Chapter 002. Global Issues in Medicine (Part 12) pps

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 pursue
opportunities abroad, leaving behind health systems that are understaffed and ill-
equipped 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.
More than half of these countries register fewer than 10 physicians per 100,000
population. In contrast, the United States and Cuba register 279 and 596 doctors
per 100,000 population, respectively. Similarly, the majority of sub-Saharan
African countries do not have even half of the WHO-recommended minimum
number of nurses. In addition to these appalling national aggregates, further
inequalities in health care staffing exist within countries. Rural-urban disparities in
health care personnel mirror disparities of both wealth and health. In 1992, the
poorest districts in southern Africa reported 5.5 doctors, 188.1 nurses, and 0.5
pharmacists per 100,000 population. The same survey found, in the richest
districts, 35.6 doctors, 375.3 nurses, and 5.4 pharmacists per 100,000 population.
Nearly 90% of Malawi's population is rural, but >95% of clinical officers were at
urban facilities, and 47% of nurses were at tertiary care facilities. Even community
health workers, trained to provide first-line services to rural populations, often
transfer to urban districts. In 1989 in Kenya, for example, there were only 138
health workers per 100,000 persons in the rural North Eastern Province, whereas
there were 688 per 100,000 in Nairobi.
In addition to inter- and intranational transfer of personnel, the AIDS
epidemic contributes to personnel shortages across Africa. Although data on the
prevalence of HIV infection among health professionals are scarce, the available

numbers suggest substantial and adverse impacts on an already-overburdened
health sector. In 1999, it was estimated that 17–32% of health care workers in
Botswana had HIV disease, and this number is expected to increase in the coming
years. A recent study that examined the fates of a small cohort of Ugandan
physicians found that at least 22 of the 77 doctors who graduated from Makerere
University Medical School in 1984 had died by 2004—most, presumably, of
AIDS. Similar numbers have been registered in South Africa, where a small study
by the Human Sciences Research Council found an HIV seroprevalence among
health professionals similar to that among the general population—in this case,
15.7% of all health care workers surveyed. The shortage of medical personnel in
the areas hardest hit by HIV has profound implications for prevention and
treatment efforts in these regions. The cycle of health-sector impoverishment,
brain drain, and lack of personnel to fill positions when they are available
conspires against ambitious programs to bring ART to persons living with both
AIDS and poverty. The president of Botswana recently declared that one of his
country's main obstacles to rapid expansion of HIV/AIDS treatment is "a dearth of
doctors, nurses, pharmacists, and other health workers."
3
In South Africa, the
departure of nearly 600 pharmacists in 2001, coupled with standing vacancies for
32,000 nurses, has put continued strain on that relatively affluent country's ability
to respond to calls for expanded treatment programs. In Malawi, only 28% of
established nursing posts are filled. Furthermore, the education of medical trainees
is jeopardized as the ranks of the health and academic communities continue to
shrink 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 of
health personnel—almost always, as most reviews suggest, from poor to less-poor
regions—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 are
working conditions in general. In many settings now losing skilled health

personnel, the advent of HIV has led to a sharp rise in TB incidence; in the eyes of
health care providers, other opportunistic infections have also become insuperable
challenges. Together, these forces have conspired to render the provision of proper
care impossible, as the comments of a Kenyan medical resident suggest:
"Regarding HIV/AIDS, it is impossible to go home and forget about it. Even the
simplest opportunistic infections we have no drugs for. Even if we do, there is
only enough for a short course. It is impossible to forget about it. . . . Just because
of the numbers, I am afraid of going to the floors. It is a nightmare thinking of
going to see the patients. You are afraid of the risk of infection, diarrhea, urine,
vomit, blood. . . . It is frightening to think about returning."
4
Another resident
noted, "Before training we thought of doctors as supermen. . . . [Now] we are only
mortuary attendants."
5
Nurses and other providers are, of course, similarly
affected.
Given the difficult conditions under which these health care personnel
work, is it any surprise when the U.S. government's appointed Global AIDS
Coordinator notes that there are more Ethiopian physicians practicing in Chicago
than in all of Ethiopia? In Zambia, only 50 of the 600 doctors trained since the
country's independence in 1964 remain in their home country. Nor is it surprising
that a 1999 survey of medical students in Ghana in their final year of training
revealed that 40 of 43 students planned to leave the country upon graduation.
When providing care for the sick becomes a nightmare for those at the beginning
of clinical training, physician burn-out soon follows among those who carry on in
settings of impoverishment. In the public-sector institutions put in place to care for
the poorest people, the confluence of epidemic disease, lack of resources with
which to respond, and unrealistically high user fees has led to widespread burn-out
among health workers. Patients and their families are those who pay most dearly

for provider burn-out, just as they bear the burden of disease and—with the
introduction of user fees—much of the cost of responding, however inadequately,
to new epidemics and persistent plagues.
3
Dugger C: Botswana's brain drain cripples war on AIDS. New York Times
A10 (13 November 2003).
4
Raviola G et al: HIV, disease plague, demoralization, and "burnout":
Resident experience of the medical profession in Nairobi, Kenya. Cult Med
Psychiatry 26:55, 2002.
5
Ibid.