Locally relevant medical education: stopping the brain drain or stunting brains?

The concept of locally-relevant medical training was first introduced by Eyal and Hurst as a way to combat “brain drain,” the exodus of trained professionals from poor sending countries to the richer countries of the West. Brain drain can have devastating consequences for the already fragile health systems of underdeveloped sending countries, and it represents a massive loss of investment for sending countries who have subsidized their graduates’ medical training only to see them leave to provide their services abroad. The WHO has since endorsed the locally-relevant training model as a way in which to address the disproportionate shortage of health professionals in poor and remote regions of the world. So, how does it work? Locally-relevant medical training is designed to make foreign medical graduates, 1) less desirable to Western hirers and, 2) better equipped to practice medicine in the scarcity conditions of their home countries. What this means is that medical students in sending countries would no longer be trained to score well on US board examinations or how to read MRI scans, but rather how to manage local endemic disease and succeed with the diagnostic equipment and supplies available in their localities.

The idea of locally-relevant training sounds practical, and it may indeed be an effective way to avoid the pitfalls of brain drain if correctly instituted. Indeed, if the paramount goal is to increase and/or introduce healthcare services into underserved regions of the world, locally-relevant training appears to be a commonsense solution. But, some may argue that it is not necessarily the answer.  First, is the locally-relevant model fair to its students? They are taught “second-rate” medicine as compared to the Western gold standard. As a result, their freedom of movement is restricted as they are no longer qualified to practice medicine in the West. Is it okay to deny these individuals the opportunity to study the latest and greatest advances in medicine simply because of where they live? Second, it can also be argued that sending countries should provide more incentive for their graduates to remain at home. This may entail increasing wages, improving practice conditions, and expanding research opportunities.

Does a focus on locally-relevant medical training unfairly place the impetus on sending countries to change the status quo? After all, blame for the phenomenon of brain drain does not fall squarely on the sending countries; it is in large part driven by a shortage of medical professionals in the West, the “pull” factors attracting foreign graduates to the West, and, surely, “push” factors that drive foreign graduates from practicing at home. Some may argue that the richer countries should implement policies on their end to protect sending countries from the harmful effects of brain drain. The West, however, is the beneficiary of the status quo; why would it “shoot itself in the foot” and preempt a scheme that is an easy fix for its own physician shortage problems? To be fair, there are initiatives like PEPFAR’s Medical Education Partnership Initiative that work to increase the local retention of health care professionals in sub-Saharan Africa and other regions of the world. But this initiative and many others do not address the real problem: there are too few medical professionals graduating each year from Western institutions to provide adequate care for its population. Countries in the West should train more homegrown medical professionals to cover their own deficits if they are serious about mitigating the deleterious effects of brain drain on sending countries. 

Guest post by David Kennedy, Medical Student

University of North Carolina at Chapel Hill

Criminalizing the brain drain

There are many numbers around to express the inequalities in health care between developed and developing nations. In Malawi, there is one physician for about 50,000 persons; compare with Great Britain, where it is considered shocking when there are districts with only one doctor per 3500. In Zambia, there is one nurse for about 3000 patients; in the United States, studies have shown that even an increase from a 1:4 nurse/patient ratio to 1:10 can have a significant impact on surgical patient death rates, as well as job dissatisfaction and burnout. Who knows what a 1:3000 ratio does for patients and nurses. But for all the contrasting figures that can be found in the scientific literature, an unscientific anecdote stands out for me. In Kinshasa, somewhere off the Boulevard du 30 Juin, there is a small dental clinic, which I noticed was absolutely jammed full every single evening, with some patients spilling out onto the trottoir. Someone told me that there are 12 registered dentists in Kinshasa, a city with estimated population of 8 million. That struck me as terribly low, though in the meantime I have learned that according to WHO estimates (2004), the average dentist/patient ratio in Africa is 1 per150,000.

Nevertheless, the industrialized world regards itself as having serious doctor, nursing and dental shortages, and part of the solution to the crisis currently involves recruiting from ... the developing world. You don't need a fully articulated theory of justice to see a deep problem here. In fact, it is old news: the brain drain of health professions from developing countries has long been discussed, moral outrage has been expressed, and various professional bodies have issued policies condemning the practice. Not that all this has had much of an impact so far. This week's Lancet, however, has a new twist on the old story. A group of authors have apparently decided enough is enough: they propose that the predatory recruitment of developing world health professionals be considered an international crime.

The idea is laudable, because the gravitas of 'crime' at least matches the seriousness of the issue. But how would it work in practice? It is difficult enough to enforce crimes against humanity, much less crimes against the universal right to health. Can one envision CEOs of recruitment bureaus being hauled off to the Hague and awaiting trial along with Charles Taylor? Besides, the defence lawyers would argue that the recruitment bureaus do not intend to endanger the health of developing nations; they are providing opportunities to skilled individuals who have the right to work where they want. It might be wiser (but not much easier) to press for enforceable national laws -- in abuser countries like Canada, United States, the United Kingdom, Australia and New Zealand -- that pose clear restrictions on the import of health human resources from developing countries, while working on the international front to address the conditions of poverty and neglect that push doctors, nurses and dentists towards greener pastures.