Ethical Issues in the Migration of Health Professionals
Many of the physicians and nurses who care for patients in wealthy countries were born and educated in resource-poor developing countries. In the United States, about 25 percent of the physicians are international medical graduates (IMGs), which means that they received their medical education outside the United States (Mullan, 2005, p. 1811). Only 3 percent of U.S. physicians are U.S. citizens who attended medical school in other countries, whereas 22 percent of U.S. physicians migrated to the United States from other countries (Mullan, pp. 1812–1814). Similar patterns exist in other wealthy, English-speaking countries, such as the United Kingdom, where over 28 percent of physicians are IMGs, and Australia and Canada, where IMGs represent more than 26 percent and 23 percent of physicians, respectively (Mullan, pp. 1811). With regard to nursing, foreign-educated nurses constitute approximately 10 percent of the U.K.’s nursing workforce, and more nurses who were trained outside that country registered to practice there in 2001 than did nurses who were trained in the United Kingdom (Dwyer, 2007, p. 37). Data are extremely limited or unavailable about the migration of other categories of health workers, such as pharmacists and allied health professionals (World Health Organization, 2006, p. 98).
Many of the source countries from which health professionals migrate are suffering as a result of severe shortages of health workers, low life expectancy, and high burdens of disease (Dwyer, 2007, pp. 36–37, 40). In both the United States and the United Kingdom, the largest number of IMGs is from India, and many more IMGs come from Pakistan. Another major source for IMGs in the United States is the Philippines. When these numbers are calculated as percentages, they reveal that countries in sub-Saharan Africa provide particularly large percentages of their limited number of physicians to the wealthy destination countries (Mullan, 2005, 1812–1816). For example, out of the 500 physicians who were trained in Zambia since that nation became an independent country, only 60 are still practicing medicine in Zambia (Johnson, 2005, p. 3). Out of a total of 3,240 physicians in Ghana, 926, or about 29 percent, were working in eight wealthy countries (World Health Organization, 2006, p. 100). Moreover, Ghana reached a dreadful equilibrium in 1999 by losing as many nurses to migration as it certified, and then it lost twice that number in 2000 (Chaguturu and Vallabhaneni, 2005, p. 1762). South Africa loses health care professionals to more industrialized countries, but it is a destination country for physicians from less developed countries in Africa (Dwyer, 2007, p. 37; Wright and others, 2008).
The causes of medical migration include both pull factors, which draw health care professionals to more developed countries, and push factors, which cause professionals to leave their home countries. According to the World Health Organization (2006), “Workers’ concerns about lack of promotion prospects, poor management, heavy workload, lack of facilities, a declining health service, inadequate living conditions and high levels of violence and crime are among the push factors for migration…Prospects for better remuneration, upgrading qualifications, gaining experience, a safer environment and family-related matters are among the pull factors…In Zimbabwe, for example, a startling 77% of final university students were being encouraged to migrate by their families” (pp. 99–101).
In some cases, patterns of medical migration reflect former colonial relationships, such as migration of physicians from the Philippines to the United States and from India and Pakistan to the United Kingdom (Mullan, 2005, pp. 1812, 1816). As stated earlier, the United States receives the largest number of its IMGs from India, which was never a colony of the United States, but that migration is facilitated by the use of the English language in both India and the United States, both of which are former colonies of England (Mullen, 2005). The use of English in the Commonwealth countries of Africa makes health workers from those former British colonies more desirable in wealthy, English-speaking countries (Johnson, 2005, p. 2). Interestingly, some former colonial powers do not rely extensively on IMGs from their former colonies. Despite France’s historical and linguistic relationships in Africa and Asia, only 3 percent of France’s physicians are IMGs (Mullen, 2005, p. 1816).
