Tie the doctors down and save an Ethiopian kid. Really?
I respect Nicholas Kristof as a journalist who has all the good intention and courage to take on many of the pressing issues faced by the developing world.
But I was shocked when I read this:
'We should rethink the training of doctors in Africa. The problem now is that it’s very expensive to train these doctors, and then they move to Europe or America; it’s a form of aid from Africa to the West. I believe that African medical schools should shift to a system so that graduates end up with non-transferrable degrees (perhaps after just two or three years of training), so that they don’t have the option of practicing medicine in the West. It’s harsh, I know, but it’s even harsher to see Ethiopian kids dying in hospitals because the doctors have emigrated to Washington D.C.'-Nicholas D. Kristof, Nytimes (2008)
The argument here can be summarized as the title for this post: 'Tie the doctors down and save an Ethiopian kid'. I hope Mr. Kristof has rethought about this after 2008. Frist of all, there is not any established causal link between the 'brain drain' and the kid dying in a rural village in Ethiopia from a preventable cause. Chances are even if the doctor had not migrated away, the kid would died. Why? There are way too many other problems plaguing the health care in resource-poor settings. The kid could have died from the lack of medical supply, a counterfeit malaria drug, a power outage during a critical surgery, his mother not having the money to take him to a doctor, a local herbal/witch doctor who performed a ritual on him and sent him home. And the list goes on. Moreover, even with no brain drain, some poor parts of the developing world have as few as < 5 doctors per 100,000 people. There are so few trained and qualified doctors in Sub-Saharan Africa the first place (each country has <2 medical schools on average). Just for comparison, the average number of doctors per 100,000 people in the US is about 271. That translates to about one doctor per 370 people. If that is a reasonable estimate for the operational efficiency of an average physician, there are then 98150 (>98%) patients who will not be matched to a doctor in the poor regions that are of concern here, assuming doctors are distributed evenly geographically. Even with the more modest requirement that UN sets: one doctor per thousand people, about 95% of the patients are not likely to get a doctor. In other words, there is about 95% possibility that the Ethiopian kid will still die even if all doctors are retained in the country (if the child's death is caused by not seeing a physician as Mr. Kristof assumes).
What really shocked me about this Kristof article is how little he values the rights of the to-be-physicians involved given Kristof has been an ardent advocate for human rights. If well trained physicians do not want to stay at home, there are reasons. And many of these reasons can be summarized as a lack of incentives to stay. Before the proper infrastructure and supporting environment are in place, forcefully keeping the doctors around will not prevent the Ethiopian kid from dying. A study done by MIT Poverty Action Lab has focused on the subject of low nurse attendance rates in rural India. What they found is that without proper incentives, nurses do not show up at work. Many of the nurses interviewed during the study felt that their rural clinical facilities have neither the equipment nor the medical supply to enable them to put their skills to good use. As such, staying faithfully at work and watching the helpless patient suffer just adds on to the frustration. Now, if a doctor is forcefully retained in the rural part of his home country to help those in need, will he feel the same way? Probably so, unless there is a holistic effort on improving the whole rural health-care system in the country. Will the Ethiopian kid still die? Probably, because the frustrated doctor is showing up late for work or just taking a day off sitting at home on the day that the kid visits. The stakes at hand are the the well-being of the doctor as well as the health of the sick child. However, sacrificing the former does not guarantee the later. The "Tie the doctors down and save an Ethiopian kid' argument appeals to the emotions of the reader rather than his rational senses.
Responding to the shortage of physicians in poor rural parts, there are other solutions. One of the most successful is the training and deployment of community health workers. Local people from the community can be easily trained to make a difference to the health status of the people around them.Partners in Health has used this model in Haiti , Peru, Rwanda etc. with a lot of success. Other similar projects are now sprouting. I am not saying that a trained community worker can replace a doctor completely. No, he/she cannot. However, training more community workers who have volunteered to engage their own communities and who are committed to make changes happen is probably more feasible than revamping the medical education system in Africa to keep doctors locked up against their will.
There are more pressing needs in global health and better solutions to address them than locking the doctors up with the unwarranted hope that doing so will save the sick child dying in Ethiopia tomorrow.
