Chapter 002. Global Issues in Medicine (Part 12)

Health Systems and the "Brain Drain"A significant and oft-invoked barrier to effective health care in resourcepoor settings is the lack of medical personnel. In what is termed the brain drain, many physicians and nurses emigrate from their home countries to pursue opportunities abroad, leaving behind health systems that are understaffed and illequipped to deal with the epidemic diseases that ravage local populations. The WHO recommends a minimum of 20 physicians and 100 nurses per 100,000 persons, but recent reports from that organization and others confirm that many countries, especially in sub-Saharan Africa, fall far short of those target numbers....
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Chapter 002. Global Issues in Medicine (Part 12) Chapter 002. Global Issues in Medicine (Part 12) Health Systems and the Brain Drain A significant and oft-invoked barrier to effective health care in resource-poor settings is the lack of medical personnel. In what is termed the brain drain,many physicians and nurses emigrate from their home countries to pursueopportunities abroad, leaving behind health systems that are understaffed and ill-equipped to deal with the epidemic diseases that ravage local populations. TheWHO recommends a minimum of 20 physicians and 100 nurses per 100,000persons, but recent reports from that organization and others confirm that manycountries, especially in sub-Saharan Africa, fall far short of those target numbers.More than half of these countries register fewer than 10 physicians per 100,000population. In contrast, the United States and Cuba register 279 and 596 doctorsper 100,000 population, respectively. Similarly, the majority of sub-SaharanAfrican countries do not have even half of the WHO-recommended minimumnumber of nurses. In addition to these appalling national aggregates, furtherinequalities in health care staffing exist within countries. Rural-urban disparities inhealth care personnel mirror disparities of both wealth and health. In 1992, thepoorest districts in southern Africa reported 5.5 doctors, 188.1 nurses, and 0.5pharmacists per 100,000 population. The same survey found, in the richestdistricts, 35.6 doctors, 375.3 nurses, and 5.4 pharmacists per 100,000 population.Nearly 90% of Malawis population is rural, but >95% of clinical officers were aturban facilities, and 47% of nurses were at tertiary care facilities. Even communityhealth workers, trained to provide first-line services to rural populations, oftentransfer to urban districts. In 1989 in Kenya, for example, there were only 138health workers per 100,000 persons in the rural North Eastern Province, whereasthere were 688 per 100,000 in Nairobi. In addition to inter- and intranational transfer of personnel, the AIDSepidemic contributes to personnel shortages across Africa. Although data on theprevalence of HIV infection among health professionals are scarce, the availablenumbers suggest substantial and adverse impacts on an already-overburdenedhealth sector. In 1999, it was estimated that 17–32% of health care workers inBotswana had HIV disease, and this number is expected to increase in the comingyears. A recent study that examined the fates of a small cohort of Ugandanphysicians found that at least 22 of the 77 doctors who graduated from MakerereUniversity Medical School in 1984 had died by 2004—most, presumably, ofAIDS. Similar numbers have been registered in South Africa, where a small studyby the Human Sciences Research Council found an HIV seroprevalence amonghealth professionals similar to that among the general population—in this case,15.7% of all health care workers surveyed. The shortage of medical personnel inthe areas hardest hit by HIV has profound implications for prevention andtreatment efforts in these regions. The cycle of health-sector impoverishment,brain drain, and lack of personnel to fill positions when they are availableconspires against ambitious programs to bring ART to persons living with bothAIDS and poverty. The president of Botswana recently declared that one of hiscountrys main obstacles to rapid expansion of HIV/AIDS treatment is a dearth ofdoctors, nurses, pharmacists, and other health workers. 3 In South Africa, thedeparture of nearly 600 pharmacists in 2001, coupled with standing vacancies for32,000 nurses, has put continued strain on that relatively affluent countrys abilityto respond to calls for expanded treatment programs. In Malawi, only 28% ofestablished nursing posts are filled. Furthermore, the education of medical traineesis jeopardized as the ranks of the health and academic communities continue toshrink as a result of migration or disease. The long-term implications are sobering. A proper biosocial analysis of the brain drain reminds us that the flight ofhealth personnel—almost always, as most reviews suggest, from poor to less-poorregions—is not simply a question of desire for more equitable remuneration.Epidemiologic trends and access to the tools of the trade are also relevant, as areworking conditions in general. In many settings now losing skilled healthpersonnel, the advent of HIV has led to a sharp rise in TB incidence; in the eyes ofhealth care providers, other opportunistic infections have also become insuperablechallenges. Together, these forces have conspired to render the provision of propercare impossible, as the comments of a Kenyan medical resident suggest:Regarding HIV/AIDS, it is impossible to go home and forge ...