Doctors with Borders

It’s hard to know what is worse about a new paper in the British Medical Journal, the simplistic economics or the troubling ethics. The paper, The financial cost of doctors emigrating from sub-Saharan Africa, adds up the government-paid cost of educating a health worker in Africa and then multiplies that cost over ~33 years by an investment factor to find the “losses” to the educating country of educating a health worker who emigrates to Canada, the US, the UK, or Australia. The authors do this for nine sub-Saharan African countries with an HIV rate of 5% or greater or more than one million people with HIV/AIDS.

The numbers, by the way, are quite small since the cost of education in developing countries is low and because our laws make it difficult for workers to immigrate, thus the authors find just 567 doctors from Ethiopia currently practicing in the four western countries that they consider; n.b. 567 is the total number not an annual flow. (Note also that  the authors gin up the costs by multiplying by an investment factor which adds virtually nothing to the analysis and confuses present and future value calculations.)

You can get an idea of the quality of this paper by asking why the authors chose to focus on countries with high HIV rates. The only reason for this is to suggest that doctors who emigrate and the countries that attract them are responsible for millions of deaths. See below.

Turning to the simplistic economics we have first the suggestion that there is a fixed number (flow) of health care workers so if the U.S. were to forbid Ugandan health care workers from emigrating to the United States this means more health care workers for Uganda. Not so; without the prospect of high wages earned abroad, investment in education (the major cost of which is born by the worker) will likely decline. The Philippines “exports” more nurses than any other country but also has far more nurses than one would expect for a country of its income class, on par with that of Spain, Hungary or Singapore. Here is Michael Clemens:

…there is no such thing as a fixed quantity of nurses to be “drained” from the Philippines or Africa, like petroleum from the ground. People — in this case mostly low-income women — react to global markets and change their career plans accordingly. Many Filipinas wouldn’t have become nurses if not for the migration opportunity, and thus are not ‘lost’ in any sense when they depart. Africans are starting to follow suit, opening career paths for professional women who would otherwise have few. This should not be discouraged through closed immigration policy, but rather taken advantage of — through the establishment of for-export nurse training programs as the Philippines has done en masse. Unlike petroleum, these women are human beings. They have rights and ambitions whose fruition in the United States is a beautiful thing.

Even on their own terms the authors calculations are faulty. Emigrating workers, for example, don’t leave immediately after they have finished their education (as the authors assume in their primary analysis), there are fixed costs to building an education infrastructure which can reduce the costs of education for non-emigrating workers and emigrating workers often send remittances back to the home country. Not all emigrating workers send remittances but wages for high-skill workers can be five or even ten times higher in say the U.S. than in a sub-Saharan African country so educating workers and sending them abroad could be a net benefit for the educating country just based on remittances. Indeed, many families make exactly this calculation. Finally, the authors don’t even try to measure externalities which is what they should be measuring.

What is most ethically troubling is that the authors implicitly treat people as if they were the property of the state. Thus, an emigrating physician is a loss even though the physician improves his life prospects and those of his children. Development is about making people better off not about making geographic units “better off.”

Lest you think that I exaggerate consider that the lead author of this paper is also the lead author of an editorial in the Lancet that advocates making it an international crime to hire African workers.

Although the active recruitment of health workers from developing countries may lack the heinous intent of other crimes covered under international law, the resulting dilapidation of health infrastructure contributes to a measurable and foreseeable public-health crisis….There is no doubt that this situation is a very important violation of the human rights of people in Africa.

…Active recruitment of health workers from African countries is a systematic and widespread problem… the practice should, therefore, be viewed as an international crime.

Yes, you read that correctly: recruiting African workers with prospects of higher wages and a better life is a “very important violation of the human rights of people in Africa.”

Addendum: See this excellent paper by Michael Clemens for more on these issues.


“ international crime to hire African workers "

That certainly does sound a very silly proposal. Hope I'm not wandering off subject here, but the world will be a better place when law is wound back closer to its original function of protecting property, peace, and freedoms against fraud, violence, and formal inequality before the law. I mean parametric as opposed to pervasive law. Paradox it may be, but less law (or more law at the margin) means stronger better law.

