Haines, Andy

Lansang, Mary Ann

Pang, Tikki

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Brain Drain and Health Professionals: A Global Problem Needs Global Solutions

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Pang, T; Lansang, MA; Haines, A (2002) Brain drain and health pro-fessionals - A global problem needs global solutions. BMJ, 324 (7336).pp. 499-500. ISSN 1468-5833 DOI: 10.1136/bmj.324.7336.499Downloaded from: http://researchonline.lshtm.ac.uk/17499/DOI: 10.1136/bmj.324.7336.499Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Creative Commons Attribution Non-commercialhttp://creativecommons.org/licenses/by-nc/2.5/orthodox clinicians to justify referral to homoeopathicservices. The use of randomised controlled trials to testthe legitimacy of homoeopathic treatments is the latestchapter in an ideological and scientific strugglebetween homoeopathy and orthodox medicine goingback to the 19th century.5 The fervour of this struggleis reflected in the 58 electronic responses to anothertrial of homoeopathy reported in the BMJ.6Are the results of placebo controlled trials inhomoeopathy convincing? Linde et al’s meta›analysisof 89 trials suggests an effect of homoeopathicmedicines greater than placebo.7 The aggregated effectsize of homoeopathic treatments, when possible publi›cation bias is taken into account or only high qualitytrials are included, is modest.8 How seriously clinicianstake these findings depends on their prior beliefs.9 Ifyou cannot conceive of highly diluted solutions withundetectable drug concentrations having a biologicaleffect, then no matter how well designed the trial orrobust the meta›analysis, a positive result will notchange your view. If you are less concerned about theintegrity of our model of the universe or are intriguedby controversial laboratory work showing the activityof highly diluted histamine solutions10 than the overallpositive result of the trials makes it easier to takehomoeopathy seriously.Despite homoeopathy’s popularity with patients,orthodox medicine has had the upper hand in terms ofinstitutional support, research funding, and strongevidence of effectiveness. Nevertheless, the flurry of trialsin the past 20 years has changed the terms of the debate.At the very least, those who consider homoeopathy to beabsurd have had to muster different philosophical andmethodological arguments to defend their position.Randomised controlled trials may be efficient arbiters ofclinical effectiveness, but they are not particularly goodfor resolving philosophical disputes.Current trials are of a high methodological standardand, if positive, may sway agnostics. Opponents ofhomoeopathy have made it clear that no number of welldesigned trials showing an effect greater than placebowill overcome their prior belief that homoeopathycannot work. Research funding is a scarce resource.Unlike other commentators in this journal,11 we believethat new trials of homoeopathic medicines againstplacebo are no longer a research priority. The questionwhether ultramolecular dilutions can have any measur›able physical effect, a scientific rather than philosophicalquestion, is best tackled with laboratory methods.However, there is still a role for pragmatic trials compar›ing the effect and cost effectiveness of orthodox andhomoeopathic treatments. Within the homoeopathicmedical community and other groups that usehomoeopathy, such as anthroposophical physicians,12there is a call for outcome studies to evaluate theindividualised treatment decisions that are at the heartof their clinical method and compare outcomes toorthodox treatment.13Gene Feder professor of primary care research anddevelopmentDepartment of General Practice and Primary Care, Queen Mary'sSchool of Medicine and Dentistry, London E1 4NSTessa Katz general practitionerLower Clapton Group Practice, London E5 0PDGF was paid a consultancy fee by Weleda, a pharmaceuticalcompany that manufactures homoeopathic medicines, todevelop prescribing guidelines. TK received a grant from theBlackie Foundation to pilot a randomised controlled trial ofhomoeopathic treatment.1 Linde K, Melchart D. Randomized controlled trials of individualizedhomoeopathy: a state›of›the›art review. J Altern Complement Med1998;4:371›88.2 Seymour J. As if by magic. New Scientist 2001;170:46›9.3 Lewith GT, Watkins AD, Hyland ME, Shaw S, Broomfield JA, Dolan G,et al. Use of ultramolecular potencies of allergan to treat asthmaticpeople allergic to house dust mite: double blind randomised controlledclinical trial. BMJ 2002;324:520›3.4 Reilly D, Taylor MA, Beattie NG, Campbell JH, McSharry C, AitchisonTC, et al. Is evidence for homoeopathy reproducible? Lancet1994;344:1601›6.5 Weatherall MW. Making medicine scientific: empiricism, rationality, andquackery