Migration of doctors because of supply and demand?

I’m glad that Glenn linked to this article from the New England Journal of Medicine on the movement of doctors from poor countries to rich countries. It’s a topic I’ve written on before.

I agree with a number of the conclusions of the NEJM article: that the emigration is damaging to the people in the developing world; that the “poaching” of medical professionals from poor countries is unethical; that public policy in developed countries aggravates the situation; that U. S. leadership could make an enormous difference. There were, however, a number of real knee-slappers in the NEJM article.

This, for example:

“ The migration of medical professionals reflects a balance of supply and demand…”

This is claptrap. The government subsidies paid to the healthcare industry in this country are enormous. GME subsidies (graduate medical education) to the tune of $80,000 or thereabouts are paid per medical resident. The number of medical schools, the enrollment in medical schools, and the specialties to which prospective doctors are directed, i.e. the supply of healthcare professionals, have all been heavily manipulated by both government and the professional medical associations.

Nearly 50% of every dollar spent on healthcare in this country comes from tax dollars i.e. is paid by the government in one form or another. The Pure Food and Drug Acts of 1906 and 1938 gave enormous powers to the members of the medical profession. Every state in the union licenses medical professionals.

Finally, since about 1950 most people in the United States have had some or all of their healthcare paid for by their employers. It’s been part of their total compensation package but it’s a part that, unlike salaries and wages, is not taxed. Hundreds if not thousands of economists have made the claim that this creates excess demand for healthcare services. People have little motivation to limit their consumption of healthcare or shop for the best deals.

Most other developed countries like the United Kingdom, France, and Canada have even more completely socialized healthcare systems.

In this environment of market distortions due to the control of supply and subsidization of demand to speak of “balance of supply and demand” is either poorly informed, evil, stupid, or insane.

Here’s another:

“Yet simply blocking migration is neither effective nor ethical, since freedom of movement is a basic human right.”

Says who? To the best of my knowledge every single country in the world has rules on immigration. Some ban it altogether. Some limit numbers of immigrants, put up substantial barriers to immigration, or otherwise control freedom of movement. Here’s what the Universal Declaration of Human Rights has to say on the subject:

Article 13.

(1) Everyone has the right to freedom of movement and residence within the borders of each state.

(2) Everyone has the right to leave any country, including his own, and to return to his country.

As you can see this is not quite the same view of “freedom of movement”. Who (other than The Wall Street Journal and, apparently, the NEJM) advocates “freedom of movement” from country to country as a basic human right?

I believe that we should eliminate the subsidies to and controls of medical education in this country. I think that producing many multiples of the number of doctors we do now is both economically warranted, socially desireable, and ethically necessary. I believe that, rather than importing doctors, we should be exporting doctors.

At the very least we should be paying foreign-trained doctors to stay home where they are urgently needed. Particularly in sub-Saharan Africa.

But, as they say, acknowledging that there’s a problem is the beginning of a solution so I welcome the NEJM acknowledging the problem.

UPDATE: Other blogs commenting on this article include

Health Care Renewal provides a physician’s viewpoint on the subject.

a-sdf wonders:

Would Africa be better off if there were more large companies creating the capital used to encourage the developement of medicines, roads, and infrastructure? If Africa were a place where companies from the United States could make money (and were forced to compete with African ones), would that affect public policy?

The democracy deficit in Africa is a problem, too. That might create an environment that would encourage more investment.

Logical Thinking from Bangalore, India comments.

KidneyNotes points to a podcast feed of the article.

Civil Commotion comments.

The Agonist reminds us that not only doctors are emigrating but nurses and medical technicians as well. I’m aware that the Philippines, for example, is suffering from a nursing shortage because of the large emigration rate.

MedPundit weighs in:

I’m old enough to remember when the rallying cry for the anti-immigrant crowd was that foreign medical graduates were making it difficult for American students to get into medical school. People complained that there were too many doctors in rural America who did not speak the language well. That it was cheaper to let these medical immigrants set up shop than to train more American doctors. And efforts were made to cut down on medical immigration. It’s an interesting strategy to change the argument to make the West a villain in this story, even though the goal’s the same.

I’m neither anti-immigrant nor anti-doctor nor anti-West. That sub-Saharan Africa needs more doctors and other medical professionals is beyond dispute. So is the fact that a lot of their native-trained professionals end up here, in the UK, and in France. And she’s just plain wrong about recruiting. Hospitals may not recruit international nurses directly but they do pay bounties to recruitment firms who do.

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New England Journal of Medicine
Brain Drain