Countries Without Doctors?

How Obamacare could spark the brain drain of physicians from the developing world.

Forget about all the members of Congress who are supposedly about to suffer from "Obamacare" blowback in the mid-term elections. Forget about the deficit, the bureaucracy, and any other critiques you might have heard about President Barack Obama's health-care reform passed earlier this year. There's a far bigger consequence looming abroad: U.S. health-care reform will exact an excruciating cost on the developing world. Here's why: Tens of thousands of doctors are about to leave their home countries -- where they are often desperately needed -- to come to the United States to meet America's growing demand.

That's right: America is about to induce massive medical brain drain. The historic passage of health-care reform legislation in March will provide an estimated 32 million uninsured Americans with health insurance. But the United States will need to rapidly grow its supply of doctors and nurses to meet the demand that creates -- a fact that will surely attract qualified doctors and nurses to America's higher salaries, better working conditions, and promise of a booming industry. There's nowhere for those health professionals to come from but overseas; the domestic education system simply won't produce enough. Enter brain drain.

Even now, the United States relies heavily on foreign-trained health-care workers. A full quarter of practicing physicians in the United States and 28 percent of U.S. medical residents come from abroad. Of these, 25 percent were trained in India and Pakistan, countries with health-worker crises so acute that the World Health Organization includes them on its list of countries with a "Human Resources for Health crisis." Each country has a mere 1.13 doctors per 1,000 inhabitants, while the United States enjoys 13.22 -- one of the highest ratios in the world. Other developing countries have already lost more than half their physicians to the United States. There are more Ethiopian physicians practicing in Chicago today than in all of Ethiopia, a country of 80 million and Africa's second-most populous country. Put otherwise, the United States is importing health workers from countries where polio still kills and paralyzes children. It is, in a word, unconscionable, and Obama's health reforms will only make things worse.

Why does the United States need so many foreign doctors? In part because the country's medical and nursing schools are turning away tens of thousands of qualified applicants for lack of places and funding to accept and train them. These young Americans are forever shut out of six-figure jobs in one of the country's fastest growing and arguably most socially rewarding sectors. Reversing this trend would take years of building new medical schools, particularly in areas where there is already a shortage of doctors. Meanwhile, demand is simply growing faster than the supply of homegrown doctors and nurses.

Look no further than Massachusetts and its experience with health-insurance reform to see why U.S. demand for foreign health workers will increase. The state's health-care bill brought an additional 340,000 people into the insurance system, and demand for health-care workers subsequently rose beyond capacity. Waiting times for new-patient appointments with an internist increased 58 percent -- from 33 days to 52 days -- and half of Massachusetts's primary-care practices closed their doors to new patients, the highest level ever recorded. Massachusetts, one of the U.S. states with the highest number of primary-care physicians per capita, experienced these shortages upon expanding its insured population by only 5 percent (by comparison, most predictions say that U.S. health-care reform will increase the number of insured nationwide by a whopping 12 percent).

Even measures in the health-care bill meant to boost the population of domestic physicians might do more harm than good. Congress has proposed providing funding to increase the number of U.S. residency positions by 15,000 to meet the anticipated increased demand for doctors. Yet these bills do not increase the number of medical-school slots. So those added residency positions will have to be filled by more than doubling the country's annual importation of foreign-trained doctors.

The apparatus to bring in these overseas professionals is well oiled, with no consideration for the potential impact of an immigrant's exit from his or her country of origin. Nurses are drawn to American soil through a well-organized, billion-dollar, private-firm-based nurse recruitment industry. Physicians tend to either apply directly to the U.S. National Residency Matching Program or be recruited by residency programs or immigration lawyers. Despite consistently being among the highest paid professionals in their homelands, foreign doctors are drawn to the United States by the pull of even higher salaries and better training and facilities.

But though the prospects for emigrating physicians might be good, the consequences for the countries they leave behind are grave. Mortality rates for infants, children, and expectant mothers are especially sensitive to health-worker shortages, with child mortality tripling as communities go from five health workers per 1,000 population to less than one per thousand, according to a 2004 Rockefeller Foundation report.

Medical brain drain affects education systems, too. Only the best and brightest can pass the U.S. certification exams, meaning that those who emigrate are often top university professors. A recently released study funded by the Gates Foundation found that migration to wealthier countries is the No. 1 cause of loss of African medical school professors -- accounting for a full 25 percent, with most going to the United States. Not surprisingly, the same study also revealed that lack of professors was one of the main barriers to training more health workers in Africa.

Even in the absence of health reform, brain drain was destined to be a growing problem for poor countries. According to studies by the U.S. Bureau of Health Professions and the Association of American Medical Colleges, conducted before the passage of health-care reform, the aging U.S. population would have needed at least 40 percent more primary-care providers by 2020, and the United States would have experienced a shortage of 124,000 physicians by 2025. With little chance of the United States meeting that demand domestically, it's likely the needed nurses and doctors will come from abroad.

Ironically, while the United States is recruiting thousands of doctors to its shores each year, it is simultaneously spending billions trying to build health systems in precisely the countries whose physicians it is stealing away. In recent years, major U.S. overseas development programs have failed to meet their goals due to a lack of health workers, and funding has started pouring into training in this sector. But what's the point, if those same doctors will later just be recruited away?

