African governments spend millions of dollars every year training physicians who will leave their home countries to live and work in wealthier nations. The result is that for countries like Ethiopia, Kenya, and Sierra Leone, more of their native physicians are now in the United States and Europe than at home. This massive movement of physician has likely contributed to health crises in many African nations, where citizens die of easily curable diseases each year.
For example, Zambia, a country of roughly 12 million people, had fewer than 646 doctors in 2006. This is less than a third of the doctor-patient ratio recommended by the World Health Organization. Zambia has only one medical school, which graduates 50 to 60 doctors a year who are then committed to serving in Zambia for 18 months after graduation. However, beyond that 18 months, about half of these doctors leave the country for more training or better paying jobs.
This problem is arguably even worse in Malawi where at one point there were estimated to be fewer than 300 doctors for a population of 15 million. A 2007 report found that there were only 15 surgeons of any kind in Malawi, making the surgeon to patient ratio roughly a million to one. And most district hospitals had only one doctor of any kind. The remainder of physicians trained in Malawi have moved to other countries or ceased practicing medicine.
By 2000, Ghana had roughly as many Ghanaian physicians working in the United States alone as it did practicing in Ghana. And by 2001, nearly half of the teaching staff of Medical School, University of Ghana, had left the country. Such shortages occur in many other African nations including Kenya, Nigeria, and South Africa, and have continued to contribute to African crises of poverty, disease, and underdevelopment.
In African nations, it is governments, not individuals, making the vast amount of financial investment in training skilled medical professionals. A 2004 study found that “African governments consistently provide more than 90 to 95 percent of the total operating budgets of higher education.” And in many cases a significant portion of total higher education budgets go to scholarship funding, including paying student stipends and living allowances such that “student fees have traditionally not provided more than token support.” Many African nations have scarce resources to begin with, and cannot afford to spend resources in which their potential return on investment flees to greener pastures.
The examples given above are instances of the phenomenon that has come to be known as medical brain drain.
Medical brain drain exists, in part, because wealthy countries like the United States have incentivized brain drain and structured their immigration policies such that they disproportionately take in highly-skilled immigrants over others, leaving developing countries without a replacement for the talent taken. As a result, resource-rich nations are in a position to be part of the solution to medical brain drain if they so choose.
Determining how best to address medical brain drain is a complicated matter. But for some, the question of how wealthy nations can best address medical brain drain is secondary to whether or not the wealthy nations have an obligation to address it.
For those of us who take it to be obvious that wealthy Western nations like the United States have obligations not to take from resource-scarce developing nations in a manner that leaves those developing nations worse off, it may seem that this latter point requires no argument. Of course, those of us who have been blessed with abundant resources and comparably high quality of life ought not to take from the poor to give to the rich—i.e. ourselves—without compensation, you might think. Yet, while most may be sympathetic to such an altruistic perspective, there are plenty who would resist the notion that this creates any kind of responsibility or obligation for wealthy nations to curb their behavior.
What I offer here are some underlying thoughts on how we can (and ought) to think about the kinds of arguments that can be made in response to those that deny that wealthy nations bear some responsibility to address medical brain drain.
First, we need to distinguish between two kinds of ways one can deny that wealthy nations have a responsibility to address brain drain. One kind of argument denies that we ought to address brain drain because they deny that brain drain is on balance harmful for developing nations. Such arguments focus on positive things that result from brain drain like reparations to home countries and the transference of medical knowledge to developing countries from wealthier nations. The proper way to address this kind of view is through empirical research.
But the second kind of way one can deny that wealthy nations have a responsibility to address brain drain isn’t rooted in an empirical claim. Rather, this second kind of response is that regardless of whether or not medical brain drain is on balance bad for developing nations, wealthy nations simply aren’t obligated to alter their practices for this reason. While the first kind of response was empirical, this second kind of argument is normative. It’s a claim about what morality does—or in this case doesn’t—require.
It is this second kind of argument that I’m most concerned with responding to here. I think there are two basic kinds of principles one can appeal to in responding to this kind of normative reasoning.
First one can appeal to a principle of distributive justice. For example, one could put forward the principle that in a world where some people are very well off and other people don’t even have their basic needs met, that those who are far better off than others (especially when their being better off is due to circumstantial good luck) have an obligation to help those who don’t have their basic needs met. This is just one of many principles in a family of views that could be offered. Peter Singer is well known for offering significantly stronger positions along this general line. While I think a principle of distributive justice along the lines of what I suggested is right, not everyone is swayed by such principles.
For those not inclined to accept principles of distributive justice, there is a second kind of principle one can appeal to. This second kind of principle is what I’ll call a justice-of-repayment principle. A justice-of-repayment principle highlights the fact that resource-strapped countries are prioritizing an investment of their resources to train physicians, and that in luring away those doctors, wealthy nations like the United States are getting something for free and doing so from those who cannot afford the loss. For someone who denies that there are general duties to ensure distributive justice, it may still seem compelling that we ought not form exploitative relationships in which we take from developing countries without repayment.
The question of how to best address medical brain drain is challenging. But a worthwhile part of addressing that challenge is putting forward the best moral arguments we can for the claim that we ought to be doing something about medical brain drain.
Mark Satta is a 2018-2019 Petrie-Flom Center Student Fellow.
Image: Mtimbwani, Tanzania— A Tanzanian mother and childhood health care specialist gathers information from a woman in 2012. Tanzanian medical providers working in partnership with U.S. service members from Combined Joint Task Force – Horn of Africa provided medical care to more than 2,100 Tanzanian women and children during a Medical Civil Action Program January 9-13, 2012.