Brain Drain -- A Dead Hero or A Live Coward

I recently watched Public Enemies, the "autobiography" of John Dillinger, that most inglorious American robber of the yesteryears. In one scene, a bank manager attempted to delay the inevitable by fiddling with his keys. Dillinger smacked him upside of the head and said matter of factly, "you can be a dead hero or a live coward". The words if ever spoken by the man, most likely, did not start with Johnny and they hold meaning for more than that banker. I thought, "surely, this is no different from the choice faced by every migrating Ghanaian doctor". But is it?

According to a Ghana Ministry of Health report, there were on average (median) 3 doctors and 35 nurses per 100,000 people in the country in 2005. That made a total of 1241 physicians and 6599 nurses in a country of more than 20 million people. There were also 791 Ghanaian trained doctors practising in countries outside Ghana (NEJM 2005;353:1810-8) and that's only those trained in Ghana. The numbers were better in 2007 with reports of 13 doctors and 92 nurses per 100,000 (NEJM 2007;356:440-3). So we have advanced a bit yes? But why exactly do physicians, with a sworn oath to serve mankind leave the hallowed shores of Chorkor and Cape Three Points for the white man's land? The reasons may surprise you.

We'll start with the obvious one -- money. See there is more money to be made in the US and UK as a health professional than in Ghana. Given the current rate of production of doctors in the US lags quite far behind the ever increasing need for them, there will always be the demand for doctors from other countries. So how much, exactly, is the Ghanaian doctor making? The statistics, as they usually are from developing nations, are murky at the least and depends on who you ask. The only information I found after scouring the web is found here. A house officer, the equivalent of a resident apparently made $700/700 cedis per month in 2007 if we are to take the word of the doctors. That's half the income an undergraduate investment bank intern makes in per week in the US. Compare this to how much a community activist turned Member of Parliament makes and you can understand the agitation of the incessantly striking doctors back home.

In a country where a plate of Selsbridge fried rice cost in the range of 4 cedis the last time I checked and does not satiate me, a man's could run through that much in ehhh, 2 months. Now let's add a wife and 2 kids and we are coming down to less than a month. And you say, the average man eats kenkey anyways so why shouldn't the doctor? You are indeed right. Include this factor, rent, utilities, count the number of extended family members our young doctor must support in addition to the mother who broke her back for him to go to school and he saves maybe 150 cedis at the outside ceteris paribus. The average income of a medical resident in the partners medical system in Boston, MA, was about $50,000 annually as of '07. That's before taxes of course, rent is much higher than in Ghana at close to $1,500 depending on where you live, average meal costs $8 so no you are not living like a king/queen. But you are living. And your dollars would go a longer way in Ghana -- or used to. So, would you rather live in Ghana and make the meager income, serving your healthcare deprived people or would you rather migrate out to serve the healthcare deprived people of the US and make much more? At least that used to be the question.

Recently, a different generation of doctors have arisen, driven by a patriotic zeal to serve their country but still, looking for the way out. Why? I had a rather disturbing facebook conversation with one of my high school mates recently. He is currently a student at the University of Ghana Medical School. He, see, was in the US on an exchange program and was looking to return for medical school and eventually, work. Why, I asked, are you, a Ghanaian, trained on my mother's tax income thinking of leaving the country when my retired mother is back there? Who will deal with her medical issues? Where is the return on her investment? The government says pay a fine if you leave immediately after training but will the fine treat her if she falls sick? I was of course not talking to someone without family in the country. He gave me a laundry list of reasons why he could not stay in the country. But before that, he summed it up in one word -- Indiscipline.

According to him, there isn't only lack of equipment with which to deliver the needed care but the available ones frequently break down and are usually not fixed. Working conditions, described as hours, available nurses, are terrible and the bureaucracy associated with the teaching and delivery of the arts and science of medicine is legendary. Add into this the general laisssez faire approach of Ghanaians and the concept of African time (Case in point, months after I'd liaised with a group of philanthropists in Boston to send books to the UGMS, I am still waiting for the reply from a vice dean of the school on whether the delivered books have been claimed from the harbour) and you get the frustrations of an idealistic young man who went into the profession with the fire and brimstone spewing prophecies of a doomsday preacher only to crash with disillusion. Of course included in those ideals is the promise of riches but one cannot deny the inherent good in him. I, as expected, berated him for expecting someone else to fix his country while he leaves to prosper in another's. He was not patriotic, I said. I, I boasted, am going back to fix the country and my education was not even subsidized by the government. But is he any less patriotic than I? Am I any better for going back? Until systemic changes are made and political will for He definitely would not be a hero for staying home. It is expected that he stays. But is he a coward for leaving? I think not.

In the following posts, look out for my thoughts on the immigrant physician-trainee experience and the generational movement with every intention of going home to help change and make a living in Ghana.


Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Barcamp09 -- Healthcare Ghana

It is fitting that the first post on this blog is from Barcamp09. Barcamp is a coming together of young Africans in the diaspora. It encompasses multiple brainstorming sessions on a myriad of issues that are pseudo-generated on the go. I just left one such breakout session on the nature of the healthcare system in Ghana. As is usual at these things, there was a lot of talk about the problems and a lot of finger pointing to lack of political will. However, there were multiple pearls of solid solutions in the rubble. From teleconferencing to mobile vans to setting up a fund for contributions from Ghanaians in the diaspora and at home, we are beginning to think of effective ways to fill the gaps in healthcare delivery in our country. A group has been set up that will, through email, continue the efforts thus begun.

If you are out there, if you care, join the cause.

Prime