This GUEST POST is written by Michael Clemens
This week, Professor Jonathan Wolff has warned the world that the United States “steals doctors from poorer countries” because it “simply does not train enough doctors to meet its voracious appetite for medical attention.” This is a strong accusation. Professor Wolff, a philosopher, should reconsider several dubious assumptions that his strong claim requires.
First, it is illegitimate to assume that it is possible for anyone to “steal” a human being. The very concept of such an act requires it to be possible for human beings to be owned by others. The notion that health workers may be owned—while presumably Professor Wolff would be offended if any person or group claimed ownership of him—is offensive. It is also illegal where Professor Wolff resides: the United Kingdom outlawed the ownership of people by other people in 1833. People, including health workers, who voluntarily leave their countries are not passive objects of others’ acts of “stealing”; they are active agents exercising a right guaranteed them by Article 13.2 of the United Nations Universal Declaration of Human Rights.
Second, it is incorrect to assume that the emigration of health workers from a poor country must cause a shortage of health workers at the origin. For decades, more nurses have left the Philippines to work abroad than leave any other country on earth. Yet in the Philippines today there are more Registered Nurses per capita than in the United Kingdom. This happened because so many Filipinos trained up as nurses to take advantage of opportunities abroad that this more than offset the departures. There is no such thing as a fixed stock of health workers in the world; they can be created, and wonderful career opportunities abroad are one of the forces that create them at home. The realities that shape the global health workforce are more complex than the simplistic picture that Professor Wolff paints.
Third, it is simply false for Professor Wolff to assert,
“If a doctor from Ghana is recruited to the US, not only does Ghana lose its doctor, it loses the money paid for the training. It may be that the doctor is likely to send a portion of earnings back home (known in the development business as ‘remittances’). But this is scant compensation.”
In fact, the average African-trained member of the American Medical Association left his or her country of training well over five years after earning the Medical Doctor degree—as I learned when I surveyed them. Thus an African country that has invested in the training of a typical emigrant doctor has already received several years of service from that doctor (without even accounting for care provided during medical school). So it is false to say that the investment in the training of those people is fully “lost”. Furthermore, African-trained members of the American Medical Association send home to Africa, on average, over $6,000 per year, even 20 years after arriving in the United States—including those who send no money. Far from being “scant compensation”, this means that the typical African-trained doctor coming to the United States has sent back much more than the cost of training another doctor in the country he or she came from.
Fourth, Professor Wolff’s argument requires the assumption that a proper policy goal of any country is that of zero immigration. Professor Wolff argues that the U.S. should train as many health workers as it needs. This, logically and inescapably, implies zero migration for health workers. (If every country did this, there logically could be no international movement of health workers as such—unless of course they gave up their professions and cleaned floors.) Zero migration of health workers means that the Ghanaian emigrant doctors Professor Wolff refers to must be forced to live in Ghana against their will—at a small fraction of the living standard of their colleagues in other countries, and of Professor Wolff’s living standard—or give up their profession to live elsewhere. “Self-sufficiency” in doctors at the destination would leave no other options for any of them. The ethical legitimacy of that state of affairs, and the consequent legitimacy of policies designed to bring it about, deserve more pondering than they have apparently received from philosophers. Taking actions that consign others to fates we would not accept for ourselves is something that we should do only with sad reluctance, based on great certainty and overwhelming evidence that directly harming health workers in this fashion will save lives. Professor Wolff has no such evidence.
Too much of the writing on health worker migration appears oblivious to the notion that health workers have agency or rights, and to the idea that the realization of health workers’ ambitions is an inherent good. I would expect philosophers to be the first concerned with such things, not the last. To anyone reading this post, I plead: If you ever say that health workers from poor countries are “stolen” or “poached”, please stop. That small change will mean that you begin to speak of them as human beings rather than owned property. Discussions of their movement must start from that premise, inside or outside our departments of philosophy.