For source countries the consequences of brain drain are severe. According to the World Health Organization’s World Health Report 2006, fifty-seven countries have a critical shortage of health workers (p. 12). Many of the source countries also experience an internal brain drain of health professionals from the countryside to the cities and from public health care facilities to private facilities (Dwyer, 2007, p. 38; Organisation for Economic Co-operation and Development, 2008, p. 68). For countries that suffer from HIV/AIDS and lack sufficient health workers to meet the United Nation’s Millennium Development Goals, the further losses of health professionals have been described as “fatal flows” (Chen and Boufford, 2005, p. 1851). As James Johnson (2005) has pointed out, “Although the developed countries of the North are giving aid with one hand, they are robbing African countries with the other by siphoning off their most precious resource—trained doctors and nurses” (p. 2). Similarly, Sreekanth Chaguturu and Snigdha Vallabhaneni (2005) have noted that international assistance has increased the availability of drugs for AIDS in developing countries, but wealthy countries are draining off the nurses needed to deliver those drugs: “It seems like a cruel joke to play: providing funds for AIDS care but simultaneously taking away the nurses who can give that care” (p. 1762). In addition, medical migration deprives poor countries of the money that they invested in educating their health professionals (Chen and Boufford, 2005, p. 1851; Dwyer, 2007, p. 37), and distorts medical education in source countries by preparing prospective migrants to treat diseases that are more relevant to wealthy countries than to local populations (Mullan, 2005, p. 1816).
However, as Francesca Colombo and others noted in an Organisation for Economic Co-operation and Development (OECD) report (2008), migration of health professionals, while making an existing problem worse, is not the primary cause of the human resource crisis in developing countries (p. 63). As explained in that report, “The World Health Organization’s estimates of regional health professional shortages largely outstrip the number of foreign-born health professionals who have emigrated to OECD countries. This means that even considering an unrealistic hypothetical scenario where migration from developing countries were to stop, these countries would still face up to considerable health human resource gaps” (p. 63). Moreover, some of the source countries that have severe shortages of nurses also have high rates of unemployment among nurses. Qualified nurses in those countries are unable to find jobs because their health systems have insufficient funds or are subject to hiring restrictions in programs of reform or because the jobs appear to be filled by “ghost workers,” people who are paid but do not actually work (Kingma, 2007, p. 1287). Thus, in some of the impoverished source countries, stopping the migration of nurses would not necessarily increase the number of nurses available to treat patients.
Migration of health care personnel to wealthier countries could provide some benefits to source countries, but the extent of those potential benefits is questionable. In theory, migrants could acquire skills that would help their home country when they return, but many migrants do not return to their country of origin, and those who do return will find that some of the skills they acquire in wealthy countries are not relevant to the needs of the local population (Organisation for Economic Co-operation and Development, 2008, p. 67). Some migrants assist their home countries on a temporary basis by teaching or providing medical services (Organisation for Economic Co-operation and Development, p. 67), but it is difficult to quantify the extent or effects of those activities.
Migrants often send money home to their families, and those remittances can represent an important share of the source country’s gross domestic product (Kingma, 2007, pp. 1291–1292). The Philippines has adopted a policy of promoting temporary migration of health care workers and using remittances to promote development of the country (World Health Organization, 2006, p. 101). However, the 2008 Organisation for Economic Co-operation and Development report concludes that remittances probably do not compensate a source country for the loss of health care professionals and do not promote development of the local health system. Moreover, these well-educated health workers probably come from families that are relatively wealthy, and therefore their remittances are benefitting those people in the source country that need this help the least (p. 64). For that reason, James Dwyer (2007) rejected the approach of trying to weigh the advantages and disadvantages of medical migration for source countries and instead advocated an approach of social justice and international justice, saying: “This concern with the least advantaged is missing from accounting models of international justice that simply tally up the average gains and losses in the respective countries. Balance sheets that try to calculate what a source country loses and what it gains in remittances and partnerships tend to ignore the distribution. The least advantaged in the source countries are often left behind because the remittances rarely benefit them, and the out-migrations undermine the public sector on which they depend. The private gains do not compensate fairly for the public losses” (p. 41).
Moreover, the destination countries are not mere passive recipients of individual health workers who choose to exercise their right to emigrate. First, the right of an individual health professional to emigrate does not necessarily require any particular destination country to admit that individual. Destination countries choose to grant entry visas to potential immigrants who are considered desirable, including health care professionals, while denying visas to many prospective immigrants who lack professional skills (Dwyer, 2007, pp. 38–39). In considering individual applications for visas, destination countries could consider the effect of immigration on the applicant’s home country but ordinarily do not consider that factor. Moreover, some destination countries permit the operation of for-profit recruiting firms, with little or no effective regulation of their recruiting practices. From an ethical perspective, governments of destination countries cannot disclaim all responsibility for unethical recruiting practices by insisting that the recruiting is conducted by private firms that those governments do not regulate.
