[Comment] The great healthcare robbery

from the Los Angeles Times

Overreaching medical journal denounces 'poaching' of medical professionals
By Kerry Howley

Is Ephraim Dagadu stolen goods? The Ghana-born and trained physician, who runs a successful family practice in Maryland, does not speak like a man who has been ripped from his rightful home and forced to toil in the Baltimore suburbs. His visage appears on no milk cartons; no cross-continental Amber Alert calls for his return. But according to a recent piece [registration required] in a prominent British medical journal, a caring U.S. would have done more to keep Dagadu from encountering opportunity abroad. He, goes the argument, belongs to Ghana.

"Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm: The practice should, therefore, be viewed as an international crime," Edward J. Mills of the British Columbia Center for Excellence in HIV/AIDS and nine coauthors write in the Lancet. They go on to suggest a place to nail those who tell Ghanaians, Kenyans and Malawians about jobs available elsewhere: The International Criminal Court.

While Mills' "off with their heads!" approach is uniquely spirited, he is giving voice to a conviction broadly held in the development community. In Kenya, there are 14 physicians for every 100,000 people. In the United States, there are 256 serving the same number. How cruel, then, when a fresh-faced American recruiter alights in Nairobi, luring away precious human resources with juicy promises of good pay and better hours. (This is sometimes called "poaching," which suggests educated African men and women are some kind of exotic prey; tellingly, MSNBC and American Renaissance News are equally fond of this phrasing.) Shouldn't we round up these deadly sirens and ship them to The Hague?

Before we pull out the handcuffs, we might pause to look at some research. Last year, Michael Clemens, a research fellow and Harvard-trained economist at the Center for Global Development, collected data on African-born health workers in the nine most popular destination countries, including the United States and Britain. He then checked the numbers against World Health Organization estimates of the numbers of doctors and nurses who work in each African country. To his surprise, he found a high correlation between the number of doctors per capita working within a country and the number of emigrants from that country working abroad. In other words, those African countries that had sent the most workers abroad also had more healthcare workers back home. Nothing in the data links even massive out-migration of physicians to child mortality.

That doesn't tell us everything about the relationship between the number of health workers in an African country and the number of professional emigrants who choose to leave. It does tell us that if the emigration of health workers hurts African countries at all, it is not the primary determinant of deadly, tragic shortages. Criminalizing the provision of information to Africans is unlikely to do much good beyond sating the understandable human hunger to "do something."

Mills reports that "recruitment strategies involve advertising in national newspapers and journals, text-messaging to health workers, personal e-mails and Internet sites." His answer to the problems of Malawi, a country with a per capita GDP of $596, an AIDS crisis and endemic corruption at every level of government: Ban those text messages. That way, valuable health workers won't think to seek opportunities outside of the colonial boundaries in which they happen to be born.

Here in the doctor-rich West, we tend to frown on censorship, and we should probably do the same when considering Africa -- especially given how little we know. It is probable that countries like Kenya are training far more professionals than the public healthcare systems can afford to employ, so nurses working abroad would not be providing medical services even if they were back home. Reducing opportunities abroad also means reducing the incentive to pursue higher education. Why spend years in medical school if your country can't employ you and the international community has deemed you ineligible to work?

For his part, Dagadu thinks a ban will have little effect on migration. Most people he knows, he says, came over on their own, or came, as he did, in pursuit of postgraduate education. Of sub-Saharan Africa, he says "the working conditions are poor, there are no good incentives, and there is social upheaval across the continent." It's not, he adds, a "stable work environment."

The problems, in other words, are deep-rooted, intimidating and not amenable to easy solutions; they have endured despite billions of dollars spent and gallons of ink spilled in the effort to eradicate poverty in sub-Saharan Africa. Just as prosecuting recruiters will not prevent African men and women from traversing the Atlantic, building walls around Africa will not lessen the toll of AIDS or enrich impoverished health systems. The last thing the West needs to be doing is actively reducing opportunities open to educated, motivated men and women from less-prosperous economies.

There is little to be gained from policing the information that finds its way over fiber-optic cables, through social networks or from the mouths of enterprising recruiters to the poorest countries in Africa. We'd be far better off policing the quality of material that finds its way into esteemed medical journals.

Kerry Howley is senior editor at Reason magazine.