In this paper I offer a non-technical summary of research on the above claims, and on related claims about the effects of skilled-worker migration on poor countries.
32 Responses
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nice sharing guy, thank you, your article is really cool
nice sharing guy, thank you, your article is really cool
Michael,
I’m in broad agreement with your post, and thrilled to see you responding to the comments here. I was surprised to see you comparing remittances to the benefit of having a doctor (voluntarily) remain in a country.
Imagine for a minute, that having a doctor in a rural health clinic is worth $50,000/yr to the government, and health care education is subsidized accordingly. Imagine that instead of staying in the country where he was trained, the doctor leaves and remits $50,000/yr to his family in the capital. Even if the two sums are equal, the overall exchange represents a transfer of public to private wealth.
I’m not telling you anything here you didn’t already know, however. That’s why I found it confusing to see your argument offered in the form it was.
I definitely agree with the thrust of this argument, but I’m not sure about the implication that countries are violating the human rights of would-be migrants by trying to train enough doctors and nurses domestically to fill those jobs. I’m American and would very much like to find a job based in France, where my girlfriend lives. But I can hardly blame my inability to do so on European universities handing out too many International Development MScs to EU nationals now can I?
There is another general viewpoint to start with he;
Stealing is taking something that does not belong to you.
The issue is not whom it belongs to at the time you take it.
Same goes for poaching.
On ‘ownership’ Clemens thinks very simplisticly along simple lines of slavery and laws.
I think one could make quite a good argument on states and leaders of certain states ‘owning people’ in an economic sense as we see (have seen?) in Libya and elsewhere.
Being lured away with money and more and how to call that is not a debate for economists. Certainly not before some philosophers have thought this over.
P.s. Ever heard of ‘golden chains’ with regards to certain employment contracts
So you’d be quite happy, @Henk, to be the economic property of your politicians, for them to do with what they will? Or is it that you think that being owned in economic terms is good enough for poor slobs born in Libya, but not good enough for yourself? You’re right, my ideas—like “all men are created equal”–are simplistic. Tommy Jefferson and I always did lack a certain nuance. Your ideas, that economic ownership of human beings is acceptable, are more nuanced and more atrocious.
Stanley, in his humor, does raise an interesting thought experiment: how do you feel about wealthy countries investing in land in poor countries to grow food to be sent back to the wealthy nation?
This is an issue that has attracted a good deal of attention lately, given rising food prices.
Are the questions of health worker migration and agriculture investment for export the same or are they different? Is it more or less ethical to recruit health workers from poor countries or to buy up their land to grow food?
Thanks very much Tim. This goes well beyond the theme of the post, but in an interesting and thought-provoking way, so I appreciate the question.
I think the first thing that comes to people’s minds when they think of US companies buying land to grow food overseas is the United Fruit Company. I don’t have specialist knowledge of the UFC’s operations, but I believe that the ethical concerns many people had with the UFC’s operations arose from its monopoly power: the UFC used relationships with shippers, retailers, financiers, and both the host-country governments and the U.S. government to establish unchallengeable market power in many areas. This meant that labor prices, working conditions, fruit prices, etc. could differ a lot from what they would have been in a more open and competitive market.
In the absence of those conditions, I don’t think there’s anything inherently unethical about corporations buying land in (say) Colombia to grow food. If such corporations could earn X dollars (in present value) selling the produce of that land in the US, they would not be willing to pay more than X dollars for that land. But in an open marketplace, a Colombian could also earn X dollars using the same land to produce the same food and selling it to the US, so it would take more than X dollars to convince him or her to part with it (which the US corporation wouldn’t do—losing money isn’t fun). In order for any such land sale to be exploitative, then, there would have to be important distortions to that process—Colombians would have to be uninformed about overseas markets, or lack access to capital, or be locked out of the market by anticompetitive practices. If there is strong evidence of those forces, our confidence in the ethics of the process should slip.
