Letter to the British Medical Journal: A Palliative

Socioeconomic imbalances have a habit of exacerbating themselves: we call them virtuous and vicious cycles. And it is near impossible to change the one into the other.

The world is increasingly one integrated system and costs and benefits are not directly linked. Those who benefit are not those who pay.

Conscience may persuade some – some of the time – to pay for the value they receive. These discussions serve as part-payment, a salve to conscience, but no pragmatist expects or believes that the brain drain will be reversed.

The convenient solution is to introduce friction to the free movement of health professionals: the health professionals pay, the benefiting countries say, “See we have made it difficult for them.” And the losing countries are left with nothing.

The entire argument seems misplaced. Seen as a unit, the whole world suffers from a dearth of health professionals.

Poor countries – Developing countries – need more health, not more healthcare or more health professionals. Below a recognised threshold, health equates with income, both direct and indirect (the entire focus of public health initiatives: potable water, sewerage systems, electrification, telephones, roads, mass immunisation, etc.) and yet still the health of nations focuses on the movement of health professionals.

A cardiothoracic surgeon or interventional radiologist can do nothing for the health of a nation sitting on a dune in the Karoo or looking off a cliff in the Himalayas. Implants of NGF producing cells for Alzheimer’s are irrelevant to a population dying of cholera for lack something simple and inexpensive: potable water.

The health of a nation has very little to do with the movement or the numbers or the training or the remuneration of health professionals: America and Cuba are the proof of that.

I am in favour of dialogue and I will award myself Brownie points for this piece; I know that it will make no difference to the health any nation, but I will feel better and that will certainly be good for me.

Competing interests: health professional

[This letter appears in the online edition of the BMJ April 2005 and will appear in the print edition in June 2005.]