The Optimist

Doctors Without Borders

Letting medical professionals and other skilled workers from the developing world emigrate is a good deal for everyone.

Immigration may be deeply unpopular with electorates throughout the developed world, but that hasn't deterred immigrants themselves: The foreign-born share of the population of high-income countries doubled between 1985 and 2005, to nearly 9 percent. And the percentage who were college graduates increased fourfold between 1975 and 2000. That's great news for the rich countries that benefit from their skills, of course. But as it turns out, it is also great news for the poor countries the migrants leave behind.

It is hard to find a more confused discussion than that surrounding brain drain. Opposition to unskilled migration is usually based on perceived self-interest, the threat of stolen jobs -- a misguided fear, but at least a rational one. But certain well-meaning Westerners call for immigration restrictions on educated workers from the developing world for the opposite reason: If you let them leave, they'll abandon their home countries to poverty and deprivation. In 2008, the respected medical journal The Lancet carried an editorial on the medical brain drain of doctors and nurses from low- to high-income economies, complaining that "richer countries can no longer be allowed to exp[l]oit and plunder the future of resource-poor nations"; the same issue carried an op-ed calling for those who recruited African workers abroad to be sent to the International Criminal Court. (Never mind that the ability to leave the country of one's citizenship is considered a human right by the United Nations.) As a result of such thinking, Britain's National Health Service has a code of practice that bans recruitment from 150 developing countries, and there have been calls for something similar in the United States.

Certainly, most skilled migrants make more money abroad than they would at home. John Gibson at the University of Waikato and David McKenzie of the World Bank document salary increases ranging from $40,000 to $60,000 a year for skilled emigrants from developing countries across a range of professions. But the money these workers make abroad doesn't stay there: The average Africa-trained member of the American Medical Association sends home $6,000 a year in remittances, often for two decades or longer. Indeed, remittances from immigrants are an incredibly powerful force for development in any number of African countries -- more than the amount of foreign aid to Ivory Coast, triple that given to Togo, quadruple that to Nigeria, and nearly six times the aid to Mauritius. And the money is put to good use. One estimate from the U.N. Conference on Trade and Development suggests if you doubled remittances to a developing country, you could reduce poverty by nearly a third.

Perhaps more importantly, countries that swap people also swap goods, ideas, and investment. Doubling the number of people who have migrated between two countries raises trade between those countries by 10 percent. And if the number of skilled immigrants doubles in a recipient country, subsequent foreign direct investment to their countries of origin climbs 25 percent. William Kerr, an economist at Harvard Business School's Entrepreneurial Management Unit, even finds that migrants transfer back knowledge about increasing manufacturing efficiency -- so productivity increases in the home country as a result. Economists Hillel Rapoport at Bar-Ilan University and Frédéric Docquier at the Catholic University at Louvain report that about half of the Indian diaspora in Silicon Valley, which ran nearly one in 10 start-ups in the late 1990s, traveled back to India on business at least once a year. They were central to the creation of India's booming IT industry, which now employs around 2.5 million people. Another idea that appears to travel along with migration is democracy -- an International Monetary Fund study found that the more students a country sent for schooling in democratic countries, the more likely the home country was to become or remain a democracy.

But what about high-skilled migrants starving their home economies of vital human capital needed for development? Actually, Rapoport and Docquier conclude that the more high-skilled people leave low-income countries, the higher educational enrollments there climb. The opportunities presented by moving abroad spur people to stay in school and learn more. Surveying the brightest students in Tonga and Papua New Guinea, Gibson and McKenzie find that nearly all of them contemplated migration, and it led them to take on additional classes.

Similarly, Michael Clemens at the Center for Global Development finds no evidence that medical brain drain from developing countries leads to shortages of medical staff back home, probably because the opportunity to migrate is one of the things that attracts people to medical school in the first place. For years, nurses have left the Philippines in huge numbers to work abroad, but the country still has more nurses per person than Britain.

And finally, of course, lots of migrants return with valuable skills and contacts -- including many of those now working in the Indian IT industry. Economists William Easterly of New York University and Ariell Reshef of the University of Virginia carried out an informal survey of the entrepreneurs behind African global export successes and suggested that one factor many had in common was experience living abroad -- usually in the country they subsequently exported to.

All of this suggests those well-meaning folk in rich countries keen to put a travel ban on anyone from a developing country with a degree might want to reconsider their position. But it also contains a lesson for American economic policy. The United States benefits immensely from its talent imports -- immigrants account for over 60 percent of Ph. D. software engineers and more than half of its medical scientists, suggest McKenzie and Gibson. The country should do all that it can to ensure that inflow continues. And it could also do considerably better when it comes to talent exports. The most recent data suggest the United States had less than a third the number of high-skilled emigrants that Britain had -- despite having a population five times larger -- and half the number of Germany. If having a large high-skilled emigrant base in other countries is a powerful source of trade and investment links, the United States ought to be finding ways to encourage more of its best and brightest to spend some time elsewhere.

But in fact, the United States is heading in the opposite direction, on both sides of the trading equation. International applications to U.S. graduate schools only last year returned to their levels in the 2002-2003 academic year after a post-9/11 slump, a function of the stagnant economy and toughened immigration procedures. And at the other end of the degree process, there is growing concern about a "reverse brain drain," as more foreign graduates from U.S. schools decide to return home rather than find jobs in America -- again, often on account of byzantine immigration rules. Meanwhile, the U.S. House Appropriations Committee has proposed deep cuts to State Department international exchange program budgets that support the Fulbright program, among others. This shortsightedness regarding a program that promotes the talent trade in both directions isn't just bad news for the development prospects in Africa or Asia; it's likely to convert into a further erosion of America's long-term productivity.