But without it, we shouldn’t rush to judge overseas land purchases. The robust industry of Colombian-run flower culture for the US market suggests that many Colombians are very savvy about overseas markets, have access to capital, and have not been shoved aside by anticompetitive practices in the US. Other agricultural industries may be different, of course, especially with regard to anticompetitive subsidies by the US government to agricultural interests in the US.
How does all of this relate to migration? One linkage I see is that as long as migrants are reasonably well informed about their decisions, we should not speak of them as being the passive recipients of others’ “stealing”, “poaching”, “taking”, “exporting”, “importing”, “exploitation”, etc. but rather see them as people just like ourselves making decisions about what they think is best for them. Rather than our default being that migrants have no idea what they’re doing, and simply passively receive the actions of others, our default should be that they are reasonably well-informed to make decisions for themselves unless we have very strong evidence otherwise, evidence the justifies paternalistic policies like forcing them to live places they don’t want to live in the name of a nebulous “greater good” that we have little evidence that we are thereby serving.
Likewise, perhaps a reasonable default position on overseas purchases of land would be that, in order to hold strong positions about its ethics, we should require extensive and forceful evidence that the decisions of locals whether or not to produce the same food themselves are constrained by coercive extrinsic forces. In the case of the UFC generations ago, those forces were clearly at work. It should be incumbent on specialists in this area—and I’m definitely not one—to show that coercive forces prevent locals from taking advantage of the profitable opportunities brought by rising food prices, before taking strong views of the ethics of the situation. Those are likely to differ country by country, food item by food item.
Let us not import bananas as we should be able to harvest all the bananas we need. Every self-respecting republic should be banana-sufficient. Importing bananas would be stealing, and banana republics would go hungry. Surely their supply of bananas is fixed in the short-, medium-, and long- run and importing their bananas means they have no bananas left to eat. Development will not happen in the absence of their bananas. I mean, they would go bananas, wouldn’t they? metaphorically speaking, of course. I call this my “banana split” multiple equilibria model of underdevelopment. Bananas, doctors, nurses — same banana. Those of you who think this is a joke — you have no peelings, all of you.
Thank you for raising these important issues about my column the Guardian. Given the nature of writing for a newspaper, I has to write in a fairly compressed form, and it is a excellent to have the opportunity to clarify.
First, I did not say that America steals doctors from anyone. You may think this remark demonstrably false as this is what the title of the published piece says. But one of the frustrations of writing for a newspaper is that professional sub-editors write the titles. Normally the Guardian does an wonderful job – much better than I can do myself – but in this case I was shocked to see what they had put up. I do not think America steals doctors, but I agree anyone could be forgiven for thinking that I do believe this.
Second, I don’t think there is any basis for saying I was assuming that “the emigration of health workers from a poor country must cause a shortage of health workers at the origin”. Like everyone in the debate I know about the situation regarding nurses from the Philippines. But this is a very unusual case. I don’t know if it is unique, but it must be very rare. Furthermore, I don’t know of a country that trains an excess of doctors for export: not even the Philippines.
Three, I agree that money sent home can be some financial compensation for the loss of a health worker. I did not have space to make my follow-up point: losing a large number of highly intelligent, educated and potentially influential and respected citizens and members of civil society, cannot be compensated by money or even the temporary importation of medical staff from the developed world. Development will not happen if these people do not stay in sufficient numbers. What matters more than money is ‘human capital’.
Fourth I am surprised at the argument: “Professor Wolff argues that the U.S. should train as many health workers as it needs. This, logically and inescapably, implies zero migration for health workers.” But surely this is an error. What training according to need implies is zero net migration – i,e, as many leave as arrive. I look forward to a world in which borders are as permeable as they are in the European Union or between American states. What I object to is a rich country that relies on, in the sense of bring unable to sustain its system without, new immigration. I would distinguish the ‘pull’ factor of active recruitment from the ‘push’ factor of wishing to experience life in a different environment.