The answer is clear: Until the United States is self-sufficient in the education of its own health workers, it will continue to risk the health of the most vulnerable people in the United States and abroad. The Obama administration has made a major commitment to improving the health of the poorest people in the world through the $63 billion Global Health Initiative. But much of this effort will be wasted if the United States continues to take from developing countries the very thing health systems need most: the people needed to run them.

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'Even the Regime Hates the Regime'

Don't be fooled by Tehran's show of strength. The revolutionary rot runs deep.

Even before last year's post-election tumult, it was palpable to almost anyone who had spent serious time in Iran that revolutionary rot had set in long ago. While every country has its tales of corrupt clergymen, disillusioned government officials, drug-addicted youth, and rampant prostitution, in a theocracy that rules from a moral pedestal these stories have long served to highlight the government's hypocrisy and hollow legitimacy.

Although Iran's amateur cell-phone journalists did a heroic job chronicling scenes of extraordinary courage and harrowing government brutality -- a record that is "more important than all of the history of our cinema," acclaimed filmmaker Mohsen Makhmalbaf graciously put it in a Wall Street Journal interview -- what is impossible to capture on video is the dismay of Iran's traditional classes who continue to believe strongly in Islam, but have lost their faith in the Islamic Republic.

Growing up in a household where my devoutly religious, veiled grandmother had an aversion to Shiite clergy, I learned from a young age that piety was not always, indeed not often, an indicator of support for theocracy. Two decades later, based in Tehran with the International Crisis Group, I came to learn through daily interaction with Iranian officials that they, too, had their doubts.

While jumping through bureaucratic hoops at the Iranian Foreign Ministry several years ago to retrieve my confiscated passport (a wrist slap compared with what many of my contemporaries later endured), I was taken aback to find that nearly every office I entered had BBC Persian or Rooz -- considered subversive, anti-government websites, which are now filtered -- on their computer screens.

In meetings, especially with Western officials, Iranian officials would parrot the party line. But in private conversations, out of earshot of their bosses, a different narrative could often be heard. A former Iranian ambassador in Asia once confided to me over dinner in Paris that as "naive" young revolutionaries, he and his friends had grossly underestimated how difficult it would be to govern Iran and satisfy its fickle population. "We didn't appreciate at the time," I was surprised to hear him say, "the enormous challenges the shah had to deal with."

I used to recount these tales to a friend of mine, a devout, American-educated professor of political science at Tehran University who ran in government circles. He would smile and recount for me his own stories. "Everyone hates the regime," he told me once, only half-jokingly. "Even the regime hates the regime."

The revolutionary slogans that once inspired a generation of Iranians have become banal background noise for a population born predominantly after the revolution. Amid the bustle of a Friday prayer ceremony in Tehran several years back, I saw a rumpled, 50-something man furiously pumping his fist up and down and chanting something unintelligible. No one seemed to pay any attention to him. As he passed me, his words became clearer:

"Marg bar Amrika peechgooshtee sadt toman! Marg bar Amrika peechgooshtee sadt toman!"

"Death-to-America screwdrivers, 100 toman! Death-to-America screwdrivers, 100 toman!"

I was curious to check out his merchandise -- cheaply priced, anti-imperialist household tools -- so I flagged him down. Sensing his first sale, his eyes lit up.

"How many do you want?" he asked enthusiastically. He had a basket of at least 30. I grabbed one and took a closer look. Turning the screwdriver in my hand, I searched in vain for the words "Death to America."

"Where is the 'Death to America'?" I asked.

He shot me a puzzled look. "You want one with 'Death to America' written on it?"

"Isn't that what you said?"

"That was just an advertisement!" he explained to me with a wave of the hand, incredulous at my naiveté. "I said, 'Death to America! Screwdrivers for 100 toman!'" Two altogether separate sentences, he argued. The small crowd we had attracted shared his incredulity and verified that there indeed had been a pause between the two phrases.

"Come back next week," he said. "Perhaps I'll have some for you then." (Sharia has not yet replaced the laws of supply and demand in Iran.)

Many close observers of Iran confess to being baffled at the country's complex politics, its internal contradictions, its cultural nuances. How is it, many wonder, that a system that has profoundly underperformed for three decades could remain in power?

The leaders of the opposition Green Movement are no doubt pondering this question today. At the height of last year's unrest, they had hoped to recruit Iran's disaffected officialdom and traditional classes. Some joined last summer, but many watched, and continue to watch, from the sidelines. "They wanted to see the Green Movement succeed," said my friend, the university professor. "But they won't make a move until things are really on the verge of change. They're afraid."

Too often we underestimate the sustainability of morally bankrupt regimes that have mastered the art of repression coupled with financial co-optation. In the cynical words of a scion of a powerful clerical family, who told me once: "When you have control over the oil revenue, you can run this country with a few million supporters and 20,000 people who are willing to kill and die for you." Maybe, though that formula did not work for the shah.

There is some wisdom in the old adage that Iran's largest political party is the hezb-e baad, the "party of the wind." Iranians have historically gravitated toward where the most powerful political winds are blowing. As anti-government demonstrations engulfed Tehran last summer, I thought of the sloganeering screwdriver salesman from Friday prayers.

"Death to the Dictator!" I pictured him saying, crying to the parched crowds. "Watermelon juice for 500 toman!"

That likely didn't happen. Not just yet. But maybe one day soon.

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