In addition, some destination countries have intentionally created their own need for migrant health professionals by failing to produce sufficient numbers of domestic professionals. Those countries have relied instead on less expensive migrant workers, who can be sent home when they are no longer needed. As Lisa Eckenwiler (2009) has written, “the growing reliance by some affluent countries on migrant health workers is not merely the result of poor planning, but increasingly, an integral part of health and labour policy” (p. iii). The 2008 Organisation for Economic Co-operation and Development report describes this as a “free rider” situation: “Countries have inadequate incentives to train sufficient health workers so long as they can rely on immigration to fill any gaps between supply and demand. Also, training more health professionals than necessary may be costly in terms of public expenditure. The resulting temptation is to risk shortages and to export them, if they arise” (pp. 35–36). The United States, for example, relies heavily on IMGs to provide indigent care, as medical residents in urban hospitals, and as practitioners in rural areas (Dow and Harris, 2002, pp. 68–69; Dwyer, 2007, p. 39).
Wealthy destination countries also have substantial influence over the policies of international lenders. Therefore, those wealthy countries bear some responsibility for the structural adjustment programs and other policies that limit public sector spending in developing countries, thereby contributing to shortages of health workers and increasing the incentive for remaining workers to emigrate (Kingma, 2007, p. 1286; Dovlo, 2007, p. 1375; Eckenwiler, 2009, p. iii). For all of these reasons, wealthy destination countries cannot claim to be mere passive recipients of individual migrants but rather bear substantial responsibility for the migration of health professionals and for the effects of that migration on developing countries.
The following excerpt from an article by David Wright and colleagues describes the history of medical brain drain, as well as the ways in which perceptions of the phenomenon and its ethical implications have changed over time. As Wright and colleagues explain here, those changes in perception are consistent with the recent trend in bioethics, described in Chapter ONE of this book, to consider important issues of social justice and population health.
Excerpt from “The ‘Brain Drain’ of Physicians: Historical Antecedents to an Ethical Debate, c. 1960–79” By David Wright and Others
Background
The recruitment of health care practitioners from developing to developed countries is now an important topic in global health ethics. The intense public policy interest in foreign-trained doctors and nurses, however, is not new. During the mid-1960s, most western countries revised their immigration policies to focus on highly-trained professionals. These immigration changes facilitated the migration of hundreds of thousands of health care personnel from poorer jurisdictions to western countries to solve what were then deemed to be national physician and nursing shortages. Although we are now beginning to understand the broad socio-geographical impact of this massive international migration of health care workers, little has been written about the historical origins of this important era of post-war medical migration.
This paper will examine the emergence of the debate over what is now popularly called the “Brain Drain”—the migration of physicians from developing to developed countries and between industrialized nations. It will demonstrate how the early scholarship on the brain drain arose not from a concern over the impact on developing countries, but from a recognition in Britain of the loss of post-war NHS physicians to North America. Occasionally, early research acknowledged that the migration of health human resources from developing to developed countries (which was also occurring apace) raised concerns. However, writings in immigrant receiving countries—such as Canada, the United States, Britain or Australia—did not conceptualize physician immigration as ethically problematic. The responsibility for such a transfer of what was then commonly referred to as “highly skilled manpower” was understood as the accumulation of thousands of defensible individual decisions made by the doctors themselves. Indeed, much of the literature emphasized the value of advanced medical training being provided by industrialized countries. Moreover, since so much of the medical migration in this period occurred between developed countries the ripple effect on third and fourth countries was seldom fully appreciated or commented upon.
By contrast, the literature over the last decade has witnessed a dramatically different conceptual framework, informed by globalization, the rise in South Africa as a leading “donor” country, and the ongoing catastrophe of the AIDS epidemic. Unlike the literature a generation ago, new scholarship has focussed on the responsibility (financially or otherwise) of receiving countries to donor countries. Such ideas reflect in part, the rise (and partial acceptance) of international treaties (such as the Kyoto Accord) whereby countries have obligations to the global community for policy decisions they make domestically. This paper explores the historical antecedents to this important ethical debate in global health care.
