Dr. Clemens has offered some spirited comments to our posting regarding health professional migration in Africa. While I thank him for his passion, there are a few points from my previous post that need to be clarified. First I never suggested restrictions on physicians mobility. Dr. Clemens and I agree that draconian anti-immigration laws are a violation of human rights, insulting and discriminatory. Not everyone is on the extreme poles in this debate. It is just that we might not want to be too quick to celebrate this trend. Surely there is some happy medium where we can allow people to migrate but also promote improvements in health care and physician work in Africa?

Secondly I do not think that generalists are going to have an absolutely huge impact on child mortality, just more than specialists. I think the ratio of specialists to generalists migrating is an interesting extension to the data that Dr. Clemens has presented. Are there more specialists than generalists?

The WHO is pretty convinced that physician density is important to achieving better health outcomes. They argue that huge increases are necessary if we are to even approach meeting the Millennium Development Goals (Scheffler, Lui, Kinfu and Poz). Could it also be that the physician density in some of these countries is simply so low and things so bad that any impact of physicians is opaque? Is there a threshold of physicians, conditions and access that needs to be met before there are gains in broad health indicators such as infant mortality and child health? It has been noted that “Africa bears one quarter of the burden of disease around the world and yet has barely 3% of all health workers” (Conway, Gupta and Khajavi).

We do agree on one point: public health interventions that address factors beyond modern medical care are going to give the biggest bang for the health care buck but I am not thoroughly convinced that generalist (or even specialist) physicians have no role in promoting health in Africa. Furthermore if people are being recruited to emigrate or simply find that there are greater opportunities if they train in western biomedicine they are by definition not working in public health or community health and training programs for context specific public health work are not springing up everywhere in private medical schools. Because leaving to practice medicine is attractive, African countries and individuals are taking up the western model of medical training – there is no incentive for anyone to develop paraprofessional programs or other models of care that would better reflect the needs of the population. Perhaps we ought to be trying to think of new models. By recruitment and the pattern of migration the western model is being promoted. We in the end agree that public health (sanitation, vaccination, etc.) are what is needed perhaps instead of encouraging recruitment of African physicians we ought to be encouraging people to enter these professions.

In a small Ethiopian hospital, located in a small town, physicians did play an important role in providing health care. Physicians are diagnosticians and in this region where cyclical outbreaks of meningitis are common they play an important public health role. By performing spinal taps and carefully analyzing symptoms they are able to alert the government and organizations in the case of a potential epidemic or save valuable resources (such as antibiotics) if it is found to be some other illness will similar clinical presentation such as malaria and pneumonia. It is not that we ONLY need physicians in Africa or should enact Draconian measures to prevent their immigration to improve their lives but that physicians can play a role in addressing health issues such as infant mortality in Africa. We must not discount that losing physicians could damage African health care. If we are going to continue recruiting perhaps we should also think of doing things that will strengthen African health care at the same time with our aid dollars. I am just simply as optimistic that losing physicians and smart talented people is having almost no impact on health care. Perhaps the gains of having these “super trained” health professionals are just not that easy to measure. Thanks again for reading our blog!

You consider it obvious that specialist physicians would not impact child mortality, which I agree with, but you consider it equally obvious that generalist physicians should impact child mortality, so that any analysis that doesn’t differentiate between the two is meaningless. What I invite you to think more about is that all physicians are extremely highly trained and specialized health professionals, by definition. Any physician in Africa, even a generalist, has had at least six years of education. It does not take six years of education to prevent and treat the huge majority of the health conditions that are devastating Africa.

Many people in public health do claim that generalist physician departure is a major determinant of child mortality. Just to take one example, Lincoln Chen of Harvard School of Public Health and his learned colleagues explicitly claim that on page 26 of this document:

http://www.healthgap.org/camp/hcw_docs/JLi_Human_Resources_for_Health.pdf

That’s wrong, and I gathered careful evidence to show that it’s wrong. You really thing that there’s a huge, strong, negative relationship between physician emigration across all African countries and child mortality, and that this is driven by the departures of orthopedic surgeons only, such that if the analysis were repeated for generalists it would show the opposite? The unmistakable negative relationship between emigration of all physicians collectively and child mortality should give you pause to reconsider your assumptions, though I can see it hasn’t.

You seem to think that the generalist physicians must matter a great deal, and that my analysis means nothing if it does not indicate which specialties of physicians are leaving. I’m baffled as to what evidence brought you to the conclusion that the main constraint on African health is the number of physicians, whether specialized or not. Let’s consider Mozambique, where the DHS survey data suggest that something like 45% of the population may never have seen any sort of modern health professional, for any reason. What do you suppose health needs are among the 10 million Mozambicans who have never had any sort of modern health care? Do you think that they depend primarily upon their access to any physician, generalist or otherwise? I can list for you the things that are killing those people — they’re in the back of the World Health Report: Malaria, upper respiratory infections, and diarrhea are by far the main things that limit life expectancy for poor rural Mozambicans and for most poor Africans. All of those are much better addressed by prevention than treatment, and none of them require anything close to the skills of even a generalist physician to treat.

Why is everyone so interested in restricting physician movement, and so uninterested in talking about deploying community health workers, improving sanitation, improving handwashing, improving bednet usage, improving condom usage, vaccine development and deployment, fighting corruption, improving performance incentives, reforming the civil service, and all of the hard work of building a health system? Maybe it’s because all of those things are difficult and take a long time, whereas obliging a physician to work in a place that he or she doesn’t want to work, and in working conditions that you probably would not accept either, is easy.