Apologies for the typos in the last – I was expecting to see a preview!
Professor Wolff, I’m very grateful that you took the time to stop by and give these very thoughtful comments on my somewhat acid post. I deeply appreciate your follow-up because it allows us to continue a critically important conversation.
First, I should not have assumed that you were the author of the headline, and I appreciate your telling me the true origin of the headline. I do want to point out, however, that even in your response note above, you use words appropriate only if you consider health workers to be passive objects of others’ actions, not agents with their own desires and welfare. You speak of countries “exporting” and “importing” health workers. Stop and think for a moment: If you decided to take a professorial post in Australia, which of your friends would remark, “I see that England has exported Jonathan.” Such a remark would be bizarre, because no one would think of your decision to work in another country in those terms. You are assumed to have agency. It is equally bizarre to describe the decision by a Filipino nurse to work in the United States as an act of “exportation”—unless we consider that nurse to be something other than a human being with agency, rights, aspirations, etc.
You describe the Filipino case as exceptional, which is common in this debate. I see no reason, and no evidence at all, that Malawi could not do exactly what the Philippines has done. After all, the fact that Malawian nurses are recruited internationally proves that it is possible to conduct international-quality nurse education in Malawi. So there is no reason whatsoever to think that high-quality private nursing education could not happen in Malawi just as it has blossomed in the Philippines—unless, of course, we destroy all possibilities for it by eliminating the international job prospects of the potential graduates, via “self-sufficiency” policies.
Yes it’s true that the brightest and most talented members of society might leave. The fundamental philosophical question—which deserves greater consideration—is who owns the brightness and talent of a person. Is the owner of your talents yourself, or those who were born around you? To state, as you do, that the potential loss of those talents due to emigration merits policy intervention is tantamount to asserting that people born near a person hold a property right in the natural gifts and talents of others born near them, so that if one such talented person chooses to remove him or herself to another place, others should intervene on behalf of the property owners (those born nearby) to prevent the removal. I disagree profoundly with that stance: I believe that you are the owner of your many natural gifts, and that you may do with them what you please. I appreciate your response because it clarifies this fundamental point of disagreement. Readers of this blog should decide for themselves who owns the natural talents of each individual, and philosophers should help them think through this nontrivial question.
Lastly, I don’t understand why you feel that “zero net migration” is a proper goal of any government. “Zero net migration” of nurses, if imposed on either the Philippines or the United States, would have destroyed the flourishing private nursing education sector in the Philippines that has given the Philippines far more nurses per capita than Great Britain. So I think it’s worth pausing to consider the possible unintended consequences of such policies. Believing in “zero net migration” means that you have decided that the existing borders of countries have been flawlessly delineated around places for which self-sufficiency is possible. I invite further consideration of whether or not it has been demonstrated that places like Haiti, Niger, and Lesotho constitute places that have any hopes of being “self-sufficient” anytime in our lifetimes, or the lifetimes of the people whose movements would be severely limited by isolationist “self-sufficiency” policies.
@ Michael Clemens:
There is one issue I am surprised that you have left out – working conditions for health workers in many developing countries, perhaps especially for nurses and midwives.
I only have access to anecdotal evidence for this, however, you may know of any research? Here’s my evidence anyways:
1. A fellow student of mine, an African citizen, felt forced to emigrate from his native country mainly because his wife, who was a nurse, refused to have sex with her boss. The pressure on her became unbearable, and her boss, a powerful individual and a doctor, prevented her from finding work elsewhere in the country.
2. Malawi has been a case in point for a country that suffers from an exodus of health workers. However, (I can’t remember which year) as many as perhaps a quarter of Malawian nurses where stripped of their diplomas after going on strike for better working conditions. Keeping anecdotal evidence #1 in mind, I don’t blame them for striking. However, being stripped of their diplomas means they can no longer work as health workers, neither in Malawi, nor anywhere else.