So doctors fail at economics? Usually everyone fails at statistics.

Peer review never seems to bother including people with relevant expertise in all covered domains.

Sometimes economists fail at economics - like these authors, usually when they can't adjust strongly-held beliefs about society to the truth.

No wait, having 3 more guys read your paper is a perfect system...

Just give up peer review and go to something online that you can edit but keeps all revisions, and anyone can comment on?

What are you fancy-pants economist scheconomist sociopaths talking about? Incentives don't matter! Everyone should work not for themselves, but for the betterment of the state or geographic units! How dare African doctors make better lives for themselves or their families, and how dare Anglo-Saxon nations hire them in another extension of racist vampiric imperialism!


It is a sad commentary on the economics knowledge of the medical profession when they write something that actually causes me to AGREE with Miley Cyrax

I wonder what the authors would make of within country mobility of physicians, or indeed professionals of any stripe? Surely every high IQ farm boy who migrates to the big city in search of any professional career removes his higher level of productivity from his home town. Perhaps that ought also to be a crime?

Only a national crime in that case - though there should be treaties governing, say, the Windsor-Detroit area, and the EU should organise the criminal law among its own states.

no need to turn an argument that's already bad enough into a strawman.
The reason the author labels this as a "crime" is that the doctors are educated using the already scarce resources of the developing country. Especially since they are trained in the big city, where the med. schools are, the situations aren't comparable.

well, in that case, then the funding structure of professional schooling is the problem. Restructuring so that the state doesn't bleed any $$$ ought to be doable, if there are credit markets (note: I lived in Kenya, such markets existed there and were somewhat well developed. I would be interested to know if there are credit markets available to the Filipina nurses).

But, I suppose that considering human capital financing structure is a bit far afield for these authors

I think that's exactly the right thought, but I doubt it'd be feasible in most poor Sub-Saharan countries. My guess would be that charging tuition high enough for a medical student to pay for her own education would dramatically reduce the number of medical students, even with education credits available (and I'm not sure those would work in many of the poorest countries).


Are you making your assertion on the assumption that there is a fundamental line between recruitment on the one hand and job-seeking by the individual on the other? Is that a valid assumption? It seems based on the assumption that the people with the money are automatically exploiting. Because to be "free" as you assert will not change the individual will now have to do the work (and the expense) of matching to the employer once the employer is banned from doing it.

I don't know if the line is "fundamental," but yes, I do think there is a distinction and that it can make sense when there is a large power/resource difference between the two sides. Recruitment limits are in place for College Sports, for example, aren't they?
Similar asymetric structures aren't that uncommon in criminal law: Buying drugs is punished much less (or not at all) than selling them. In Scandinavia, soliciting prostitution is illegal, but not prostitution itself etc.

My larger point, though, is not that the authors are necessarily right - I feel there must be a better solution than criminalization - but that I found the glib and thoughtless answers of the first dozen or so commenters, who didn't bother to read the original piece or think about the issue for more than 10secs incredibly off-putting.

I can think of a few differences between the potential farmer and the African doctor.

- The lifestyle difference between a US farmer and a "big city" professional career are not so vastly different that market forces cannot work their magic if there is a dire shortage of the former. Wages go up 10% there, -10 % here, people and institutions and sensibly and smoothly respond. But do your economic models predict anything useful _in the medium term_ when face with a 100x disparity?

- Even ignoring the preceding point, the fact there are no immigration restrictions in one country makes it easier for market forces to do their (beneficial) work.

- Even ignoring the two preceding points, if there is a national government it can implement transfers to easy the pain (e.g. farm subsidies)

- The farming community does not pay all on its own to train people for these "professional careers" (?? lawyers? investment bankers? ???). These training costs, to the extent they are socialized at all, are generally broadly distributed throughout a country.