I’ve spent time in a clinic in Kibera, the vast slum in Nairobi, and seen the basic, common conditions that most desperately poor patients coming to that clinic are presenting with, the enormous majority of which simply do not require the care of even a generalist physician, much less a specialist. I am therefore baffled by how you or anyone else could come to conclusion that the number of physicians leaving Kenya is a primary constraint to improving health for most Kenyans. In fact, the burden of proof lies on you to demonstrate that such an outlandish claim is true.

You say I “overlook” all sorts of things that physicians do. If you take the time to read the papers I was briefly summarizing at the presentation you saw, you’ll see that child mortality was just one of the measures of health outcomes and access to care that I test for any sort of cross-country relationship with the emigration rate of physicians and Registered Nurses. The others include the fraction of births attended by skilled health personnel, the fraction of children with acute diarrhea in the past two weeks who were seen by a health professional, life expectancy, vaccination rates, the fraction of HIV patients receiving antiretroviral therapy, and several others. *None* of these has any discernable causal relationship with physician or Registered Nurse emigration rates, across 53 African countries. That doesn’t mean that there is no relationship whatsoever, and I explicitly said this in the seminar. Instead, it means that the *other* determinants of access to care and health outcomes are probably *vastly* more important than the emigration rates of the most highly skilled. I don’t “assume” that, I show it, and if you think you can demonstrate that Tuberculosis deaths are primarily caused by international movements of physicians, I invite you to conduct that analysis, because the burden of proof is on you. That’s a strong, questionable claim, and no one should have the right to force anyone to live in a place they don’t want to live without a stack of evidence documenting the good that this will accomplish.

Sure, even if the most highly skilled are not treating infants with diarrhea, they might be needed to build health institutions, as you point out. But international movement is also a key part of building those institutions. I asked a research assistant to spend a day collecting the biographies of as many African health ministers as he could find on the web. He found twenty one such biographies. How many of them had lived and worked abroad for a substantial portion of their careers as health professionals? Twenty. So maybe the phenomenon of international movement itself is important to building solid health institutions, even though you seem quite confident that movement can only destroy them. Perhaps the forces that shape long-run institutional development in Africa are more complex than either of us, or anyone else, fully grasps or is able to engineer via very blunt instruments like migration policy. You think that the Malawian Ministry of Health will grow stronger and stronger the more migration we prevent per se, i.e., the more highly trained health professionals we trap in Malawi against their will? Now there’s a radical belief that should require evidence to support it.

You go on to call me “moralistic”. I think you need to think more carefully about what it means to restrict the movement of an African, an act that caries ethical consequences that should horrify anyone reading this. In Mozambique, an Enfermeiro Geral (something like an LPN here in the US) was earning the equivalent of about $1,200 a year when I was there two years ago. The same woman (most are women) could easily earn $40,000 with the same medical qualifications if she lived where I’m from, in Montana. After adjusting for cheaper prices in Mozambique, that means that she earns about $3,000 a year in New York purchasing power. What would your life be like if you had to scrape by on eight dollars and twenty one cents today, for every last one of your expenses: rent, food, tuition, everything? You would barely be able to survive, and you could never hope to have anything like a decent career, raise a family, send your children to good schools, and so on. You would never in a million years accept any job that compensated you $8.21 a day, because you feel that you deserve more.

When you coercively restrict the movement of a health professional, you are informing a real person that they must accept that job that you would not accept. Do you consider that a purely ethical act? And anyone who points out the severe ethical problems of that act is a “moralistic” blowhard? I’m sorry you feel that way. I believe that forcibly preventing someone from accessing the same job opportunities that I take for granted by birthright is profoundly unethical, because I did not choose to be born in New York rather than Maputo. If you think that migration is *causing* Africa’s health problems, then stopping migration must be the solution to them. But stopping migration per se, without changing anything else, is one and the same with coercing people to work in conditions they don’t want — conditions we would never accept because we feel we deserve better, but if we’re willing to force others to accept them by restricting movement opportunities, apparently we’ve decided that others don’t deserve what we deserve. I do not feel that I deserve greater professional opportunities than any African has.

Make no mistake: Restrictions on recruitment of health professionals are coercive, because they ban people from informing health professionals making $3,000 a year about opportunities for them to escape poverty. Nobody stepped in to stop you from finding out about the extremely highly paying jobs you’re going to have in your life, and if they did so, consigning you to instead work in poverty, you should be outraged. Hiding information from people is coercive. “Self sufficiency” for destination countries is also coercive, because this is the policy of ensuring that all jobs here are filled by those already here. Both of these make it much harder for people who had the gall to be born in Africa to access the extremely high-paying jobs that you and I can count on in the United States, and forcibly restricts the options available to them. If you think that coercing people is a good way to build institutions, Kim Jong Il would like to employ you in one of his ministries.

The end of your post calls for debate based on “evidence”. Evidence is one thing that is entirely absent from your post, but that doesn’t stop you from blasting me and my analysis. In my writings and in this post, I’ve offered plenty of evidence for my conclusions, far more than anyone who advocates restricting health professionals’ movements through recruitment bans or “self-sufficiency”. I invite you and other readers of this post to read the evidence I’ve gathered and think much more carefully about whether or not you would feel comfortable looking a person in the eye whose life is a constant struggle compared to yours, someone who has found a way out and wants to take it, that you have determined that you’re going to remain rich and they’re going to remain poor. If you have no qualms about doing that, then definitely ignore me and my “moralistic” rants.

the problem i think for him is that the line of separation between public health and health system impacts is blurred. i also didn’t appreciate some of the comments he made during the question and answer session- some of which were particuarly disturbing – but i won’t bother to mention them here.

he also had a tendency to paint everything with a broad bush. How can we expect to analyze any given health system if we keep lumping all of “africa” together? Countries in Africa need ( and deserve) to build health systems which will address key issues like the double burden of disease. You can’t do that if you don’t have a health workforce.

excellent post!