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From the Service d’anesthésie-réanimation, CHU Mongi Slim, La Marsa, Tunisia.
Address correspondence to: Dr. Mohammed Salah Ben Ammar, CHU Mongi Slim, 2046, La Marsa, Tunisia. Phone: 21698637190; Fax: 21671764845; E-mail: ms.benammar{at}rns.tn
This article on manpower issues by Professor Mohammed Salah Ben Ammar was first published as an Editorial in French in the "Journal Maghrébin d’anesthésie-réanimation et de médecine d’urgence" (
J Magh A Réa 2004; XI:183). His thoughts on the brain drain from African countries to North America, from poorer countries to richer ones, should be kept in mind when discussing manpower issues in Canada, specially the ethical and moral questions they raise in light of our ever-growing "need" for foreign medical graduates.
Jean-François Hardy MD FRCPC
Former Editor-in-Chief
THE distribution of intellectual wealth in the world is being hit hard by the consequences of the new knowledge-based world economy. Medicine has not been spared this trend and it affects both poor and rich countries, the East as much as the West. But the phenomenon is devastating in Africa. Out of a total of 302 doctors originating in Cape Verde, 231 work in Portugal and only 71 in the Cape Verde Islands. In Guinea-Bissau, the proportion is 358 to 197...
According to the Afro-Arab Parliamentary Conference (10th meeting in Addis Ababa in 2003), 54% of the doctors, 26% of the engineers and 17% of the scientists who have graduated from Arab and African universities work in Europe or North America... The 2003 United Nations Development Program report shows that over 15,000 Arab doctors emigrated to the industrialized countries between 1998 and 2000 and 25% of the 300,000 graduates from Arab universities are practicing abroad. According to the World Health Organization, approximately 23,000 African academics emigrate to the developed countries every year.
In Great-Britain, 31% of practicing doctors and 13% of practicing nurses are of foreign origin. In New Zealand, 600 South African doctors practice medicine. This hemorrhage has an incalculable impact from every point of view. It represents a net drain of over 1.5 billion dollars a year for Africa. Paradoxically, this continent spends three times more than that to cover the costs of 100,000 foreign volunteer physicians.
The United Nations estimates that the loss to Africa for each of these emigrants is $184,000. The demand for labour is so great in some highly knowledge-based service sectors in the industrialized countries that the need to implement a selective immigration policy has become a clearly stated political policy. The United States of America issues 115,000 work visas annually to graduates. Each visa earns an annual profit for the United States of $100,000. Third world countries are therefore helping the greatest power in the world to the tune of 12 billion dollars a year.
In other words, this represents a hemorrhage of intellectual wealth, and this movement only increases the disparity in its distribution in the world.
After having been colonized for decades and poorly prepared for independence, Africa is confronted with a drastic lack of qualified managerial-level personnel. Over 40 years of independence have not sufficed to rectify the situation. Worse still, as soon as one of its children distinguishes himself from the rest, he is diverted, attracted by remuneration which corresponds more closely to the work actually performed and/or by a more promising professional environment and/or by excellent continuing education and the chance to work in a better managed system.
Working conditions in the two areas cannot be compared. Inevitably, the most creative, most highly trained and most enterprising section of our youth decides to leave, if it has the choice. In fact, the deep-seated motives don’t matter; there may be several reasons and they may vary from country to country and from individual to individual. Whether they are professional and/or personal, the result is the same for the poor countries.
The African academic system is in distress. Emigrating academics and doctors know this full well and the movement is accelerating. The number of students far outweighs capacity. Teachers’ salaries are ridiculously low and it is not rare for African academics to have a second trade, as taxi drivers, small storekeepers or sometimes teachers giving private lessons.
The brain drain does not only flow abroad; the private sector represents another form of exodus, an internal one in this case. Out of 5,000 Kenyan doctors, only 600 agree to work in the state sector.
It would not be realistic here to suggest global solutions to a problem as old as the world, but we would like to attract attention, if only to a limited degree. Ethics are very far-removed from this field and this has, in fact, been true of North-South relations in all domains so far. It is only morality that can force the rich countries to change the rules of the game. For the African countries the only solutions to contain the damage include the respect for knowledge and the availability of acceptable training opportunities, together with opportunities for flexible exchanges with foreign countries and investment in infrastructure to serve research, in other words developing local skills and proving that local personnel can excel. It is incomprehensible that millions of dollars are spent on transporting football teams, whereas a college teacher must struggle to obtain a personal computer!
It is certainly true that skills abroad help development, because of the money sent back to the country and the contribution to local universities. Academics must try to create a new ethics of North-South cooperation. One solution would be to consider some form of compensation for universities in the South. It would not be impossible to balance North-South exchanges by strengthening and facilitating cooperation. It would be perfectly feasible, and fast, to allocate a specific aid budget to train university researchers. Other solutions could include facilitating access to the logistics available in industrialized countries for Africans remaining in their homelands. Given the frantic industrial competition that prevails, only the militant commitment of our researcher colleagues in the North can change things.
It is everyone’s responsibility, and an exclusively moral one, to take action aimed at hospitals and other institutions, to create a solid tradition of exchanges.
This article has been cited by other articles:
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  L. Lee Avoiding exacerbation of the skills exodus Can J Anesth, August 1, 2005; 52(7): 775 - 775. [Full Text] [PDF]
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