3. A second fellow student of mine is married to a Ugandan doctor. She currently works in the UK, and when I asked her why she migrated, she answered simply: Working conditions and management practice in Uganda. The money was not really important to her – she is from a rich family anyways. But she found it unbearable to work under the conditions the Ugandan health system could offer.
This is all anecdotal evidence. Especially the one about Malawi is dubios, and I have no further proof than stories from Malawi. However, being familiar with working conditions and management culture in Malawi and a few other African countries, it seems perfectly plausible.
I would be very interested in hearing your opinion on this, and perhaps you can also refute/confirm the Malawian story?
@Tord Steiro: Thanks very much, this is a valuable contribution. In the paper that I linked in the post, I talk about survey evidence on this. For example, the World Health Organization conducted a survey of African health workers in six countries, asking if they were considering emigrating, and if so, why. Though they often mentioned remuneration, at least as common were concerns about personal safety, professional training, their children’s welfare, and many other things that health workers all over the world care about. These factors further complicate the ethics of eliminating their professional prospects abroad by fostering “self-sufficiency” in all the places they could go.
In the same paper I discuss unnecessarily restrictive laws in Kenya and Zambia that, in the past, have made it difficult for Registered Nurses to practice privately (decreasing their power in the workplace), laws supported by the physicians with whom they would compete if they were able to practice privately more easily. So there are lots of examples of things that can be improved to make better use of human resources for health, aside from the blunt and ethically problematic instrument of coercing into staying where they are against their will, rather than focusing on changing the things that make it difficult for them to stay. And I really appreciate your highlighting this critical issue.
I am probably in well above my head – this is not my profession – but I do find this debate highly interesting. Hence, I have a few points I would like to mention:
1. Power relations and labour markets:
It seems to me that Doug North’s theories of ‘Open Access Orders’ and ‘Limited Access Orders’, OAO and LAO, are applicable in the workplace as well as elsewhere. Let’s look at the workplace as a LAO. Then, rent-seeking, in one way or another, would be the main purpose of management and high positions. Hence, the less power the employees have in the workplace, the better for the management/employers, as it is easier for them to extract various forms of rents from their employees.
This also corresponds well with some of Carl Marx’s comments on capitalism – the struggle between capital (or employers/management) and labour (employees) – and rent-seeking behaviour. A functional capitalism, as we know it today (and not attributable to Marx), could only materialize when the power was more or less balanced between the capital (or employers/management) and labour (the employees), and when access to higher positions and ownership where open to all — at least in theory.
Perhaps issues concerning power in the workplace are much more important for a country’s development than commonly thought?
2. Then, given that outmigration for (skilled) labour can play a role in equalizing the power between capital and labour – in the workplace and perhaps in society as a whole – we could perhaps expect high outmigration to be positive for development in the long run, by helping the process of breaking down what North terms the LAO, rather than negative.
Of course, any other issue, like easy access to self-ownership and private practice, would also be beneficial within this framework. Interestingly, Bill Easterly (who else!) have pointed some evidence for this:
http://aidwatchers.com/2010/02/four-ways-brain-drain/
http://aidwatchers.com/2010/07/fitting-kwame-the-cabbie-into-the-brain-drain-equation/
3. Another issue mentioned in this debate is the importance of a critical mass of civil society. If we continue to think within the in OAO-LAO framework, civil society is a critical ingredient in the transition. It must be bad for democracy, and the transition in general, then, if ‘Open Access Orders’ ‘import’ highly skilled individuals who could have secured a critical mass of competent civil society figures from Limited Access Orders?
On the one hand, it is not part of this debate, as they will often be eligible for seeking political asylum, secondly, it may not be a problem. In fact, outmigration of highly skilled labour may be good for democracy (Bill Easterly again): http://aidwatchers.com/2010/10/when-the-brain-drain-is-healthy-for-democracy/).
