A new study documents for the first time the devastating exodus of doctors from Africa and the Caribbean to four wealthy English-speaking nations, the United States, Britain, Canada and Australia, which now depend on international medical graduates for a quarter of their physicians.
The findings are being published today in The New England Journal of Medicine. The study is likely to fuel an already furious debate about the role the developed world is playing in weakening African public health systems that have already been hit with pandemics that have shortened life expectancies in some countries.
Dr. Agyeman Akosa, the director general of Ghana's health service, said in a phone interview from Geneva, where he is attending a World Health Organization forum on the global medical staffing crisis, that his country's public health system was virtually collapsing because it was losing not just many of its doctors, but its best ones.
"I have at least nine hospitals that have no doctor at all, and 20 hospitals with only one doctor looking after a whole district of 80,000 to 120,000 people," Dr. Akosa said. Women in obstructed labor all too often suffer terrible complications or death for lack of an obstetrician, he said.
The study found that Ghana, with only 6 doctors for each 100,000 people, has lost 3 of every 10 doctors it has educated to the United States, Britain, Canada and Australia, each of which has more than 220 doctors per 100,000 people.
Dr. Fitzhugh Mullan, a professor of medicine and public health at George Washington University, who carried out the study, tapped into databases in the four rich countries to learn where their international medical graduates had come from.
He said the flight of doctors was less the result of deliberate policies in the wealthy countries than of their failure to train enough doctors to fill their own needs. For example, the United States has about 17,000 medical school graduates each year for 22,000 first-year residency slots.
"One of the most important things the United States can do for global health, frankly, is to educate more physicians in the United States to work in the United States," he said.
The biggest losers are the small to medium-size countries of Africa and the Caribbean. Dr. Mullan's research found that Jamaica, for example, has lost 41 percent of its doctors and Haiti 35 percent, while Ghana has lost 30 percent and South Africa, Ethiopia and Uganda 14 to 19 percent.
In an editorial that accompanies Dr. Mullan's article, Dr. Lincoln C. Chen, director of the Global Equity Center at Harvard, and Dr. Jo Ivey Boufford, a professor of health policy at New York University, call the exodus of publicly trained doctors "a silent theft" by the richest countries from the poorest.
Crumbling public health systems in poor countries, they wrote, also threaten the health of Americans in the face of potential outbreaks of avian flu and SARS. "Protecting Americans requires viral detection and interdiction at points of origin," they wrote.
Public health leaders in Africa say they will have to reform their own ailing systems. Dr. Francis Omaswa, who was director general of Uganda's health service until July, said that half of its doctor positions were vacant - and that the exodus was not the only cause. For example, he said, some unemployed doctors cannot find jobs because they are not adequately advertised.
Dr. Omaswa, now a special adviser to the World Health Organization on human resources for health, is helping to devise a set of proposals for what African and developed countries can do to ease the staffing crisis. "Africa cannot solve it alone," he said.