- Even if such communities did pay all such cost, in the farming community it would merely be as mistake rather than out of a desperate, truly life critical, need that _some_ people so trained remained in the community. If you ran a country and had a choice between 0 doctors, or subsidizing training for countless students knowing that only 1 out of 1000 would remain helping your population, what would you do? (That's supposed to be hard question!)

Oh, almost forgot: even if you are right as a matter of principle and logical consistency, a small issue... misallocated farming abillity in one nation is, well, not the tiniest fraction as important as a shortage of medical staff in a poor, illness-stricken, country.

Based on Alex's summary, I share the contempt for their ignorance of economic (incentives? what incentives?) and, unless the summary is unfair, a deeply immoral stance on human capital. But ... there nevertheless is kind of a serious issue here it seems, one that from a global human welfare perspective seems dire. Simply sniping at people who are deeply misguided in their proposals to fix things seems a bit incomplete. Do you deny that they are reacting to a serious problem? If you do, I suppose end or story, but if you don't, what better constructive suggestions do you have?

We can discuss the details, but the point is, how worth it is the discussion if this is just like the problem of my boss wanting to only train me on his proprietary software and me wanting to learn more generally marketable skills? I already knew doctors thought they were special.

Spend some time at a government hospital in South Africa and you will see why many doctors and nurses of all races have emigrated or want to. Low pay, poor working conditions, high levels of bureaucracy and political appointments at management level all contribute to this.

South Africa has a very low ratio of doctors per population head count and it shows in areas such as high infant mortality rates, treatment of HIV/AIDS, etc. The government is appealing to ex-Commonwealth countries such as Canada, Australia and NZ not to "poach" our medical practitioners.

Every major city in the world has a community of ex-SA doctors and nearly all of the doctors I know of personally have emigrated (GP, dentist, paediatrician, gynaecologist). Good luck with with "emotional blackmail" or appealing to loyalty or nation-building. Putting bread on the table in a secure environment counts more.

STRONGLY agree. Attacking rhodies for leavign after Mugabe went out of his way to wreck the country will be a *tough* sell

Never forget the primary directive of leftism: if you employ someone, you are oppressing them.

So, yeah, it is not a stretch at all to say that hiring an African doctor is a human rights violation.

Get with it, Alex.

Ah, but that someone has the right to the fruits of your labor, Jim. That's not oppression.

The sad thing is that this will be seen as "serious analysis" and you will be considered a right-wing radical blogger.

I seem to recall Bill Clinton publicly signing a bill that limited the number of admissions to medical schools
( )
in a deliberate attempt to create enough of a doctor shortage that doctors' pay didn't decline.

Why don't any of the people bemoaning the "doctor drain" start by proposing to alter or repeal that bill?

Main issue is that paying that many more residents is expensive. Is a no-go in the current era of austerity.

Why does residency have to cost the government anything? Can't residents take out loans like they did for their first eight years of training?

I'm guessing from your name that you consider yourself a libertarian. So it's interesting that the article you link to mentions only a limit on the government sponsorship of residencies. In the libertarian paradise, aren't all residencies paid for privately?

And where exactly is your evidence that (1) this was Clinton's doing, and not that of the GOP which controlled the congress when this bill was passed and (2) that he was doing this at the behest of the medical community (generally known to be fairly GOP leaning) rather than simply capping Medicare spending on that item?

If you're going to make a thoroughly bogus claim, it's pretty stupid to link to a source that thoroughly discredits it.

This is part of a larger trend of blaming these countries' problems on the West in any way possible, ignoring their own dysfunctional governments.

Of course there are some problems with Western interference, and there is a lot to regret about colonialism. Ultimately, however, this position is (ironically) very condescending.


your stuck in the eighties. At the moment few Africans in Africa involved in policy discussion blame the west for their problems.

"(the major cost of which is born by the worker)"

So isn't this simply a question of who pays for the worker's education? If the worker paid the fully loaded cost, then surely they are free to do what they like. If they paid less than that, then presumably the co-payer (e.g. an employer in the private sector or the military) could insist on some sort of commitment (work n years or pay back the cost) and everybody would be even. No?

I believe most such "bonds" are unenforceable in any decent court of law (unless it is a military bond).