Another case in point on this issue, what is the point of having highly competent academics when the government decides to fire them?
http://www.bnltimes.com/national/42-all/703-no-perks-for-chanco-poly-as-thugs-stalk-kabwila.html
http://www.nyasatimes.com/national/health-activist-receives-death-threats.html
I would have linked to further evidence on my previously mentioned Malawi story, but I could not find any credible sources.
4. What does the empirics say?
I do not have much to contribute here, and your paper do cover a lot of ground. However, the data from my country (Norway) suggests that outmigration did not impede growth. Let’s look at the data:
Norway experienced particular strong waves outmigration in the years 1880-1893 and again in the years 1902-1911. According to Norwegian historian Yngve Nedrebø the great majority of the migrants where skilled workers. Consequently, Norway experienced particularly high GDP growth in the periods 1882-1897 and 1905-1916. The first period also corresponds with the mechanization of Norwegian agriculture.
P.S.
I apologize for putting the links in this way, but I did not manage to do it in any other way…
Let’s not forget that a lot of highly trained Indians who emigrated have returned to the country. So while it may initially have seemed that India was losing out from the migration of skilled professionals, few people would now be making that argument giving the benefit of the IT industry to the Indian economy. So allowing freer movement of trained professionals benefits not only the professionals themselves but also the home country in the long run.
@Art: This is a great point and I appreciate your bringing it up. Back in the 1970s and 1980s, many in Indian complained of the “brain drain” as engineers flocked out of India. But in a landmark program of research, AnnaLee Saxenian has documented the ways that Indian emigres and returned migrant Indians were critical to the founding of the high tech industry in India from the 1980s through today.
Likewise, Bill Kerr has shown that technical knowledge flows to Indians in India more from Indians in the US than from others in the US. There are many other examples: What at first glance seems like a straightforward “loss” can in fact have much more complex effects.
When you invest in the people, then they become hman resource for the country. And if no government is getting any ROI (Return of Investment), it’s a loss in the short term for the national growth. I am not standing against migration. But tell me justification of subsidy taken by few elites to be educated in the third world country and earning bucks heavily in USA. How can a poor country justify its spending on igher education if the majority of the human resource migrate to foreign nation.
There is different between training costs of nurses and Doctors in the case study of health workers. As per the case of India, we have at least five times expenditure done on the Doctors than nurses for their specialized studies. So when a highly talented Doctor migrate from the pool of limited Doctors, India suffers much. Since the pool of nurse is large (in comp. to Doctors) and investment made by Government subsidy is low, the losses are less.
The migration factor depends on skill of the labor set and subsidies given by Government in their training and education.
@yayaver: Certainly it is true that when physician education is given unconditionally for free, departure of a physician means that the subsidy is not doing what it was intended to do.
But clearly blocking migration permanently—as if the Indian state has purchased ownership of that person—is not the only solution to that problem. Another solution would be to change the system of universal unconditional free physician training. For example, the government could create a student loan system, so that people wishing to acquire physician education for the purposes of working internationally would have a way to pay for their own educations, out of the substantial money they can earn abroad. This would be good for the coffers of the Indian state, and good for Indians wishing to work internationally.
Another solution would be to create a limited property right in the educated person, as I discuss in the paper of mine that I linked in the post. For example, the Brazilian government pays for the international PhD education of Brazilians, contingent on 2 years of subsequent living and working in Brazil. They do not claim indefinite ownership of the educated person, but they insist on some service as well. So it would be reasonable for the Indian government to expect some years of service out of a person who has received free public education. The problem with “self-sufficiency” of the kind advocated by Professor Wolff is that it would mean that no Indian doctors could ever migrate, i.e. they would be permanently owned by the state, and that is an ethically problematic situation.
I enjoyed the post and, even more, the following debate! A puzzling issue, philosophical indeed. Sometimes based on slight choices of words. I agree with Michael when says you cannot steal and own people. However, I do agree with Eli, too, in assuming a figurative meaning to the “stealing” term. I believe, eventually, that focusing on etymology questions is moving the attention from the compelling issue: why do people decide to migrate, even opting for a painful and sometimes highly risky decision (this is the my case!).
