Lack of medical workers causes new health crisis in developing countries

By Kavita Chandran and Tan Ee Lyn
Reuters

Wednesday, October 1, 2008

BANGALORE, India: When her baby turned blue, Nivetha Biju rushed the child to the emergency room of an Indian hospital and watched helplessly as the baby lost consciousness because the nurses on duty had no idea what to do.

Eventually, a doctor saved the baby's life. But many patients are not so lucky in India and in other developing countries, where a scarcity of doctors and trained nurses means there is often no helping hand in times of need.

A lack of skilled personnel has health systems in developing countries "on the brink of collapse," said Ezekiel Nukuro, an Asia adviser for the World Health Organization.

"In some countries, deaths from preventable diseases are rising and life expectancy is dropping," he said.

Some specialists say the health crisis in such countries is being exacerbated as Western countries relax stringent immigration regulations to attract doctors and nurses. Doing so helps the West's flagging health systems while saving money on expensive training.

But this "brain drain" leaves gaping holes in the health care systems of countries where children die daily from diarrhea and where diseases like AIDS, tuberculosis and malaria run rampant.

Aid agencies have warned that a "blue card" plan in the European Union to attract highly skilled migrants like hospital workers, which gained initial backing from ministers, would make the drain worse.

Africa, which has a quarter of the world's disease burden but only 3 percent of its health care workers, is affected the most. Across Africa, AIDS patients are often left unattended for days in rudimentary clinics staffed by a single overworked nurse and a few untrained orderlies. Doctors often visit only once every few weeks.

"There is a clinic run by a nurse who is over 70 years old, and she can hardly remember what she did with a patient yesterday," said Dr. Pheello Lethola, an HIV and tuberculosis specialist in Lesotho, where almost one-quarter of the population is infected with HIV, the virus that causes AIDS. "Yet she still runs the clinic because there is no one willing to there."

The lack of medical workers in Africa is most pronounced in regions where AIDS has whittled away the ranks of health workers.

"A nurse taking care of 400 patients is paid $3 a day in Malawi - not enough even for a bag of maize," said Moses Massaquoi, a doctor with the aid group Médecins Sans Frontières in Malawi. "So health care workers move overseas or work private companies here."

WHO officials said in a report in July that international aid to Africa should be used to increase doctors' salaries and to bolster recruitment and training. The report also said that efforts to connect African hospitals with laboratories and specialists abroad through the Internet and telephone, a practice known as telemedicine, might ease cost pressures in countries that lack skilled personnel.

In Afghanistan, some of the best public hospitals cannot afford disinfectant or rubber gloves, and doctors and nurses do not earn enough to feed their families.

In India, patients may spend days lined up for tests and drugs at New Delhi hospitals because there are not enough doctors and nurses to attend to them all.

"Many end up sleeping outside the clinics, and we are now looking at building shelters so people can come and stay," said one AIDS activist, Loon Gangte, adding that some patients abandoned treatment because the waiting was too grueling.

Indian doctors and nurses are being hired away either by private medical centers that cater to an expanding middle class or by hospitals abroad. Some leave medicine and take jobs in the growing and relatively high-paying information technology sector.

"Demand is greater than the supply," said Dr. Sunita Maheshwari, a pediatric cardiologist at a hospital in Bangalore who returned to India to practice after graduating from Yale University.

"India traditionally lost all our best nurses and technicians to the West because they too don't have enough," Maheshwari said. "So what do they do? They poach from here."

India is estimated to need 600,000 more doctors, 200,000 dental surgeons and one million nurses, as well as X-ray technicians, dental hygienists, physiotherapists and laboratory technicians. There is one nurse for every 1,000 patients in India, compared with about 11 for every 1,000 in Europe.

India boasts of a flourishing "medical tourism" industry, with low-cost plastic surgery and other procedures attracting patients from around the world. Yet poor, sick Indians often get no medical assistance at all.

Experts say there is no easy solution, because the problems of developing countries, including war, disease and malnutrition, often persuade those who are able to leave to do so. But they do suggest that retention strategies could reduce the problem.

"It would be impossible to solve or stop migration of health workers," said Nukuro of the WHO. It is an "individual's basic human right to freedom of movement."

But he said he believed that political and international commitment and innovative strategies, like "partnerships and alliances and long-term investments should be among the key ingredients in tackling medical 'brain drain."'

Some practical steps being taken in India include reducing the burden on health professionals by training housewives to give medical advice for conditions like diarrhea and to dispense fever medicine, oral hydration tablets and rapid diagnostic kits for malaria and pregnancy.

Such community-based training projects are also under way in African countries, especially in remote, rural areas.

"This is a small intervention, but it will have a big impact on reducing maternal mortality rates and infant mortality rates," said Naresh Dayal, the Indian health secretary.