Doctors migrate from developing countries to wealthier countries in order to further their careers, or improve their economic or social situation. The World Health Organization (WHO) has long recognized that migration of health personnel from developing to developed countries creates unfortunate imbalances in the global health workforce [1
America's physician workforce has been significantly infused with foreign-trained international medical graduates (IMGs) since World War II. The purpose of this paper is to describe a sub-population of IMGs in the USA, those who have trained in one of the 47 African subcontinent nations.
African governments have been very clear about their objections to the wholesale migration of their physicians to rich countries. In 1996, South Africa's then-Deputy President Thabo Mbeki implored the World Health Assembly to take measures to stop the flow of physicians from poor countries to rich ones. In 1995, South Africa itself banned the recruitment of doctors from other Organization of African Unity countries [2
Nonetheless, large numbers of African-trained physicians leave home upon completion of their medical school training in search of careers in higher-income countries. They leave behind health systems in sub-Saharan Africa that are severely stressed: life expectancy is only 50 years, 162 children in 1000 die before reaching their fifth birthdays, and only half have access to clean water sources [3
]. Further, AIDS prevalence among those 15 to 49 years old is estimated to be 8.4% [4
], and in four countries, adult HIV prevalence exceeds 30% [5
]. While health improvements in Africa will require a broad agenda of development activities, access to an educated workforce of health professionals is also essential [6
African country health systems and workforce data are poor, making it difficult to estimate the effects of physician migration on sending countries. The World Bank has documented this data gap, noting "Quantitative data on the health workforce is notoriously unreliable in most countries...In poor countries, government and professional information systems are weak, when they exist at all, and are rarely comprehensive (often there is no information on the private sector) and up-to-date" [7
]. Indeed, the way many African country ministries of health learn about the extent of their own emigration is through gleaning data presented by destination countries [8
]. This paucity of sending-country data makes it difficult to fully describe the impact of migration on countries of origin.
The 47 nations of sub-Saharan Africa have a total of 87 medical schools, although 11 countries have no medical school at all and 24 have only one each (see Table ). The population of the subcontinent totals over 660 million people, with a ratio of fewer than 13 physicians per 100 000 population, or a total of 82 949 doctors [9
]. By comparison, the United Kingdom (UK) has 164 physicians per 100 000 and the USA has over 279 physicians per 100 000 (or almost 800 000 doctors for a population of 284 million).
Physician workforce distribution and number of medical schools by African country
The dependence of the United States on IMGs is encoded in various policies, most specifically Medicare's financial support for significantly more residency positions than we have domestic medical school graduates [10
]. Additionally, the USA will waive the exchange visitor requirement that would otherwise return IMGs to their home countries after residency training in exchange for agreements to practice in underserved USA settings. Further, the USA will grant permanent residency status to IMGs under a variety of conditions [11
The UK has initiated efforts to meet its own health workforce planning needs while paying attention to global equity considerations by adopting a formal "code of practice" that prohibits its National Health Service employers from recruiting health professionals from a long list of developing countries [12
]. While this code has not resulted in a reduction in nurse recruitment, the number of physicians migrating to the UK has declined for a brief period (but is now back up) [8
]. Recently, two prominent medical journals in the UK, the Lancet
and the British Medical Journal
, have editorialized on the effects of the brain drain in poor countries, recommending an international code of ethics prohibiting the recruitment of developing world health professionals by rich countries [14
While the UK has a centralized health system well positioned to address these issues, both within its health care system and with representatives of other nations, the USA, in contrast, has a fractured health system that is less able to engage these issues. Agencies of the USA government have been reluctant, unable or unwilling to impede free-market driven physician migration.
United States policies have always been quite friendly to physician migration, even taking into account toughened medical licensing examinations and tightened immigration rules over the past four or five decades. Furthermore, even though some types of immigration have been more restricted since September 11, 2001, Congress subsequently expanded the number of foreign physicians who will be granted favorable immigration status (HR 2215, passed 10/3/02 increases the number of J-1 visa waivers allocated to state health departments from 20 to 30; further, the Department of Health and Human Services took over the role formerly played by the USA Department of Agriculture in handling applications of J-1 waivers, thereby ensuring additional foreign physicians will have access to waivers.).
One of the most common initial points of entry for IMG physicians into the USA medical workforce is residency training program enrollment, even if physicians have already completed postgraduate training in their home countries. The reliance of many inner-city hospitals on IMGs has thwarted calls by medical policy organizations, such as the Council on Graduate Medical Education, to reduce the number of IMGs admitted to residency programs as a means of narrowing the IMG pipeline to the USA
There is little debate within the USA government or other institutions about the social justice implications of obtaining health professionals from poor countries [16
]. Typically, research on the issues surrounding the role(s) of IMGs in the USA has focused on 1)whether IMGs practicing here contribute to a surplus of physician labor (which could tend to lower physician salaries and/or drive up health care costs) [17
]; 2) the quality of care delivered by IMGs [20
]; and 3) the contribution of IMGs to the "health safety net" in rural or underserved areas [21
The ethics of health professional migration from poor countries to rich ones is complicated by the competition of legitimate interests – each country's need for an adequate health workforce as opposed to each individual's human right to travel. When health professionals travel to receive training and then return to apply their skills, there are advantages to the home country. Additionally, emigrants of all social classes from poor countries typically send funds home to relatives, although sub-Saharan African remittances, at less than USD 5 billion, comprise the lowest dollar amounts of any other poor world region [8
]. Further, it must be noted that individuals having benefit of public funds for their medical training are sending their remittances home to private parties with no direct gain for the health or education systems.
Immigration theory informs us that "push factors" prompt professionals to leave poor countries in favor of settling in higher income countries [22
]. Negative factors in the sending countries include insufficient suitable employment, lower pay, unsatisfactory working conditions, poor infrastructure and technology, lower social status and recognition, and repressive governments. Simultaneously, "pull factors" in wealthier countries systematically attract physicians. These include training opportunities, higher living standards, better practice conditions and more sophisticated research conditions.
The "world systems framework theory" stresses the more permeable barriers between and among countries created by the standardized curriculum and English language used in world medical schools, the use of common research methods and shared scientific knowledge, the easy articulation of requirements of practice across countries, and the weakened nationalism that occurs as a result of professional training [23
]. Other theories characterize migration as a decision of family units, rather than individuals, emphasizing the insurance nature of establishing what are, in effect, "branch offices" in multiple locations [24
Given the enduring migration from poor countries to rich ones, only likely to increase with the international liberalization of trade in health services [25
], concerns for global health require the maintenance of an adequate health workforce in poor countries.