Friday, March 30, 2007

Mellennium Challenge Series 22: Public Health Crisis and Brain Drain! Whose brain?

Dear Patriotic Ethiopians and Friends of Ethiopia:

Re: Public Health Crisis Due to Ignorant leadership in Africa not western educated health professionals!

You train your child to imitate you r neighbor and wonder does not respect you? Health professionals in developing world want to mimic their teachers and their textbooks. Who are the teachers who wrote the medical text books? Not the local healers? So Why be surprised if the health professionals migrate to meet their teachers and the market they have been trained for?

The African Public Health Crisis defined as lack of clean water supply, adequate nutrition, and epidemics of preventable diseases such as Malaria, TB, Diarrheal diseases and HIV pandemic is not due to brain drain of health workers but brain drain of political leadership that does not focus on enabling policies!

Let examine the myth that the brain drain of health workers is the cause of the above public health crisis and impending pandemics. The brain drain is in the area of political leadership, where ignorant, uneducated copy cat parrots who manage to get in to power with the wrong premise and without appropriate relevant qualification and expertise and abuse their privileges, once they get them is the real problem. These uneducated pedestrian or rather jungle politicians do not know any thing about governance, neither how the peasants survive in their rather hostile environment, be it in farming, trade etc. neither know how to consult those who know. This is the real problem!

Unfortunately, this ignorance is compounded by the so called researchers who do not have skills and expertise in research itself and copy what ever the WHO or World Bank or other institutions produce and distribute it as fact. How many of the World Bank or WHO experts live and work among the peasants who have to contend the effects of public health crisis such as lack of clean water supply, poor harvest and most importantly lack the information on how Malaria, TB and HIV as well as gastro-intestinal diseases spread from person to person. That is at the heart of the problem. The experts should be forced to live and work in these environments, if they are to make their living pontificating on these issues.

The so called literature publishers know how to publish and the content and relevancy of their publication is never challenged by those who consume them, as the authorities that review these papers themselves have never lived in these real situations. They all perpetuate the same myth that is not based on facts.

Now we have a series of pseudo researchers who blame the wrong reason as they themselves are not educated nor have the experience of living on the ground or the real lab or do not know their histories. Especially, how the developed world managed water harvesting, distribution and maintenance or food production and distribution as well as public health institutions that promote health education, prevention and early intervention.

There is no evidence in recorded history where a physician has developed a water-safety and distribution network. That is not his or her training. That might be the work of the public work engineer or local developer, etc. At no time in history has a nurse developed the latest water drilling, harvesting and distribution center. That is not their training. A physician, nurse or any one of these trained therapists are not trained in water engineering, food processing, proposal development, budget forecasting, nor in food productivity cycles and market forces. so, why blame the wrong person or profession for the wrong reason?

Unfortunately, the majority modern health professionalas are not trained even in basic public health principles and their training is no different than the shop keepers at the corner of the street. They wait when clients walk into their office and depend mainly on the stories that their self selected clients tell them. They do not have the advanced technology to confirm their suspicions or tentative diagnosis by ordering relevant tests, scans or blood workup, etc. They work in the dark. Any body who wants to blame these poorly trained and poorly equipped health workers for the massive public health crisis in developing world is shear ignorance, callous and irresponsible.

Let us closely examine some of the critical problems of public health to show without a shadow of doubt current health professionals have nothing to do with the impending public health crisis in any one country.

Preventable Diseases, such as Malaria, TB, HIV Malnutrition and waterborne- common and exotic diseases are due to the environment that is convenient for the reproduction of the parasites, bacteria and viruses respectively.

Malaria Eradication Programs of the 1960s were successful because they addressed the parasite directly, not the blanket that WHO and few corporations are marketing today. It is the parasite stupid not the blanket. Unless we eradicate the parasite no amount of (tents or blanket) is going to stop the spread of the Mosquito that carries the parasite. We need to target our efforts either on the parasite (plasmodium) or on the carrier mosquitoes (falciparum, vivax, etc). So long as these two agents (the cause and the carrier) are operational they will continue to infest the public, to make any dent in the problem- the cycle has to be broken.

