Poaching Foreign Doctors

Too often, the Yukon — geographically isolated, with a population of just 31,000, and with few career advancement opportunities — is merely a portal for young medicos to move through on their way to metropolitan Canada. “We are constantly getting raided,” says Whitley. “The bigger medical centres in the South come up and say, ‘Here’s what we can offer you.’ imgs come here, qualify, and then move on to some other part of the country.” The result is a chain reaction, internal to Canada: outlying regions experience perennial shortages and are always in recruitment mode. Still, Whitley says that the Yukon government does not actively recruit overseas, sticking strictly to health fairs across Canada. “Everyone is aware of the complexity of the moral issues around the autonomy of doctors and other medical people to choose where they want to live and work,” he says. “And if we poach the best and brightest [from developing countries], are we obliged to compensate in some way?”

Whitley’s concerns don’t seem to bother the Saskatoon Health Region. In March, the Saskatoon StarPhoenix published a column by the region’s vice-president of human resources, Bonnie Blakely. Just back from a nurse recruiting trip to the Philippines, she was attempting to refute charges that offshore recruiting in poor countries was unethical. Not so, she argued; such efforts “enrich both communities.” Nowhere did she acknowledge that Canada’s ratio of nurses to population is 10 to 1,000, while in the Philippines it is 1.7 to 1,000. Rather, Blakely stuck to her guns, citing the Philippine government’s support for the venture, claiming that the nurses would earn good salaries and send money back home, and pointing out that if Saskatchewan didn’t scoop them, somebody else would.

Professor Labonté, who co-authored the book Health for Some: Death, Disease and Disparity in a Globalizing Era, explains that gross inequality of resources has given momentum to the movement of health care professionals. “The poorest countries are going through a collapse of their public health systems, often the result of dual crises in both financing and management,” he says. “Meanwhile, globally, there is a brisk labour market for highly skilled professionals in many fields, but notably in health care. In that competition, the poor countries can’t possibly compete.” Health training, he says, is widely seen as a passport to a better life, a difficult trend to deal with for well-meaning organizations fighting “unethical recruiting.”

Margaret Zondo, a Zimbabwean who works for the Presbyterian Church in Canada, confirms that skills migration is particularly devastating for African health care, “with [the loss of] teachers, engineers, and scientists close behind. It costs $200,000 [US] to train a doctor in Zimbabwe or South Africa,” she says, “and they end up in places like Manitoba, where one in three rural doctors is from Africa.” Zondo herself personifies the migration. Ten years ago, armed with an mba from Edith Cowan University in Australia, she became the permanent secretary of Zimbabwe’s Public Service Commission, a high-ranking job that left her in ultimate charge of 170,000 civil servants. It was a difficult time. In the mid-1990s, the International Monetary Fund compelled Zimbabwe to reduce its public service by 25 percent in order to qualify for continued foreign loans and aid. The effect, Zondo says, was that skilled and educated people were cut loose, and many of those who kept their jobs were underemployed and forced to moonlight. (Zondo described a close friend, a linguistics professor, who double-shifts as a chauffeur for a wealthy businessman.) In 2001, with Zimbabwe spinning out of control, she bailed and came to Canada.

“These days, when South Africans leave to go to North America and Europe, Zimbabweans and Malawians move into South Africa to fill the gap,” Zondo says. The hole left in Zimbabwe is partially filled by Cubans, who, having been recruited by the Zimbabwean government, are paid more and in foreign dollars, two facts that cause considerable resentment. (Remittances, Zondo adds in an aside and with obvious frustration, are fine for family and friends, but they don’t stimulate local economies, and, worse, they “hold down unrest, helping governments survive that shouldn’t.”)

Another absurdity was pointed out three years ago by the Commission for Africa, convened by then British prime minister Tony Blair. It argued that the number of foreign technical experts recruited by Africa far exceeded the number of skilled migrants leaving the continent. That is, for every educated African national making an exit, the developed world responds by sending more than one medical professional, engineer, lawyer, teacher, government analyst, or environmental planner. It’s madness, Zondo says: “The very least the West could do is use more of that [foreign aid] money to employ our skills.” Indeed, estimates vary, but as much as 35 percent of the total foreign aid sent to Africa each year goes to pay the salaries of foreign professionals.

In an attempt to address one aspect of the issue, the United Nations Educational, Scientific, and Cultural Organization (unesco) and Hewlett-Packard have engineered a unique partnership called Piloting Solutions for Reversing Brain Drain into Brain Gain for Africa. It provides grid-computing technology to universities in Algeria, Ghana, Nigeria, Senegal, and Zimbabwe, and aims to establish information-sharing links between researchers who have stayed in their home countries and those who have left. Without access to top-flight research in the North and West, the strength of African universities diminishes, which in turn makes it increasingly difficult for them to attract the best and brightest. The University and College Union in the UK, which devoted itself to an in-depth study of the issue two years ago, is now advocating the development of programs “aimed at encouraging African higher education unions to organise and develop such that they can themselves argue for capacity building work in the education sector in their home countries.”

These are noteworthy efforts, but ultimately long-term solutions require the contributions of a very broad circle on both sides of the divide. In a recent press release, Dr. Danielle Grondin, director of the migration and health department for the Geneva-based International Organization for Migration, argues that “international migration of health human resources is not a good or a bad thing, per se. Its effects depend on the policies and flanking measures put in place to guarantee equity, access, and quality of services in accordance with the particular national situation.” While allowing that “pull factors, especially the promotion and enforcement of ethical recruitment practices,” should be addressed, the iom stresses that “retaining health care workers in sending countries means addressing factors that often push them to leave, including difficult working conditions, low salaries, excessive workloads, and lack of career prospects or training opportunities.” The iom, that is, places at least as much responsibility on the sending countries.

Labonté notes that “as much as we rich countries have obligations to stem this, the so-called source countries have responsibilities themselves.” Kenya is a case in point, he says. It is home to thousands of trained nurses it desperately needs but cannot employ, due to a lack of money to pay them, and a lack of money or means to set up clinics — all the organizational and management shortfalls that paralyze a country. “The Philippines,” he says, “deliberately trains nurses for export, hoping for the remittances they will send back to the country, while enduring shortages at home. What are you supposed to do about that?”

While any road to a long-term and equitable solution is fraught with pitfalls, Keith Martin, the federal Liberal critic for international development and a medical doctor who has visited Africa twenty-six times, laments that Canada isn’t doing much of anything. He points to the Commonwealth Code of Practice for the International Recruitment of Health Workers, a 2003 proposal in which the signatory countries agreed not to recruit actively; Canada wouldn’t sign on. Instead, in 2005 the Liberal government adopted measures to speed the training and certification of foreign health care professionals already resident in Canada, so we could use them here more expeditiously and effectively. “If we’re going to do that,” Martin says, “we’re obliged morally to help on the other side.” His prescription? “For every international health care worker we take on here, we should train two in their country of origin . . . The present government could do it, [but this] would mean big changes at the Canadian International Development Agency, where getting anything through is like pushing sand uphill,” Martin says.