Council of India more than 80% work in the urban
centres while 80% of Indians live in the villages. The city of Chennai
alone has 20 hospitals offering kidney transplants. In effect there are
two Indias-the hi-tech shining rich urban India and the low tech rural
poor India which escapes the radar scan of the rich and the famous. Inside
the hi-tech city of Bangalore alone one in eleven children daily dies for
want of low tech solutions like clean water and sanitation. Just outside
the commercial capital of India, Mumbai, there is a small Adivasi village,
Jamsar, where daily children die of malnutrition!

India has another problem of too many specialists and “super
specialists” and too few well trained family physicians or generalists.
Any country that has this picture has the worst health scenario. US is one
such and has the last but one rank in the 14 industrialised countries
evaluated recently, mainly because of the surfeit of specialists and
dearth of family doctors.(2) With the per capita income at $470, India
ranks 161 in the world. India spends 5.1 % of its GDP on health (Pakistan
4%, Sri Lanka 3.7%, China 5.4% and Brazil 7.6%) most of which goes to
maintain the hi-tech government hospitals and the salaries of government
doctors. Hardly anything goes for basic health needs like clean drinking
water, three meals a day uncontaminated by human and/or animal excreta, a
toilet to avoid the deadly hookworms, smoke free dwellings, a roof over
the poor man’s head instead of the star-lit sky, and economic empowerment
of women to feed their starving children.

If we could assure the poor man about the viability of his off spring
he would accept family planning easily. If India could invest a part of
its GDP for exclusively providing the basic health needs mentioned above,
India’s health scenario will change for better completely, the brain drain
notwithstanding. India will be happy to contribute physicians to the world
as it is India's biggest export commodity. Our present medical education,
where the student is taught within the four walls of the hi-tech medical
teaching hospitals, where the teachers use technology to practise medicine
will never be able to practise medicine in our villages conscientiously.
They are fit to man lower grade posts in foreign countries or in the hi-
tech private hospitals mushrooming in India with the new label of “Health
Tourism Industry.” These hospitals hardly do anything for any body’s
health. They all cater to medical care of the sick and the well segments
of society. The latter, routine screening, is a big industry in the
present world of Corporatocracy.

We would be happy for those that choose to migrate. Let us revamp our
medical education to meet our rural needs and improve our basic health
needs. “People who believe that doctors and hospitals keep society’s
health are mistaken” wrote Denis Burkitt years ago. Where there are more
doctors, society’s health is the worst. (2) We need more trained public
health workers and villages health watchers. There is a growing awareness
of these lacunae in our set up. It is interesting to know that all those
that have no stake in India’s health care and are enjoying the economic
security of the west are writing about “brain drain”. They make it appear
that their “brilliance” is not being taken care of in their mother land.
They have conveniently forgotten that their training did cost the poor
Indian tax payer a lot of strain. It reminds me of what Bob Hope, the
American humorist, once said: “In the US all those that know how to run
the government are unfortunately either driving taxis or cutting hair!”
How true?

Yours ever,



1) Mullan F. Physician Emigration. Health Affairs 2006; 25: 380-393.

2) Starfield B. Is US medicine the best? JAMA 2000; 284: 483-485.

Competing interests:
None declared

Competing interests: No competing interests

24 April 2006
BM Hegde
Retd. Vice Chancellor