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Criminalizing the brain drain

By Stuart Rennie

There are many numbers around to express the inequalities in health care between developed and developing nations. In Malawi, there is one physician for about 50,000 persons; compare with Great Britain, where it is considered shocking when there are districts with only one doctor per 3500. In Zambia, there is one nurse for about 3000 patients; in the United States, studies have shown that even an increase from a 1:4 nurse/patient ratio to 1:10 can have a significant impact on surgical patient death rates, as well as job dissatisfaction and burnout. Who knows what a 1:3000 ratio does for patients and nurses. But for all the contrasting figures that can be found in the scientific literature, an unscientific anecdote stands out for me. In Kinshasa, somewhere off the Boulevard du 30 Juin, there is a small dental clinic, which I noticed was absolutely jammed full every single evening, with some patients spilling out onto the trottoir. Someone told me that there are 12 registered dentists in Kinshasa, a city with estimated population of 8 million. That struck me as terribly low, though in the meantime I have learned that according to WHO estimates (2004), the average dentist/patient ratio in Africa is 1 per 150,000.

Nevertheless, the industrialized world regards itself as having serious doctor, nursing and dental shortages, and part of the solution to the crisis currently involves recruiting from… the developing world. You don't need a fully articulated theory of justice to see a deep problem here.

In fact, it is old news: the brain drain of health professions from developing countries has long been discussed, moral outrage has been expressed, and various professional bodies have issued policies condemning the practice. Not that all this has had much of an impact so far. This week's Lancet, however, has a new twist on the old story. A group of authors have apparently decided enough is enough: they propose that the predatory recruitment of developing world health professionals be considered an international crime.

The idea is laudable, because the gravitas of 'crime' at least matches the seriousness of the issue. But how would it work in practice? It is difficult enough to enforce crimes against humanity, much less crimes against the universal right to health. Can one envision CEOs of recruitment bureaus being hauled off to the Hague and awaiting trial along with Charles Taylor? Besides, the defence lawyers would argue that the recruitment bureaus do not intend to endanger the health of developing nations; they are providing opportunities to skilled individuals who have the right to work where they want. It might be wiser (but not much easier) to press for enforceable national laws -- in abuser countries like Canada, United States, the United Kingdom, Australia and New Zealand -- that pose clear restrictions on the import of health human resources from developing countries, while working on the international front to address the conditions of poverty and neglect that push doctors, nurses and dentists towards greener pastures.

Stuart Rennie is a Research Assistant Professor in bioethics at UNC-Chapel Hill. He's project manager for the NIH/Fogarty bioethics grant and ethics consultant for UNC-Gap projects in the Democratic Republic of Congo and Madagascar.