Thanks Antonio. I couldn’t agree more that the real question is why people migrate — which should also be what policy seeks to affect. That’s the main theme of the paper that I linked.
The problem with policies that coerce people to stay where they are–like eliminating jobs available to them abroad, i.e. “self-sufficiency”–is precisely that they ignore this question of why people migrate. Coercion shows no interest in changing people’s incentives; it just unilaterally eliminates options for them. In order to feel comfortable doing that to others, we’d have to have the mindset that those people’s rights and ambitions don’t have quite as much worth as our own. And this is the same mindset that leads people to use bizarre language like describing a person’s voluntary decision to better their own life as a passive act of being “stolen”.
So the reason I focus on the language is to ask people to critically examine the mindset with which they view migration. But the critical issue, as you say, is the fundamental reasons that people choose to migrate. When we start thinking of migrants as active human beings rather than passive resources, we get interested in incentives.
Thanks Eli for this thoughtful comment. I am sure you’re right that most people who use words like “stealing” and “poaching” don’t truly believe, deep down, in the ownership of people. But Professor Wolff uses these terms with the clear implication that countries offering those legitimate incentives you speak of are acting immorally, with no qualification. No one thinks that a sports team recruiting a star should be jailed for doing so, but an editorial in The Lancet actually asserted that people recruiting African health workers abroad should be tried in the International Criminal Court, alongside the perpetrators of the Srebrenica Massacre. Not many people think that “taking” someone’s girlfriend, if that were even possible, causes death; plenty of people think that “stealing” doctors does. If they’re right, the stealers are responsible for deaths.
This point of view is bizarre. I’ve met nurses working in Mozambique for US$110 per month, knowing that the same work could easily earn them 40 times more elsewhere—i.e. the same wage that I and my family get to take for granted because of our birthplace. To suggest that offering those Mozambican women professional opportunities like mine is a clearly immoral act with no ambiguity or mitigation, deserving of blunt pejoratives like “stealing”, is a view whose lack of nuance is undeserving of a professional philosopher.
By pointing the spotlight at words like “stealing”, I want to draw attention to the mindset one would have to have in order to write an article like that Guardian piece without ever mentioning the life-transforming good that is also wrought by giving health workers from poor countries professional opportunities that most readers of this blog enjoyed from birth. If we think of health workers from poor countries as full human beings who have dreams and aspirations and rights that are exactly as valid as our own dreams and aspirations and rights, we would never think of making simplistic moral accusations against people who help them reach their dreams and aspirations by exercising their rights.
If it were clear that we weren’t making such moral accusations—as in sports recruitment—using words like “stealing” in a playful sense would be fine. But the Guardian piece is deadly serious in its accusations.
Great post. Until further evidence,however, I’d give Wolff a pass on stealing. Op-ed writers don’t write the headlines. The headline writer,however, deserves the condemnation.
Alex this is a good point and I agree. Words like these are extremely common in writings on health worker migration, so I want my plea to stand in general, but I can’t be certain that Prof. Wolff himself endorsed the headline of this particular piece.
With great respect for every other point you’ve made, I think it’s probably safe to assume that Professor Wolff doesn’t believe it’s possible to own human beings. “Stealing” is a common informal word for luring people from one group to another by way of legitimate incentives. Universities do it with professors; sports teams do it with players; Mr. Moser even suggests it could be done with girlfriends, though I’m less sure about that one.
I respect the need to use language with clarity and sensitivity while we talk about important subjects, but his meaning hardly assumes the legitimacy of slavery.