Mosquito net is good for the European Tourist with prophylaxis, who is there for ten days, may be more, not for the indigenous populations who live there through out the year. What is good for the tourist here is not good for the indigenous population. It is the same analogy, the health professonal trained for and with developed technoligies is no good for the developing world where these tools are none existent.

If you tell this to the tourist WHO, UN or Work Bank expert he or she cannot understand. How did Europe and North America get rid of Malaria, TB and all the infectious diseases that is today rampant in developing countries? These are where the so called puppet researchers should spend their time. If you tell this to the scientists and public policy makers who have interest on the mosquito net or blanket market industry, they will not listen. Just see how the US congressman/woman short circuits the electorate once the K street lobbyists had a chance to wine and dine them. It is the same thing! It is the money stupid!

I personally believe all health workers (in developed and developing countries) should be educated on the principles of public health, epidemiology, medical statistics and behavior science, regardless of their specialization and evntual choice of where they wrok. So, the question is that the health workers in the developing world have to stop imitating the developed world and start their own curriculum that is relevant to their situation.

The current breed of physicians, nurses, health technology scientists are trained by the standards and expectations of the west and it is no surprise they migrate to practice the type of medicine that they have been trained for. That market is not in developing world where they live but in the developed world where the text books, teachers and labs come from. They are responding to both their passion and the wealth that is offered in the west.

I am sure this is not rocket science or brain surgery. If you train a child to disrespect you, your culture, language and way of life and allow him or her to mimic the neighbors or worship the Western culture, he or she will just do that. We need to change the curriculum of health professionals in the developing world to reflect the challenges and opportunities of their respective societies. May be then, we will have engineers, scientists and politicians who have the skills and competency to respond to the challenges of their communities on the ground.

Please read on the P2P article that generated this response below.

Belai Habte-Jesus, MD, MPH
Global Strategic Enterprises, & Partners for Peace and Prosperity,,,

Posted by: "BT Costantinos" btcostantinos

Thu Mar 29, 2007 4:45 am (PST) How the Brain Drain to the West Worsens Africa's Public Health Crisis RotimiSankore (2006-09-14) In its 2006 annual report, the WHO reports that out of57 countries, 36 countries in sub-Saharan Africa suffer from a severe shortage of health workers, such as doctors, nurses, pharmacists, lab
technologists, radiographers and other frontline or support staff. Rotimi
Sankore argues that the 'brain drain' is slowly and indirectly killing the

In times of crisis and epidemics, diplomacy is a luxury the dying cannot
afford, especially when millions of Africans know that an over emphasis on
niceties will almost surely lead to millions more deaths.

Conventional wisdom has it that Africa is suffering from an AIDS crisis. In
reality, Africa is suffering from a public health crisis, and the AIDS
pandemic is the most significant symptom of that crisis, which has been
worsened by the drain on Africa's healthcare workforce to the 'West'.

The amazingly wrong political diagnosis of the challenging healthcare problems
facing Africa and indeed the planet, has blunted the obvious fact that
tuberculosis, malaria, a host of other preventable diseases and malnutrition
still claim more African lives than the 2 million deaths attributed to
HIV/AIDS annually. Combined with HIV and AIDS, these diseases are rapidly
turning Africa into a continental graveyard. Yet the emphasis remains mainly
on AIDS, which has been crowned the most sexy villain.

The countries with little or no health worker shortages and better health
infrastructure have managed to cope better with HIV/AIDS because they are
better able with preventable diseases like TB, sexually transmitted
infections, sexual and reproductive rights education and malnutrition. AIDS
is a problem on its own, but it is also being fed by other unresolved health
problems and the lack of political will and courage

Resolving Africa's public healthcare crisis will resolve most of the other issues and be a step towards isolating AIDS which can then be tackled more easily. The first step
must be resolving the health worker shortages, which includes dealing with
the "brain drain".

2006 has been a landmark year for HIV/AIDS in terms of the number of huge
international meetings and conferences organized. These include the Abuja
African Union Special Summit on HIV/AIDS, Tuberculosis and Malaria in June;
the UN General Assembly Special Session on HIV/AIDS (UNGASS); and the 16th
International AIDS Conference in Toronto in August.

