Michael Clemens of the Center for Global Development has put forth a provocative argument regarding the immigration of African health workers in a discussion event at the Wagner School and two recent essays that can be accessed online here and here. Antithetical to the prevailing concerns about African “brain drain,” Dr. Clemens claims that migration of health professionals is actually good for development and does not adversely impact the health outcomes of the departure countries. In support of his views Dr. Clemens offers some economic arguments and some highly problematic moral ones to fill the gaps.
The economic arguments advanced seem to be quite simple. Based on the data that he presents he finds that the counties with the highest migration of health professionals do not have lower levels of health professionals per capita left at home. In many cases they have greater density of health professionals. Therefore, he concludes that educational opportunities have arisen in the departure countries in response to the recruitment and migration and that this is good for the African education systems. This fails to consider opportunity costs, as every talented individual choosing to enter into specialized medical training is not entering into public health training. Furthermore this offers inspiration to those in the poorest countries to achieve more. Additionally, the migrants continue to benefit their home countries by spending home remittances, making it easier for others at home to find employment and finally “spreading American technologies and ideas to the world.” The argument is then related back to health as Dr. Clemens finds that under five child mortality is unaffected by the number of health professionals migrating.
The very simplicity of the arguments presented is the most important flaw. Dr. Clemens takes all physicians to be the same and have relatively similar impacts on health outcomes in primary care and public health. He does not provide any details about the specialties of the physicians migrating nor does he suggest the impact that this aggregation of health professionals has on his analysis. If the physicians migrating are specialists, then of course primary health outcomes are not likely to show major variations. Moreover, focusing on infant mortality further confounds and clouds the analysis adding very little value. Infants by definition have little interaction with medical care and infant mortality in public health is considered to be much more indicative of the social determinants of health and not the robustness of a particular medical care system. Dr. Clemens also overlooks the possibility that medical professionals make contributions to health in areas such as surgery, trauma, and infectious diseases such as tuberculosis and meningitis. He also fails to acknowledge the other contributions of highly trained and often specialized medical professionals in terms of health system leadership and biomedical research. To truly understand the results of migration we must carefully weigh all of these variables.
From these arguments Dr. Clemens proceeds to draw some startlingly moralistic conclusions from a largely economic analysis. Dr. Clemens contends, Africans only “deserve not to die,” whereas North Americans (and really anyone fortunate enough to live in proximity to specialized medical care) are free to access the highest level of specialty care available. This begs the question what do poor uninsured Americans deserve? How about those in rural communities? Or is this lower class health care “deserved” only by those inhabiting that vast continent, referred to so generally in all of Mr. Clemens discourse? All of this rhetoric sounds oddly familiar, as if Orwell’s pigs are laughingly chanting that all animals are equal, but some are more equal then others. From the data presented both in the presentation and his articles available here, there is no basis for the conclusion that Africans deserve less. While the health needs of African countries in terms of focus and human resources is clearly different from Western countries this has nothing to do with the moral conclusions that are drawn. If we are to accept that physicians are not, as Dr. Clemens contends, what Africa needs (or apparently deserves) it does not follow that western countries should be actively recruiting skilled, intelligent individuals from Africa to fulfill shortages here.
Ultimately, the debate over professional migration in health care deserves and requires more analysis based on evidence. Academia must do better and not fall back on moralistic solutions to complex and urgently important public health issues. We must continue to ask hard questions and seek robust data. That is the least that Africans deserve.
Posted by ashley27 