Still, a fascinating and informative post. Thank you.
actually, even if its true that some of the trained health professionals leave, i think that the ones that migrate are the ones that are either the most skilled or most experienced. by that logic, average skill falls in the Home country.
also, there might be a skills mismatch, a glut in certain skills because of the expectation of migration. this is certainly true in the philippines. there are many unemployed nurses, or nursing graduates working in non-health related fields. this glut is exacerbated by migration limits imposed by labor importing countries. i’m surprised mr. clemens isnt aware of that.
No need for surprise; I’m perfectly aware that many nurse graduates are unemployed in their countries of origin. For example, when I was in Kenya in 2006, there were several thousand unemployed Registered Nurses in Kenya according to the National Nurses Association. This, the Chief Nursing Officer of Kenya told me, was because the government had placed a hiring freeze on nurses in the public sector for the previous three years, while the schools continued to churn out nursing graduates. Professor Wolff’s “self-sufficiency” proposal would mean that those nurses, who cannot work as nurses in Kenya, cannot work in other countries either. That’s no solution, unless one simply does not care about Kenyan nurses’ welfare and rights.
It’s always amazing to me how willing people are to attribute all the ills of the world to migration. In the above comment, GabbyD asserts that nurse emigration is the reason that there are too many nurses in the Philippines. Others assert that nurse emigration is the reason there are too few nurses in other countries. Whether there are “too many” or “too few”, someone can always find a way to blame emigration for it.
Please consider the fact that stopping migration per se means forcing people to live in a place they have demonstrated that they don’t want to live. Each of us should only feel comfortable doing that if we would feel comfortable with a government official telling us that we must live in a place we don’t want to live, because that official’s calculations indicated that the “right” number of people like us didn’t live in that place.
I think that few readers of this blog would truly feel comfortable being forced to live somewhere they tried to leave, because all the jobs they could have taken elsewhere had been filled up and denied them by “self-sufficiency” policies. Yet many are comfortable doing the same thing to others. That’s something I can’t wrap my head around. Apparently I need to read more philosophy.
So people also can’t “steal” girlfriends?
One question I have is whether this holds true in countries that lack the capacity to train many / enough physicians or nurses. In the Philippines it’s been a net positive because the country has (obviously, by virtue of having so many staff) been able to train more people than the number who emigrate. But that doesn’t seem to be equally true for all countries. Ie, why use the Philippines as an example rather than, say, Zambia? Even if the remittances outweigh the costs of training the doctors, a country might still lack the capacity to train enough health staff.
Starting from the belief that people should be able to immigrate to make better lives for themselves (which is a good place to start), one might still conclude that the system (or lack thereof) needs a lot of improvement.
And of course, now that I’m reading the paper you linked to, I see include six examples of how the system can be improved. Should have read first!
@Brett, thanks very much for this thoughtful comment. I didn’t mean to suggest that migration doesn’t place stress on human resource systems in developing countries’ health sectors. Certainly it does. The question then becomes whether migration itself is the root cause of that problem, or health system weakness is the root cause of the problem. Focusing on “stealing” by other countries only makes sense if migration itself is the root evil, which is ethically problematic because it certainly is not an unmitigated evil for people to get to choose where they live (as you and I do). What I appreciate about your comment is that you bring the focus back to the right question: What is the root cause of the problem?
If the root cause of the problem is that (say) Malawi’s private health education system is not as strong as that found in the Philippines, then aid agencies would do well to help strengthen Malawi’s private health education system—for example by providing seed money for private-sector schools to help health workers interested in working internationally pay for their own educations, as most Filipino nurse emigrants do. Such schools would be easily self-financing once they got off the ground, since it only costs about $25,000 for the start-to-finish education of a Registered Nurse in Malawi, an amount that the same person could earn in a few months of work abroad. This would be a triple win: for the migrants, for Malawi, and for the destination country.
But to get to work on innovative solutions like that we would need to stop focusing exclusively on movement itself as the problem. From that we will only get proposals to limit movement, like Professor Wolff’s isolationist “self-sufficiency” proposal, whose efficacy and ethics are both highly questionable.