The Transnational Migration of Physicians, c. 1960–79
By the early 1960s, governments in western industrialized nations recognized with alarm that the domestic production of professionals—university professors, engineers, scientists—was insufficient to provide the same level, let alone a surging demand, for professional services within their respective societies. Nowhere was this more acutely felt than in the domain of health care where rising affluence and technological advances in the treatment of diseases led to a growing need for medical personnel. In English-speaking Commonwealth countries, this demand for health care services was accelerated by the advent and extension of universal state-run health insurance systems which unleashed a seemingly insatiable appetite for state-funded procedures. Western, industrialized English-speaking countries were thus to experience in the 1960s and 1970s an acute problem of access to physicians which would be characterized, by the press, as national doctor “shortages”
The “Brain Drain” of Physicians from Britain to North America
The term “brain drain” appears to have become popularized in the context of a substantial body of work about the impact of physician migration on countries in the developed rather than developing world. Mainly written by American and British scholars, this literature was the first to address the impact of medical migration on the health systems of the “first world”. In Geographical Mobility and the Brain Drain, McKay characterised the term “brain drain” as a “peculiarly British invention” that was coined in the mid-1950s (by the Royal Society) to capture the social and professional impact of British medical graduates leaving the country to seek opportunities in North America. McKay’s study traced large numbers of Scottish medical graduates who flocked south to England, across the Atlantic to the United States and Canada, and down under to Australia and New Zealand
Western Bioethics Meets Global Social Justice
There appear to be several reasons why the migration of physicians from developing to developed countries did not coalesce in the 1960s and early 1970s into a major ethical debate. The first concerns the unpredictable movement of the physicians themselves. While plenty of statistical information was available regarding the inflow of migrating physicians to wealthy countries, the outflow (emigration) records of developing countries were fragmented, if they existed at all. Social scientists had to, in effect, piece together the larger puzzle by working backwards from data in recipient nations. In addition, this poorly understood drain of resources was supposed by most scholars to be only temporary. It was frequently assumed that many foreign-born or trained physicians who had migrated would eventually return home following a period of additional or “advanced training” in the developed country. The reality that most of these physicians settled abroad permanently or migrated to yet other developed countries was not widely recognized. The degree and nature of permanent international migration of physicians from poorer to richer countries had to be determined before it could be assessed or judged to be explicitly unethical.
Complicating matters…was the phenomenon of certain developed countries—like Britain and Canada—being in the then top nations as both donor and recipient countries, owing to their status as countries used as “stepping stones” to elsewhere. In these cases, nations simultaneously received physicians from abroad while they themselves were losing health human resources to medical migration elsewhere. Further, there were a small number of countries who began supporting the migration of physicians either for geo-political, historical or financial reasons. Castro embarked on a self-conscious policy of training physicians for export, in order to support the ideal of socialized medicine and socialist politics. Ireland, a country that had a long history of out-migration, reconciled itself to the fact that many physicians would leave for elsewhere by generating a capacity to graduate more doctors than the country could absorb. Finally, in a manner analogous to its support of nurse and caregiver migration, the Philippines appears to have encouraged the out-migration of physicians in order to facilitate the flow of millions of dollars of remittances.
Cultural attitudes and racial prejudices also played an important role. Most scholars of the 1960s and 1970s viewed foreign-born and -trained physicians—especially those from underdeveloped nations—as inferior to the medical graduates from developed countries. In other words, most early sources that investigate doctor migration demonstrate a prejudice towards the quality of care provided by foreign medical graduates, even though many countries were relying heavily on these foreign workers to fill the gaps in their health service systems. It took a good decade for international medical graduates to prove themselves worthy of being considered and discussed as equals with physicians trained in industrialized countries. Only then could the ethical problems begin to be articulated with respect to the drain of medical personnel from developing countries to developed ones. Foreign physicians had to be appreciated as being valuable resources before ethical, transnational concerns could be conceived of, and applied to, their situation.
Finally, there seems to have been an implicit understanding that it was ultimately the physician’s choice to leave his or her home country—which removed culpability from developed countries for “stealing” medical personnel. As health economist Alfonso Mejia put it rather elegantly, “Learned men (and women) have always travelled abroad seeking a more congenial intellectual milieu to realise their full potential”. The physician’s decision to migrate was understood to be a very personal calculation based upon a unique set of factors for each individual, the prevention of which would itself be both impossible and unethical. How could the post-war Western World embrace refugees and economic migrants but deny the right of educated individuals to better their personal situations?…
Thus even those who were coming to understand the magnitude of the problem recoiled from suggesting interventionist measures to stop it. There appeared to be a conceptual chasm: how could thousands of defensible…[individual] moral decisions constitute one large collective ethical problem?
