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I’d always assumed that in some kind of tournament to establish the worst global trouble— education vs. health care, global warming vs. ethnic conflict — one particular powerhouse of problems would win again and again: corruption. It is, of course, utterly demoralizing to its victims, but its most destructive property is that it prevents the solving of all other problems. A crackdown on corruption — and a cultural change toward intolerance of it all levels — wouldn’t end Tanzania’s problems, but it’s impossible to imagine any progress against them without it. That said, I’m coming to see a potential dark horse rival: brain drain. It is no secret, of course, that the tiny number of highly educated and skilled professionals Africa desperately needs have been fleeing to the West for decades. But after getting some preliminary sense of the scope of the problem here and its demoralizing effect on those who stay behind I am frankly surprised it doesn’t get more attention. Surely, along with corruption, it must be one of the two dominant impediments to development. And it is a problem, I’m sorry to report, in which the United States is heavily complicit. We are, of course, a nation of immigrants, and the moral questions raised by the brain drain problem are admittedly not simple. But they are more simple than many let on, and the necessary discussion about the implications of our role in the problem have simply not taken place, at least on a broad political level. One of the nice the things about blogging is I can get away with a somewhat lower standard of evidence than in gathering material for a published article - which is a good thing given my 30 KBps Internet connection. But a few minutes of slow web surfing through UN reports and other papers turns up a few mind-boggling stats: _ 5,000 doctors from sub-Saharan Africa practice in the United States. About 30,000 African Ph.D.s live outside Africa. _ In at least five countries — Haiti, Cape Verde, Samoa, Gambia and Somalia — more than half of university-educated professionals have moved out of their home countries in recent years. Kenya has lost more than one-third of its skilled professionals. _ More than 3,000 doctors have left Ethiopia, leaving around 900 to treat a poulation of 80 million. _ Tanzania, Uganda and Ethiopia have two neurosurgeons; Malawi and Zimbabwe none. There are more Malawi-trained doctors in Manchester, England than in Malawi. Here in Tanzania the problem is acute and demoralizing. In the entire Kilimanjaro region there is one psychiatrist, who is actually a neurologist. The generally respected KCMC hospital in town has 2-3 OB-BYN physicians but delivers 3600 babies per year — more than Duke, which has more than 50 OB-GYN faculty. There is no pathologist at the hospital. A 2006 McKinsey report on health-care workers (available here: http://bit.ly/bTZ4yc ) found the key bottleneck to health care in Tanzania, where life expectancy fell by 8 years over the previous decade, is not drugs or facilities but health care personnel. There are about 25,000 nationwide (including physicians, nurses and other trained workers), a figure that would have to increase by a factor of 3 to match the density per full population in Kenya and 30 times to match the United States. Even South Africa has 10 times the density. Of those 25,000 in Tanzania, fewer than 1,000 are physicians, and many of them work in administrative or government jobs. It certainly isn’t just medicine — there is an acute shortage of accountants, lawyers, engineers and teachers (more on Tanzania’s own education system in later posts). The consequences of these disastrous figures are of course severe, though the mechanism is actually, I think, more pernicious than I had previously understood. It is not simply the absence of essential professionals but the poisonous effect on the healthy development of a society. I hesitate to talk about cultural evolution in Darwinian terms because of obvious dangers and shortcomings in such an approach, but it strikes me nonetheless: when a species evolves, the new traits or adaptations that are most favorable to success are reproduced, and eventually crowd out the non-successful traits and become ubiquitous. As a society evolves, brain-drain completely short-circuits the process. Traits that lead to success — education, personal responsibility, accountability, ambition, discipline — are the traits that help people to leave, so they are “rewarded” by being removed from the pool. Those traits are not only no longer around to benefit the country as a whole, but they are no longer on display for others to model. The only path to success on display is departure. It is difficult to blame professionals for seeking opportunities in places where they can often earn 10 times as much in salary (though older doctors here say medical students now have little sense of calling and intend all along to go abroad). There are such deep systematic flaws in the health care system here that I doubt that I, in their shoes and even aside from the issue of salary, would have the energy and commitment to stay and practice here, instead going abroad and asuage my guilt with remittances and the odd medical mission trip back home. Even the American doctors who come here out of service and commitment are quickly beaten down by the systemic problems. Still, none of that is to say there shouldn’t be a thorough and serious conversation in the U.S. about out own role in the problem. While reasonable people can disagree about the wisdom of particular appraoches to immigration policy, one of the most infuriatingly ingorant aspects of the debate is the myth of the “lazy immigrant.” To the contrary, immigrants are, almost by definition, some of the most ambitious people in the country. Lower-down the socio-economic ladder, they are the ones who have taken the most initiative to improve their lives by coming (often illegally and at great danger) to the United States. Higher up the ladder, our visa policies favoring highly educated immigrants have transformed American universities and the U.S. economy. There would be no Silicon Valley without them, and U.S. universities would award fewer than half as many science Ph.Ds (and find it completley impossible to teach sections of their sciences courses to undergraduates). Many of those Ph.Ds stay on to work in the U.S., paying taxes (ample evidence has been established that on balance immigrants contribute far more in tax dollars than they receive). The U.S. (and western Europe) grant preferences to people of extraordinary ability in categories like science, business and the arts. People with advanced degrees and money to invest are also favored. As the New York Times noted this week ( http://nyti.ms/9EEisq ) the United States is finally and belatedly trying to ramp up production of physicians, a development long delayed by the abominably self-interested Association of American Medical Colleges and American Medical Association, which have controlled the supply of physicians for decades in a misguided and deeply destructive attempt to protect doctors’ wages (especially those of the specialists who dominate its membership). Of course, as anyone who has visited a VA hospital in middle America can tell you, our health care system would be completely non-functional without the labor of doctors from India, the Phillipines, Nigeria and other developing countries that can hardly spare them. There are legitimate arguments about whether more doctors leads to more health care costs. But the fact remains we turn away thousands of well-qualified medical school applicants each year, channel most of them away from urgently needed primary care fields, and then import the labor shortage and comparatively low cost from countries where many if not most citizens may never see a physician during the entire course of their lives. (In the comment section of the Times article, one apparently well-informed reader reports that in 2007 17,000 freshman medical students were admitted and 32,000 well-qualified applicants rejected, while the number of residency slots — 25,000 — has declined in recent years. Meanwhile, in Massachusetts, the only state with universal health care, the average wait to see a physican is 64 days). The United States is a nation of immigrants, and there is also, of course, a moral case for offering opportunities to hard-working foreigners who aspire to come there. To be sure, there would be an element of cruelty in shutting the door entirely. But there is also an element of cruelty in not considering a middle-way — more university fellowships and funding, for instance, contingent on the recipients returning to their native countries. What if the World Bank set up a kind of international version of (pre-privatized) Sallie Mae student loan corporation, offering heavily-subsidized education loans for students who stay in their own countries, and charging them much higher interests if they move abroad? Then they would be free to do so, but at a price, and the “tax” on that decision would be funnelled back into more education for others. The benefits we’ve derived from being such a desirable destination, regardless of the nonsense people spout about the “price” of immigration, have been considerable. Yes, there is a cost - it’s just that most of it isn’t born by us. If f the whole regime of immigration policy again comes front and center in Washington, perhaps that can be part of the discussion. Please comment, post or e-mail your thoughts - I know many of you have much more first-hand experience with these issues than I do.