Not in the U.S. These are very common and enforceable (note the "or pay back the cost").

I know they are common in contracts; but are there cases where they have gone to a court and successfully settled? It's like the non-compete clauses. Extremely hard to enforce in courts.

I think he's talking about student loans. On the other side we are talking about The Lancet proposing an international law that changes he rules for doctors who signed up under different conditions.

".There is no doubt that this situation is a very important violation of the human rights of people in Africa." Wow - what an outlandish claim. So allowing medical practitioners to practice where they like under the terms they choose is a human rights violation. And the implication is that a policy forcing practitioners to stay in their country of origin regardless of working conditions would represent a reform and thus would advance the cause of human rights?

geez - you guys really have a hard time reading, no? There is much to disagree with in the articles, but the article talks about banning active recruitment by professional organizations, not free and voluntary movement of hc workers. (From the lancet article: "Health workers should have freedom of movement and choice of where they live and work, just as any workers should")
Everyone here seems happy to engage in glibertarian snark, without any willingness to actually address the ethical dilemma that's quite real.
You have tax payers of poor countries subsidizing the health care system of richer countries, by educating a share of their medical workforce. And that in a situation where doctors are needed badly in the poor countries. Yes, the health care workers should have the right to work and practice where they want, but the ethics of this become more complicated if their fellow citizens don't have that right. What's the ethical justification of allowing a doctor to move to the US, but not a car mechanic?

Sebastian - this is just a financing problem. See Robert Bell's comment above.

That's not a human rights violation, just bad policy. If countries want to tax remittances or impose a head-tax on the departure of health care workers to help make up for the lost investment, they are free to do so.

I don't think this distinction makes much sense. How can it be perfectly ethical for a doctor to move from Malawi to England, yet an international crime for an English hospital to offer someone that opportunity? What is it that makes the hospital blameworthy, but not the doctor? The problem for the authors of the editorial is clearly that medical professionals are leaving Africa. According to them, this needs to be "discouraged." It is easy to see why they would frame it in terms of recruitment--this is more relevant to their audience, and it sounds better to blame Western medical organizations than poor Africans who are trying to improve their lives. However, I see no justification for drawing a moral distinction there.

Furthermore, stopping these recruitment programs would probably remove this opportunity for most of those involved. It is awfully hard to apply and compete for positions in the standard way when one is a continent away, as well as facing cultural and economic barriers.

"The overall estimated loss of returns from investment for all doctors currently working in the destination countries was $2.17bn,,,,The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom ($2.7bn) and United States ($846m)."

Astonishing they get the conclusion wrong after answering the cost-benefit (to the best of their ability). At a high of $58k to train a doctor that sounds like a pittance. Should the education cost be internalized? Maybe. That sounds pretty easy with many possible options to do so without interfering in recruitment. In fact, exporting medical training could be a profit-center if they get creative.

Human capital, signaling...oh nevermind.

Of course the difference makes sense. The closest parallel I can think of would be cigarettes: Policy makers view smoking of cigarettes as undesirable. Yet a ban is seen as both too much of an interference with personal liberty and the risk of unintended consequences of prohibition is too high. So we don't ban cigarettes, but we ban ads for cigarettes.

As I note above, more generally, asymmetric rules/laws governing the legality and/or morality of commercial interaction are quite common in general. As is the case with Scandinavian laws on prostitution they are often motivated by pragmatism rather than abstract principles.

As Frank mentioned before, the home nations of the African doctors are doing the best to encourage them to emigrate. It is not just the bad work conditions, but also omnipresent cronyism and nepotism.

Why should they let be off the hook?

Basically, many of the emigrating African MDs are escaping something akin to a labor camp. You want to keep them in by international law.

Marian - so a "labor camp" for poor people who don't have skills urgently needed in rich countries (but would still have a _much_ better life moving there) is OK, but for middle-class people with those skills it's not?
I agree that, if we had general free mobility of people across borders this wouldn't be an issue.
If the people from, say, Uganda could follow their doctors to the UK and work there as waiters, cab drivers etc., making a multiple of what they're making now, the situation would be different.
But as long as we're making a concerted legal and law enforcement effort to not allow those people to come to (let alone work in) Europe, luring those people most needed there, like Doctors, to the rich countries seems ethically dodgy to say the least.