These events reflect the huge progress that has been made in tackling
HIV/AIDS. With the exception of the most backward governments and
institutions, it is clearly understood by the majority that inequality in
gender relations is one of the most significant factors behind heterosexual

On the other hand, these events underscore the huge failures and missed
opportunities in the struggle against HIV/AIDS, the biggest yet being the
comprehensive failure to resolve the human resource and health
infrastructure crisis in Africa.

The problem seems to be that acknowledging, prioritizing and acting on the
"brain drain" problem means that governments of countries that have
benefited from the "brain drain" have to take responsibility, and cease
their recruitment of healthcare workers from Africa. Likewise, many African
governments will also have to address their governance problems and the
working conditions for healthcare workers as means to counter the "brain

United Nations population researchers conclude that unless the spread of HIV
is halted or reversed, Africa will top the global AIDS death league with
about 100 million deaths by 2025. This is more than double the projections
for India and China of 31 million and 18 million respectively, both of which
have larger populations than Africa. People aged between 16 and 45 years of
age will be most affected.

It is remarkable that institutions and social movements alike focus not on
the continent's health care crises, but on anti-retroviral drugs only.
Anti-retroviral drugs are useful but when there are no healthcare workers to
administer them to patients, they become useless

To drive the point home, let me put it like this, no war can be fought
successfully without soldiers.

In April 2006, the World Health Organization (WHO) officially acknowledged
what African intellectuals have been saying for the last three decades, that
the "brain drain" from all sectors of African society, but especially from
the health sector, is slowly and indirectly killing the continent.

In its 2006 annual report, the WHO reports that out of 57 countries, 36
countries in sub-Saharan Africa suffer from a severe shortage of health
workers, such as doctors, nurses, pharmacists, lab technologists,
radiographers and other frontline or support staff. The report noted that
the richest countries are filling their shortages by draining away doctors,
nurses and others from less developed countries.

As a result, one in four doctors and one in twenty nurses trained in Africa, is now working in the 30 most industrialised countries. Consequently, Africa is the only continent
where the absolute number of shortage of health workers (817,992) far
outstrips the current stock of 590,198.

Other studies have shown that "the majority of the countries in sub-Saharan
Africa also do not meet the WHO's recommended ratio of 1 to 1,000 [doctors].
Indeed, there are fewer than 10 doctors for every 100,000 people in 24 of
the 44 Sub-Saharan African countries for which the statistics are
available." (Orji, Utsimi & Uwaje in paper presented to the International
eHealth Association in 2005).

In contrast, Cuba has a doctor-population ratio of 1 to 165, South Korea 1
to 337, the UK 1 to 610, the USA 1 to 358, and Italy 1 to 165 (UNDP/Human
Development Report, 2004). Figures from the International Development
Research Centre (IDRC) state that on average, "The doctor-patient ratio is
currently one per 500 in wealthy countries, and only one per 25 000 in the
25 poorest countries."

The main factor that contributes to the low doctor-patient ratio in Africa
is the "brain drain". Quoting WHO and OECD figures amongst others, the IDRC
illustrates the problem in Nigeria and South Africa. "One-third to a half of
all graduating doctors in South Africa migrate to the US, UK and Canada, at
a huge annual cost to South Africa (lost investment in education/training) .
Including all health personnel, the losses for South Africa reach US$37
million annually. This exceeds the combined (multilateral and bilateral)
estimated education assistance for all purposes, not just health
professional training, received by South Africa in 2000." Alongside this,
"over 21 000 Nigerian doctors are practising in the US, while there is an
acute shortage of physicians in Nigeria."

Not surprisingly, the IDRC concludes that "another reason for the
deterioration of health-care systems in developing countries is the 'brain
drain' of health professionals€ ¢â’ ¦ which primarily benefits wealthier nations,
such as the UK, the US and Canada, [and] calls into question G8 commitments
to support developing countries in reaching health targets of the
International and Millennium Development Goals".

