To the Editor: As African physicians who have experience inboth the developing and the developed worlds, we believe thatMullan (Oct. 27 issue),1 like others who have written aboutthe metrics of the physician brain drain,2 overlooks three importantpoints. First, given the limited number of residency positionsin the source countries, if the migrating physicians who aredescribed in this article had stayed home, they might not haveattained the qualifications they now hold. This would have lefta workforce of minimally trained doctors with even fewer jobsbefitting their qualifications. Second, a reversal of the "fatalflows" of doctors from poor to rich countries, as touted byChen and Boufford in the accompanying editorial,3 would notnecessarily lead to an effective increase in the number of practicingphysicians, given the unequal geographic and socioeconomic distributionof physicians within source countries. Anecdotally, we knowmany such physicians who, out of frustration, have left medicinealtogether. These internal losses buttress our third point:the real effects of physician migration cannot be captured bystatic (stock-of-manpower) indicators.4 We need to quantifythe effects on flows and distribution of physicians within thesource countries. These countries must actively contribute tocrafting ethical and effective solutions. We hope that the WorldHealth Report 2006 will encourage such developments.5
Uzor C. Ogbu, M.D. Netherlands Institute of Health Sciences 3000 DR Rotterdam, the Netherlands uzorco{at}yahoo.com
Onyebuchi A. Arah, M.D., Ph.D. Academisch Medisch Centrum 1100 DD Amsterdam, the Netherlands
References
Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-1818. [Free Full Text]
Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health 2004;2:17-19. [Medline]
Chen LC, Boufford JI. Fatal flows -- doctors on the move. N Engl J Med 2005;353:1850-1852. [Free Full Text]
Hyder AA. Third world brain drain: performance of health professionals and systems needs to be assessed. BMJ 2003;327:929-930. [Free Full Text]
To the Editor: One of the major problems of being a physician or scientist in a developing country is the shortage of academicopportunities. Medical migration, or "brain drain," from thesedeveloping countries is at least partially due to the potentialrisk of being deprived of such academic opportunities and losingscientific skills, which can lead to "scientific brain death."Since the Internet provides rapid access to the scientific media,physicians from developing countries can now update their knowledgemuch more easily and have access to any scientific publication.An awareness of the amazing developments in their fields anda shortage of academic opportunities make emigration to a betterscientific environment an attractive option for many physicians."Brain drain" is widely considered as one of the therapeuticoptions for the prevention of "scientific brain death."
To the Editor: Mullan joins Chaguturu and Vallabhaneni (Oct.27 issue)1 in raising timely issues for developing countries.A disheartening development in the Philippines is the increasingnumber of physicians who are retraining to become nurses. Mostdoctors there receive an annual salary equivalent to less thana month's pay for a nurse in a U.S. hospital. Immigration tothe United States for nurses is much simpler than it is forphysicians. Since the year 2000, more than 3500 Filipino physicianshave taken accelerated nursing courses and have left for nursingjobs abroad. More than 4000 physicians are now in nursing school.These students include not just new physicians but internists,surgeons, anesthesiologists, family practitioners, and subspecialists.2
On the basis of Mullan's brain-drain formula and the actualnumber of Filipino physicians abroad, which is close to 22,000,the emigration factor for the Philippines increases to 19.4percent. Widespread awareness of these issues is important becauseplugging the brain drain will require a multilateral approachinvolving not just source and recipient countries but a globaleffort for equitable health care.
Angela F. Domingo, M.D. Edsel Maurice T. Salvana, M.D. University Hospitals of Cleveland Cleveland, OH 44106 angela.domingo{at}case.edu
References
Chaguturu S, Vallabhaneni S. Aiding and abetting -- nursing crises at home and abroad. N Engl J Med 2005;353:1761-1763. [Free Full Text]
Galvez Tan J, Sanchez FS, Balanon VL. The brain drain phenomenon and its implications for health. Presented at the International Conference on the Medical Workforce Washington, D.C. 2004. (Accessed January 13, 2006, at http://www.up.edu.ph/forum/2005/Jul-Aug05/brain_drain.htm.)