Sebastian, you're right in pointing out the moral dubiousness of the situation.

It is not that easy, though. When it comes to European voters, they do not seem to be concerned with working immigrants, but with the sort that ends up on permanent, multi-generational welfare.

The Lancet failed to put the other option: To give Jeff Sachs a trillion dollars to save the world, I'm sure it overlaps with their ideological stance on these matters and just as practical.

Importing badly trained nurses with bad attitudes and indifferent English is certainly a crime for the victims of their 'care'.
But they are pigmented and the ' patients' are not - so tough on your grandmother.

What garbage, do you have any evidence to support your contention that pigmented nurses in the west are badly trained with a bad attitude.

For the purposes of argument, accept the authors' analysis (Governments lose money on investments in doctors).
Now, two solutions emerge: (1) Attempt to ban doctor-poaching (2) Invest in primary/secondary education for the many, rather than tertiary education for the few

The second sounds crazy - countries need doctors! But, 12 year olds working the fields is crazy too. If you're a utilitarian, there's no question. If you're not, I still think you'd be hard pressed to defend educating 1 doctor over 30 secondary school children (rough cost comparison from Kenya, I used to live there) as being tax revenue-maximizing for the state, or better along any other measure (including health outcomes)

The problem with your prescription is that extreme approaches are often welfare minimizing. A city with 20,000 educated children and no doctors is worse off than one with, say, 19,000 educated children and a few doctors.

Right. Further, education is only useful when there are opportunities to use it. Otherwise you will have well-educated 12 year olds working the fields.

Any excuse to throttle the supply of imported physicians must sound like music to the ears of existing practicing western doctors. A lot of these papers are nothing more than a Local Teamster objecting to non-union workers etc.

Interesting how the arguments have evolved over the years. Earlier foreign doctors were ill-trained and hence immigration was bad for us . Of course, it sounds nicer if we claim we are looking out for the best interests of the third world.

I think that's right. Similarly, the American Garment Workers Association funding anti-sweatshop propaganda. That said, it's disgusting even by rent-seeking standards.

In a (perverse) way, I admire the US trucking lobby. When they oppose Mexican truckers driving into the US at least they don't claim their opposition is for Mexico's own good.

From a purely selfish standpoint, I really hope this law gets passed, because the unintended unanticipated consequences are bound to be hilarious.

According to the Lancet editorial, the author favors mandated "repatriation of professionals" as a remedy. So I guess we can look forward to U.N. thugs accosting dark-skinned physicians and asking to see their papers. Yup, should be a hoot.

They nowhere say that they are in favor of "mandated" repatriation.

I guess we interpret the concept of government-supported repatriation differently...

As jk says, this "hard power" approach to development (force people to stay where they are) is closely related to the Jeffrey Sachs "soft power" approach: make a place with a crummy economy superficially more attractive. Thus reducing migration to places with better economies.

The doctors are clearly more productive in their destination. So, before we can even get to the ethical question we must answer others.
Do we know that remittances don't totally or partially offset the superficial losses to the source countries? I suspect we don't know.
Do you really need doctors who can operate in the high-tech US to solve the big problems in Africa? Put another way, why are Africans training doctors in knowledge that is not specialized to African problems?
Are doctors really attempting to escape their education costs? We don't see a lot of doctors in the US move to Africa to escape quarter to half-a-million dollar loans.
Can the exernalities be internalized in cheaper ways? We want to import middle class educated individuals, we need to certify them, maybe we pay there home country for that certification.

Yeah, but that gives no option to play with human lives like with chess pieces on a board.

There is a saying that if you have a hammer, everything looks like a nail.

The BMJ staff sees the current state of things as "malady" that needs to be "treated" or at least "controlled", and they suggest to use "isolation" to achieve that point.

So predictable.

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