in mid›Victorian Britain. Soc Hist Med 1996;9:175›94.6 Taylor MA, Reilly D, Llewellyn›Jones RH, McSharry C, Aitchison TC.Randomised controlled trial of homoeopathy versus placebo inperennial allergic rhinitis with overview of four trial series. BMJ2000;321:471›6.7 Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, et al. Arethe clinical effects of homoeopathy placebo effects? A meta›analysis ofplacebo›controlled trials. Lancet 1997;350:834›43.8 Linde K, Scholz M, Ramirez G, Clausius N, Melchart D, Jonas WB. Impactof study quality on outcome in placebo›controlled trials of homoeopathy.J Clin Epidemiol 1999;52:631›6.9 Vandenbroucke JP, de Craen AJ. Alternative medicine: a “mirror image”for scientific reasoning in conventional medicine. Ann Intern Med2001;135:507›13.10 Brown V, Ennis M. Flow›cytometric analysis of basophil activation: inhibi›tion by histamine at conventional and homoeopathic concentrations.Inflamm Res 2001;50 (suppl 2):S47›8.11 Lancaster T, Vickers A. Larger trials needed. BMJ. 2000;321:476.12 Evans M, Rodger I. Healing for body, soul, spirit: an introduction toanthroposophical medicine. Edinburgh: Floris, 2000.13 Riley D, Fischer M, Singh B, Haidvogl M, Heger M. Homeopathy andconventional medicine: an outcomes study comparing effectiveness in aprimary care setting. J Altern Complement Med 2001;7:149›59.Brain drain and health professionalsA global problem needs global solutionsMigration of medical professionals from devel›oping countries has become a majorconcern. This brain drain worsens thealready depleted healthcare resources in poor coun›tries and widens the gap in health inequitiesworldwide. It is time that international organisationscollaborated to protect the value of this “intellectualproperty”: where medical professionals cannot be dis›suaded from moving, the country that trained themshould at least gain from their movement.In Africa alone, where health needs and problemsare greatest, around 23 000 qualified academic profes›sionals emigrate annually.1 Information from SouthAfrican medical schools suggests that a third to a halfof its graduates emigrate to the developed world.2 Theloss of nurses has been even more extreme—for exam›ple, more than 150 000 Filipino nurses3 and 18 000Zimbabwean nurses4 work abroad. A recent reportfrom the United Kingdom estimated that 31% of itsdoctors and 13% of its nurses are born overseas; inEditorialsBMJ 2002;324:499–500499BMJ VOLUME 324 2 MARCH 2002 bmj.comLondon the figures are 23% and 47% respectively.5These reported figures are likely to be underestimatesas many migrate unofficially.The cost implications are significant. With 600 of itsmedical graduates registered in New Zealand, thefinancial cost to South Africa was estimated at $37m.6The United Nations Commission for Trade and Devel›opment has estimated that each migrating Africanprofessional represents a loss of $184 000 to Africa.7Paradoxically, Africa spends $4bn a year on the salariesof 100 000 foreign experts.1 8 In an example of braindrain within the country, Kenya estimates that only 600doctors work in public hospitals out of more than 5000registered9; the rest have moved abroad or are workingin the private sector. “Brain waste” also occurs whenhealth workers end up working outside the health sec›tor or as unskilled labour in the country they move to.Some benefits may also result for the exportingcountry. These include substantial financial remit›tances from expatriates, improved training, and longterm professional networks. The adverse effects,however, are likely to predominate.What factors influence medical professionals toemigrate? Key reasons include poor remuneration, badworking conditions, an oppressive political climate,persecution of intellectuals, and discrimination.Researchers cite lack of funding, poor facilities, limitedcareer structures, and poor intellectual stimulation asimportant reasons for dissatisfaction. Other keyreasons for emigrating are personal ones. Theseinclude security, the threat of violence,10 and the wish toprovide a good education for their children.Some countries which have shown the foresightand commitment to improve domestic conditions havesucceeded in effecting a brain gain by attracting backmedical professionals. Thailand and Ireland havereverse brain drain programmes offering generousresearch funding and monetary incentives as well asservices and assistance. Developing countries need toaddress the structural, political, and economic prob›lems that lead to the brain drain.Possible solutions include demanding compensationfrom departing professionals; delaying their departurethrough compulsory service; increasing salaries in thepublic health sector; permitting health professionals inthe public sector to do some