The conceptual leap—from an individualistic bioethics attitude which framed ethical issues within the doctor-patient-relationship to one that began to conceptualize collective rights and identify problems of global social justice—was a long time in formation. Bioethics was, for the longest time, rooted in moral dilemmas arising from the increasing use of medical technologies particularly within North American and Western settings. Bioethics was thus preoccupied with micro-ethical issues and has only recently begun to focus on what are increasingly called global health ethics. This intellectual shift is reflected in the growing use of the term “global health” in medical literature, one which took off in the 1990s as a term to replace international health. As Brown et al. explain, global health in contradistinction to “international health…recognizes the growing importance of actors beyond governmental or intergovernmental organizations and agencies”. The transnational migration of health workers clearly falls within this “global” realm and outside the traditional discourses of Western bioethics.
Out of Africa
During the 1980s and early 1990s, the interest in the international migration of foreign-trained doctors subsided in concert with the dramatic decline in the licensing of IMGs in most western countries. By the late 1990s, however, the issue of national doctor and nursing shortages had emerged as a major topic of concern and public interest. By this time, rural regions of industrialized countries were finding themselves denuded of primary care and looked abroad to foreign-trained doctors as a solution. For the last decade then, western countries have ramped up their licensing of foreign-trained doctors. But, unlike a generation ago an ethical and public policy debate has emerged around this phenomenon. In this current era of globalization, politicians and policy makers could no longer claim ignorance about the impact of medical migration on donor countries.
Within the new ethical debate, South Africa has played a totemic role. Devastated by the AIDS pandemic and struggling with rebuilding a post-apartheid civil society, the dramatic exodus of (mainly) white doctors, aided and abetted by western countries, has touched raw nerves. The exact number of doctors who are practising abroad is unknown, but the South African Medical Association estimated in 2002 that over 3,500 (approximately 50%) of its domestically-trained doctors were living abroad. Ironically, South Africa itself backfills, by recruiting African doctors from poorer states, such as Uganda and Tanzania. The South African Medical Journal describes a “medical carousel”, in which doctors seem to be continually moving to countries with a perceived higher standard of living.
The ethical debate currently revolves around several related issues. Critics point to the purposeful underproduction of health human resources in the West to be supplemented, as a matter of policy, by foreign medical graduates. This results, they argue, in the depletion of health human resources in countries that are not only poorer but often plagued by serious public health challenges. On the opposite side, commentators suggest that it would be unethical to restrict the free movement of skilled labour in an era of globalization. Physicians, they argue, have as much a right to safe working conditions, or decent pay, as anyone else does. Some have even argued that the poor public health conditions in Africa are “a result of factors unrelated to international movement of health professionals”. Others lament that, even if a restriction on the emigration of health professionals may be desirable, it would be largely impossible to enforce. Nevertheless, the embarrassing optics of rich countries exploiting the health human resources of African countries devastated by the AIDS epidemic—one that has unfortunate trappings of neo-colonialism—has led to some intermittent policy initiatives. Britain, for example, recently pledged to tighten the loopholes in its three-year old commitment to stop recruiting from the “developing world”
At the 2005 World Health Assembly, the WHO resolved that World Health Day in 2006 should focus on the crisis of international migration of health personnel. Additionally, the assembly determined that their General Programme of Work, 2006–2015 should focus on the complexity of issues involved in international health human resource migration. Yet, despite recognition at the highest public policy levels, the question of physician migration and recruitment has failed to gain much traction from the lay public. Perhaps there is little popular appeal in industrialized countries to solutions that may, in many unpredictable ways, make the complex problem of doctor shortages worse. And so the brain drain continues and threatens to worsen over the next decade. As this article has demonstrated, the current wave of international physician migration, accelerated in part by health policy and immigration decisions made in industrialized countries, has a longer history to it than many current scholarly articles acknowledge. An historical perspective assists us in understanding the broader social and economic forces at work, as well as the changing ethical framework within which we understand this complex issue facing the world today
Source: Excerpted from “The ‘Brain Drain’ of Physicians: Historical Antecedents to an Ethical Debate, c. 1960–79,” by D. Wright and others, 2008. Philosophy, Ethics, and Humanities in Medicine, 3(24), [http://www.peh-med.com/content/3/1/24] (citations, references, tables, and some text omitted). Copyright 2008 Wright et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
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