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  1. 1

    Doctor Whom

    I have concerns that we may at times be depriving underserviced places of trained health workers. But what to do – the solutions largely seem impractical or well intentioned gestures that will not be enforceable even at a basic level.

    Cuba seems to do a great job with training and exporting Doctors to where the regime wants them to go. Not many Cuban doctors emigrating to Australia.

    I’m not sure I’d want to be a Cuban doctor if I was gay or independently minded. Cuban doctors are required to note in medical records the extent of a patient’s political integration. There is no patient right to privacy or informed consent.

    This blog (and Prof Mooney’s blog would not be allowed in Cuba). – I know that is a side issue…

    As to a ban on the import of foreign trained doctors. Most of them are from Ireland or UK. Would you ban them from coming out?

    Why ban doctors from Ghana from exercising their choices and not those from UK?

    What if the doctor from Ghana who is in Australia is repatriating money back to help his sisters and nephews train as doctors and nurses but would not be able to do this if the doctor was still in Ghana?

    Why would we prevent Ghanaian doctors from shifting to Oz but not prevent doctors working in disadvantaged suburbs or towns here in Oz from shifting to Toorak or North Shore?

    Why not try forcing Australian trained doctors to work (and live) here in areas of need they don’t want to work in first? Lets clean the buggers out of the Melbourne inner city and force them to NT and Broadmeadows.

    What if a Ghanaian doctor just want to travel and work around the world – ok for UK doctors to do that but not for Ghanaians?

    What if the Ghanaian doctor hates the working conditions or wants to get more experience in other countries?

    How do you enforce a ban on immigrating? Ask Castro and China for advice?

    With regard to other workers – the Philippines for instance actively promotes itself as experting nurses and health care workers. India also sees health workers as an export industry to an extent.

  2. 2

    Ian Haywood

    The vast majority of overseas recruitment is done by public hospitals, to the point of sending recruiting agents to countries such as India and Sri Lanka and bringing doctors across by the dozens.
    It is important to note this is a result of decades of governments deliberately keeping medical student numbers below requirements, to provide (successfully) an supply-side reduction in Medicare outlays.

  3. 3


    Yes Ian but it will be very interesting to see whether the increase in the number of medical graduates will solve workforce shortages or simply reinforce more workforce imbalances (if they flock to sub-specialisation and urban practice). I don’t detect a great deal of optimisim in rural workforce circles that simply boosting doctor numbers will lead to more people working in general practice, urban fringes, rural and remote, Indigenous health and other underserved areas. Someone quipped to me recently: a tsunami doesn’t travel far inland….

  4. 4

    Gavin Mooney

    Dr Whom you miss the point. No one is talking bans. A I indicated in my original piece: “The WHO Board recommended that: ‘countries should abstain from active international recruitment of health personnel’ and went on to say – and this is the key – ‘unless equitable bilateral, regional, or multilateral agreement(s) exist to support such recruitment activities.’”

    The issue is one of compensation or (as I prefer it) reparations.

  5. 5

    Ian Haywood

    Popular specialties like, say, plastic surgery, are capped in numbers. You can’t do it just because you want to. The caps are set by a combination of State and federal regulations (contrary to popular beliefs the specialist colleges don’t have final say on numbers)
    So much of the extra medical students will end up in GP and other areas that currently struggle for numbers, such as pathology, geriatrics etc.

  6. 6

    Doctor Whom

    Gavin – I wasn’t having a go at you – but more musing out loud. It’s not all that straightforward to me.

    Didn’t the old Soviets make you pay back all your education etc expenses if you wanted to emigrate?

  7. 7

    Jon Hunt

    My experience is in rural areas where the doctors seem to come from india or africa. I agree that it does seem unfair to let these poorer countries go to the trouble to train them, only to have us go and poach them. These doctors leave to find a safer and better life, despite the restrictions placed upon them here. It would seem fair for our government to offer some compensation for this, given the burden the loss of these doctors must create. But I doubt our government would have much of a sense of fairness.