To the Editor: Mullan's important report demonstrates that anontrivial portion of the physician workforce has immigratedto richer nations from low-income countries. However, well-intentionedbut misguided policies in source countries also contribute tosuch flows, and we should not discount their importance. Manyarticles in the field of economics demonstrate that income differentialsbetween source and recipient countries are the principal determinantof decisions regarding migration.1 In many source countries,government clinics are the primary source of employment forphysicians. Wages are not allowed to adjust to market levels,thereby exacerbating the pressure on physicians to emigrate.Moreover, many source countries provide enormous public subsidiesto medical education, thereby contributing to the training ofmore physicians than there would be if tuition levels were higher.Finally, in contrast to the view of Chen and Boufford, physicianmigration is not necessarily a "fatal flow." If physicians werenot able to find work in high-income countries, evidence suggeststhat potential students might not continue to become physiciansin their home countries.2,3
Amitabh Chandra, Ph.D. Harvard University Cambridge, MA 02138 amitabh_chandra{at}harvard.edu
References
Borjas G. The economic analysis of immigration. In: Ashenfelter O, Card D, eds. Handbook of labor economics. Vol. 3A. New York: North-Holland, 1999:1697-760.
Willis RJ, Rosen S. Education and self-selection. J Polit Econ 1979;87:S7-S36. [CrossRef]
Berger MC. Predicted future earnings and choice of college major. Ind Labor Relat Rev 1988;41:418-429.
The author replies: Over the past half century, as global travelhas become easier and the paths of medical credentialing havebecome more standardized, migration of physicians from poorercountries to wealthy Anglophone nations has become commonplace.Dr. Chandra and Dr. Gemici raise the important issue of thepaucity of medical-training opportunities in low-resource nationsas an acceptable rationale for medical migration from poor countriesto rich ones. Although one can respect the desire to emigrateto obtain better opportunities, it is hard to make the casethat advanced training in medicine is either a "right" or goodhealth policy. The desire of ambitious physicians to seek betterpractice and economic opportunities is understandable, but lessdefensible are the medical-education policies of Anglophonecountries that fail to train a sufficient number of physiciansto meet their own needs and then draw on the ambition of doctorseducated elsewhere.
Dr. Chandra, as well as Drs. Ogbu and Arah, suggests that withoutthe opportunity to move abroad in search of training, many physiciansin low-resource countries might eschew the study of medicine.This premise illustrates another deleterious aspect of currentlarge-scale emigration. The brain drain is actually a safetyvalve for systems in need of reform. It is a launchpad for somenations' brightest young minds who, if they stayed at home,would demand change and probably lead that change. This perspectivewill not be well received by many migrating doctors, but ifglobal calls for a reduction in poverty and an increase in healthequity are to make any headway, these medical minds will haveto be part of the solution, not the exodus.
The troubling report of Drs. Domingo and Salvana on the retrainingof Filipino physicians as nurses in order to enter practicein the United States dramatizes the truly pernicious effectof the human-resource vacuum caused by the failure of the UnitedStates to train enough doctors or nurses for its own needs.Medical and nursing educators and policy leaders at both endsof the immigration road need to develop strategies to mitigatethe brain drain. In the United States, this means, first andforemost, training toward the goal of self-sufficiency in themedical workforce.
Fitzhugh Mullan, M.D. George Washington University School of Public Health and Health Services Washington, DC 20006 fmullan{at}gwu.edu
Arah, O. A., Ogbu, U. C., Okeke, C. E.
(2008). Too Poor to Leave, Too Rich to Stay: Developmental and Global Health Correlates of Physician Migration to the United States, Canada, Australia, and the United Kingdom. Am. J. Public Health
98: 148-154
[Abstract][Full Text]
Previous