IDRC findings also reveal that "developing countries invest about US$500
million each year in training health-care professionals, who are then
recruited by or otherwise move to developed countries€ ¢â’ ¦

Meanwhile the United States, with its 130, 000 foreign physicians, saved an estimated US$26 billion in training costs for nationals€ ¢â’ ¦ while estimates suggest that Africa
spends approximately US$4 billion annually on salaries of 100 000 foreign
experts (all sectors, not only health) to 'build capacity' and/or provide
technical assistance, and incurs a loss of US$184 000 per migrating African
professional" .

Dr Peter Ngatia of AMREF puts it more sharply: "Africa literally subsidizes
the West. It is a reverse subsidy from the poor to the rich€ ¢â’ ¦ History is
replete with instances of outflows of human resources from Africa to the
rest of the world. The disgraceful and shameful slave trade epitomizes this
outflow, which robbed parts of the African continent of its young and
strong-bodied men and women.

This was followed by the colonial exploitation of the same in-fighting imperial wars that had nothing to do with Africa. The recent migration of workers, in the opinion of many, is nothing new. It is a perpetuation and perfection of what started centuries ago and has
continued unabated."

He expands by saying "According to the International Organization for
Migration (IOM), Africa has already lost one third of its human capital and
is continuing to lose its skilled personnel at an increasing rate, with an
estimated 20,000 doctors, university lecturers, engineers and other
professionals leaving the continent annually since 1990. This same source
estimates that there are currently 300,000 highly qualified Africans in the
Diaspora, 30,000 of whom have PhDs."

Taking these factors into account, a coalition led by the US based
Physicians for Human Rights, HIV Medicine Association and Association of
Nurses in AIDS Care issued a 15 point plan at the July 2006 G8 summit aimed
at ending Africa's healthcare worker shortage.

The statement emphasized that "G8 countries, particularly the US and UK, should reduce their reliance on health workers from abroad and seek to become self-sufficient in meeting their own health worker needs. For example, they should increase the
domestic training of nurses, doctors, and other health workers.

The United States should also develop a code of practice on international recruitment
of health professionals, which includes not actively recruiting health
workers from developing countries except in the context of an agreement with
those countries that respects the right to health in those countries and is
mutually beneficial."

The British Medical Association has also cautioned that severe shortage of
healthcare workers in sub-Saharan Africa because of migration to developed
countries is a significant component of Africa's AIDS crisis, and that
countries like the UK must end their reliance on overseas doctors and

It is crucial to continue to stress the role of the "brain drain" in
undermining African development in order to fight the myth that millions of
Africans are dying of AIDS because Africa is a useless continent incapable
of saving itself from anything. But stressing this is not enough. Africans
must also lead from the front, or complain all the way to their graves,
where only the silence of the tombstones will speak for them.

There is no doubt that Africa can rebuild its healthcare workforce both by
further training and attracting some of those in the Diaspora back home. The
fact that a small country like Cuba, despite political and economic
constraints, has a better doctor to patient ratio than most of the world's
developed countries also shows that it can be done by any country with the
right healthcare priorities.

There is no human right more significant than the right to quality public
health care. The infected and the deceased need first to live in order that
all other rights to be significant.

This is why, as a contribution towards upholding the right to a healthy life
in Africa and resolving Africa's health care crisis, the AIDS and Public
Health Program of CREDO-Africa, together with partners in Africa and around
the world, are launching a campaign towards:

- That African governments make resolving the health worker shortage their
number one public health care priority.
- That governments of countries that have benefited most from the "brain
drain" cease such policies and examine ways to compensate Africa's health
care system for the damage their recruitment policies have done. - That the
theme of the next International Aids Conference is focused on scaling up
human resources and health care infrastructure, especially in Africa.

- That all intergovernmental organizations such as UNAIDS and its key
agencies focus on and act rapidly towards resolving the human resource and
infrastructure shortages in Africa and the infrastructure in the next eight
to 10 years.

*Sankore is Coordinator of Centre for Research Education & Development of
Rights in Africa [CREDO-Africa] . He can be contacted at: info@credonet. org

*Please send comments to editor@pambazuka. org or comment online at
www.pambazuka. org

BT Costantinos, PhD
Africa Avenue, PO Box 13309,
Tel. +251 (11) 551 1224, Facsimile +251 (11) 551 3851
Addis Ababa, Ethiopia.
www.costantinos. net

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