private practice; providingeducational benefits for their children; and trainingparamedics who can fulfil many of the roles of doctorsbut whose qualifications are not recognised outside thecountry. They must aim to provide a stimulatingenvironment for professional growth with adequatefunding, facilities, and a vibrant intellectual community.Funding agencies should put more resources intoimproving the conditions and training for health careprofessionals and researchers in low income countries.Importantly, when such training is provided abroad itshould be relevant and applicable to the problems ofthe country of origin so that the difficulties and frustra›tions experienced by those returning to a poorer envi›ronment are minimised.On their part, developed countries should think ofthe impact of brain drain on health care in poorercountries and consider reimbursing these countries forthe cost of training the health professionals theyimport. They need bilateral agreements with thesecountries and a recruiting process that would minimisethe adverse effects on the health care of the exportingcountries. The recently published guidelines by the UKDepartment of Health11 address the ethical issuesinvolved in the international recruitment of nurses anddoctors. They recognise that old practices of recruit›ment without regard to the negative impacts in thecountry of origin are no longer acceptable. Clearly, weneed better evidence on the extent of the problem ofbrain drain, its impact on both countries, and the effec›tiveness of measures to deal with it.What part should international organisations play,given the global nature of the brain drain? Just as intel›lectual property rights need to be discussed bydeveloped and developing countries together, so alsoshould the preservation of the intellectual property of anation, embodied in its health professionals, beaddressed by international organisations. The WorldHealth Organization could convene a forum of govern›ments and international organisations such as theInternational Organization for Migration, the UnitedNations Educational, Scientific, and Cultural Organiza›tion, the United Nations Development Programme, theWorld Bank, the World Medical Association, and theCouncil of International Organizations of MedicalSocieties. They could agree on a declaration and aninternational code of ethical guidelines,12 keeping inmind the harm that migration of medical professionalsmay cause. Currently the office of the Pan AmericanHealth Organization is working closely with interestedstakeholders and member countries on a programmeof managed migration of nurses in the Caribbean,traditionally a major source for recruiters. A global per›spective, agreed ethical principles between countries,and a systematic approach using the convening powerof international organizations should be the way toaddress the problem of brain drain.Tikki Pang directorResearch Policy and Cooperation, World Health Organization,Geneva, SwitzerlandMary Ann Lansang executive directorINCLEN Trust, Manila, PhilippinesAndy Haines deanLondon School of Hygiene and Tropical Medicine, LondonWC1E 7HT1 Brain drain costly, African report says. Int Herald Trib 2001;18 Oct.2 Weiner R, Mitchell G, Price M. Wits medical graduates : where are theynow ?. S Afr J Sci 1998;94:59›63.3 Corcega T, Lorenzo M, Yabes J, sde la Merced B, Vales K. Nurse supplyand demand in the Philippines. The UP Manila, 2000;5:1›8.4 Mangwende B. Health sector records massive brain drain. Daily News[Zimbabwe] 10 April 20015 Glover S, Gott C, Loizillon A. Portes J, Price R, Spencer S, et al. Migration:an economic and social analysis. London: Home Office, 2001.6 Medical migration and inequity of health care. Lancet 2000;356:177.7 Oyowe A. Brain drain: Colossal loss of investment for developing coun›tries. The Courier ACP›EU 1996;159:59›60.8 Seepe S. The brain drain will continue unabated. Mail and Guardian(Johannesburg) 2001;30 Mar.9 Siringi S. Kenya government promises to increase doctors’ salaries tocurb brain drain. Lancet 2001;358:306.10 Amore LGC. My part in the brain drain. BMJ 2000;321:841.11 Department of Health. Code of practice for international recruitment.London: Department of Health, 2001.12 Bundred P, Levitt C. Medical migration: who are the real losers ?. Lancet2000;356:245›6.We ask all editorial writers to sign a declaration of competing interests(bmj.com/guides/confli.shtml#aut). We print the interests onlywhen there are some. When none are shown, the authors have ticked the‘‘None declared’’ box.Editorials500 BMJ VOLUME 324 2 MARCH 2002 bmj.com

Brain drain and health professionals.

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Brain drain and health professionals.

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