  8. 8


    David Lewinsohn (compiler of the Medical Directory of Australia) and I have an article in the 1st March issue of the MJA on the migration motivation of 469 South African doctors who have come to Australia – a 20+% sample of all South African doctors here.

    I am not at liberty to disclose its contents pre-publication, but ask those who have contributed above to read it, as it discusses some aspects of doctor-migration which have not been considered by Gavin or by the commentators.

    Certainly, there is angst in Australia, Canada, the UK, the US and some European countries about doctors leaving doctor-deprived Africa (and other former European colonies elsewhere), but the reasons for emigration are complex and cannot be resolved by well-intentioned treaties (such as the UK has with South Africa) nor by heavy-handed restrictions by either the donor or the host countries. As an example of the futility of such an approach, Filipino doctors are re-training as nurses to emigrate to the US, because a nurse visa is easier to obtain. [Ong WT. “A Doctor’s Covenant to address a staff shortage.” [Letter] Lancet 2005; 365: 846.]

    We need a lot more knowledge about WHY doctors emigrate from their homelands. Our study is probably the largest ever done on this topic. And what the South African doctors have told us applies, mutatis mutandem, to many immigrant doctors from other countries as well. As more information has been advanced by these doctors in reply to my 76 questions than can be encompassed in a journal article, I have a book almost ready for publication.

    Peter Arnold, former Deputy President, NSW Medical Board, former Chairman AMA Federal Council, co-author of Tatz, Arnold and Heller, “Worlds Apart: The Migration of South African Jews to Australia”, Rosenberg 2007.

  9. 9

    paul.laris -

    I’ve recently returned from a visit to Cuba and to Escuela Latino Americana de Medicina or ELAM, the Cuban medical school which trains thousands of young people from all over the developing world (and the poorer parts of the USA) to be first class primary care physicians. They get their medical education free, but they must come from poor communities and they must return to work in those communities when they graduate. Around 2% reneg on that obligation, usually going into private practice in their home countries. For the rest its a solemn personal commitment to themselve and their people. Call it canny soft power politics by Fidel, or call it compassionate humanism, but as Gavin notes, it seems reamrkable that a semi-developed country like Cuba can manage it, and we either can’t or won’t adopt such an obvious and positive solution.

  10. 10

    John Ashmore

    Clemens has recently been arguing that it is not health workers’ faults per se that they wish to migrate, but rather the structural arena in which they find themselves. As such, they should not be stopped. The problem with this argument, however, which effectively builds on internationalist models of migration that stress positive spillovers to brain drain, is that there is a large difference between coercibly stopping health workers and removing active recruitment (as Gavin Mooney noted). I think we must therefore not throw the baby out with the bath water. I support the WHO’s initiative, and would also add I believe there are a number of solutions on the side of developing countries which also do not constitute coercion, and so should not be forgotten about.

    I am working in South Africa to help determine the effect of doctors’ multiple job holding on retention for example; and I know there is other valuable purpose-driven research being conducted such as on task shifting and the utilization of HRM tools. Whether or not there are positive spillovers to migration, it would take a keen imagination to believe they outweigh the negative aspects in developing countries themselves; as well as a strange reading of ethics to think there is no imperative to compensate for such inequity, especially when developed countries have actively supported the process. I therefore also support the call for reparations, which should help pay for retention strategies, such as improving the work environment from which people flee, as well as the training of new workers.

  11. 11


    Dr. Whom above gives paradigmatic examples of one of the aspects of this discussion: the agreement discriminates individuals on the basis of their profession. To be fair, all the signatories should extend the ban to all recruitment. Why are we assuming that only doctors must stay to provide for their deranged governments and medical aids. Surely the public and private employers in the underpriviledged societies would benefit from similarly restrained engineers, lawyers and tradesmen.


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