The Optimist

Wanted: Smarter Patients

The key to improving medical care in the developing world isn't better doctors -- it's educating everyone else.

In 2007, a team of World Bank researchers studying the quality of health care in developing countries visited a clinic in rural Tanzania. They watched as a mother brought her 9-month-old into the doctor's office, carrying the child on her back. The mother stood in front of the desk and told the doctor that her daughter had a high fever. Without moving from behind his desk, where he could not see the girl, the doctor filled a prescription for malaria medicine and sent mother and child on their way. The World Bank research team stopped the pair and asked some follow-up questions. A nurse on the team quickly found the child was suffering from pneumonia, not malaria.

The doctor was not overworked; he saw 25 patients that day, comparable to the average primary care physician in the United States. And he was trained in diagnosing both malaria and pneumonia, both common diseases in Tanzania. Moreover, the health facility had the medicine to treat both diseases. But without the intervention of the research team, the child would have died. The World Bank's research suggests the incident was hardly unique. On average, doctors in Tanzania take fewer than a quarter of the diagnostic steps needed to confirm malaria in patients showing symptoms. The average number of questions in an interaction with a public-sector doctor in India is precisely one: "What's wrong with you?" MIT economists Abhijit Banerjee and Esther Duflo surveyed health care in Udaipur, India, and found that patients were given a shot in 66 percent of visits to private medical facilities -- usually unnecessarily and usually steroids and antibiotics, which cause premature aging and exacerbate the problem of drug-resistant strains of bacteria, respectively.

A considerable proportion of deaths in the developing world -- more than a third of them, according to the World Health Organization -- are the result of just a handful of communicable conditions: pneumonia and other respiratory infections, diarrheal diseases, AIDS, malaria, and tuberculosis. There are plenty of reasons for this -- not least low vaccination rates, poor sanitation, and limited access to treatment -- but one big factor is the kind of misdiagnosis the girl in the Tanzanian clinic received: Even patients who are lucky enough to be treated are often misdiagnosed and have treatment prescribed incorrectly. That is why it is great news that a number of cheap diagnostic tools simple enough to be used by patients themselves are coming online.

There is no simple solution to the problem of getting doctors to do their job better in developing countries. Training and education alone certainly won't cut it: The World Bank researchers found that three years of additional medical training improved diagnostic performance in Tanzania by just 1 percent, because all too often the problem is not lack of knowledge but lack of application. But if the supply side of the health-care equation is daunting, what about demand? Part of the solution might be to empower patients with more knowledge -- to create better-informed consumers. And one way to do that is to provide access to cheap and simple diagnostic kits that would allow patients to test for common diseases themselves. If a doctor prescribes treatment for malaria to a sick child without proper diagnosis, and a home test has suggested that in all likelihood the child has pneumonia, then parents can demand a proper exam or go to a different doctor.

Diagnostic devices are big business worldwide. Diagnostic imaging -- tools like X-ray machines and MRIs -- alone accounted for nearly a quarter of global medical-device sales revenues in 2009, to the tune of more than $50 billion. But the tools are designed for rich countries, to be used by skilled technicians to uncover rich-world medical conditions -- which is unsurprising, given that the United States, Germany, Japan, France, Italy, and Britain account for 70 percent of global sales. (Three-quarters of those medical devices that do end up in developing countries do not function and remain unused.) To empower medical consumers in poor countries, diagnostic technologies need to be very simple, hygienic, and cheap. Think of mobile-phone-based eye exams, cholesterol and glucose test strips, and the home pregnancy test.

Diagnostics for All (DFA), a nonprofit medical firm, is working on a range of such simple tests for use in the developing world. Its initial project is designed to spot the side effects of medicines used to treat people with tuberculosis and HIV/AIDS in developing countries. Around a quarter of the 2.8 million people in the developing world on AIDS medications are suffering liver damage as a result, compared with a 2 percent rate in the United States, thanks in large part to more active (but currently expensive) screening after which treatment regimens are changed. The DFA test, targeted to cost 10 cents or less, is a piece of paper that changes color, like a chemistry class pH tester, depending on liver toxicity -- one color indicates the need for closer monitoring, another the need to change the treatment immediately. The company is also developing a test for spoiled milk and an aflatoxin test that will allow farmers to identify crops affected by mold that can cause stunting and liver damage. It will do so at one-twelfth the cost of existing tests.

DFA tests don't require clean water, syringes, refrigeration, lab equipment, or skilled technicians. Users put a drop of blood, urine, or milk on the edge of the paper, and it is wicked to the test material printed on the card, which changes color if the milk is spoiled, the liver is damaged, or the crop has been affected by the mold that produces aflatoxin. They literally blot test material onto paper.

DFA's CEO, Una Ryan, told me that the company is contemplating similar tests for fever and diarrhea. Given the quality of health-care services in many developing countries, that kind of information could be lifesaving. And if it empowers some patients to demand more from their health-care workers, it might play an important role in improving the quality of service provided to everyone else, too.

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