Each year, U.S. hospitals hire approximately 5,000 foreign medical graduates (FMGs) to fill first-year medical residency positions in order to overcome domestic medical graduate shortages. Entering the country on temporary J-1 visas issued by federal and state governments, most FMGs eventually remain in the United States to practice medicine. According to a 2004 World Health Organization report in Health and Human Resources, they account for 23.3 percent of active physicians practicing in the country.
While the impact of FMGs in U.S. medicine has been routinely discussed in terms of quality of care and downward salary pressures, scant attention has been paid to the harmful effects of the "physician brain drain" in the developing world. Though proponents of medical migration have emphasized the importance of labor mobility and the rights of FMGs to seek better lives for themselves and their families, the resulting destruction of medical infrastructures abroad suggests that reforms to relieve U.S. dependence on FMGs are needed.
The brain drain of FMGs into the U.S. initiates a chain reaction of physician shortages that is ultimately passed on to poorest countries of the developing world, particularly in Africa. Zambia, for example, has retained only 50 or so of approximately 600 doctors trained in the country since 1964, while Zimbabwe and Ghana have kept less than 30 percent of their medical graduates since the early 1990s. Other nations in the region have suffered similar losses, and now more than 12 percent of all physicians trained in sub-Saharan Africa are working in the developed world, leaving fewer than 13 doctors to care for every 100,000 Africans.
Though its implications for health care delivery and disease management are obvious, this exodus of physicians is also coupled with dwindling resources for teaching the next generation of medical professionals, reduced capacities for accommodating medical sub-specialties and increased workloads -- creating even greater incentives for seeking jobs in richer countries. As usually the best and brightest FMGs are recruited for foreign work, the average skill level of domestic human capital diminishes with each graduating class of medical students, further crippling the ability to provide high-quality care. Economically speaking, the United Nations Conference on Trade and Development has estimated that the physician brain drain costs African nations nearly $4 billion per year, or one-third of official development aid appropriated to the continent.
Due in part to the admonishment of many human rights organizations and physician groups, governments in the developing world have been reluctant to erect barriers that might slow the physician brain drain. However compelling a case can be made for physicians' "inalienable right" to live in whichever country they see fit, no outright legal or moral basis for such claims exists, especially in light of the medical devastation FMGs leave behind. Given that local populations help subsidize the expenses of physician training -- and given that the populations in question are among the sickest and neediest in the world -- it seems unreasonable and unethical that they are frequently abandoned by those to whom they have conferred their trust and monetary support. Forcing the poor to continue gambling on the medical charity of others, instead of re-building and maintaining the internal institutions and work force needed for care at home, surely runs counter to the spirit of medicine.
Likewise, the policies of special-interest groups in the U.S. that artificially constrain the number of graduating medical students should be reexamined, especially when an excess of sufficiently qualified applicants already exists. The United Kingdom, for instance, has recognized the inequities inherent in utilizing subsidized foreign medical labor and has instituted legislation to curtail its aggressive recruitment from the developing world and improve the domestic physician supply. The International Organization for Migration and WHO will convene later this year to draft an international code reflecting similar guidelines, and the U.S. medical profession would do well to engage itself in this debate.
Besides simply training more students for U.S. needs, reforms to increase the number of bonded slots in foreign medical schools, changes in curricula to meet local demands, stricter rules governing entry/exit visa requirements and better compensation schemes should be incorporated into a focused dialogue between the leaders of the developed and developing worlds. As evidenced by many positive contributions of FMGs to health care in the U.S. and the strength that comes with diversity, solving the brain drain problem should not mean chaining foreign physicians to their clinics back home, but it should entail, in the least, a strategy that ensures care to those who need it most.
The result will be a world rife with medical independence -- not disease.
Jason Lott is a first-year student in the School of Medicine from Anniston, Ala. Whole Lotta Love appears on Mondays.
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