It was not an unusual death. Kunj Desai, a young doctor in training at University Teaching Hospital in Lusaka, Zambia, had seen many that were not so different and were equally needless. Still, this was the one that altered all his plans. "A guy came in, and he had a stab wound," Desai recalled, "and his intestines got injured." The operation was delayed, and the wound became infected. "Whatever he was eating would come out of his belly," Desai said. A carefully managed diet would have helped the man heal, but there were no dietitians at the hospital nor any IV drips of liquid nutrients with which to feed him. "He withered away to probably about 100 pounds when he died."
The man was in his 30s, and his wife and children would have to fend for themselves. It was 2004, and Desai had worked at the chronically understaffed and underfinanced hospital for a year and a half. The hospital blood bank was often out of blood, and the lab was unreliable. The patients were often so poor that Desai would pay for private lab tests out of his own pocket. Desai came home in tears one day after being unable to save a premature baby boy. When the man with the stab wound died, the accumulation of preventable deaths — at what was, he kept reminding himself, the best public hospital in the country — finally became too heavy to bear.
"We were pretending to be doctors," Desai, who is 35, told me when we first met. This was in the cafeteria of University Hospital in Newark, and Desai was still in his surgical scrubs after a 30-hour shift. He talked about what he saw in Lusaka in the somewhat stream-of-consciousness way that war veterans sometimes speak about the battlefield. "What was I really doing?" he said. "Making myself feel happy? No."
As an idealistic, energetic young doctor, Desai imagined he would spend his career in Zambia, serving those in desperate need. But over the months at the hospital, he found himself fantasizing about another life — as a doctor in America. And in 2004, after he finished his internship, Desai quit his job at the hospital and began studying for the exams for a training position at an American hospital. Even while he did so, he told himself that after his stint in America, he would return to Zambia. His fellow Zambians, he knew, suffer from some of the gravest health crises in the world, not least of which is that Zambia's doctors tend to leave the country and never come back. "After completing residency training in the United States, I hope to return to Zambia and work where the need is the greatest, the rural areas," he wrote in a personal statement when applying for jobs in the United States in 2005. "I am Zambian, and I am committed to improving the quality of care that fellow Zambians receive."
Two years from now, Desai will be a fully qualified surgeon in America. He has a wife and a young daughter (he had neither when he moved to the United States), and once he's qualified, he can expect to make a very good living — the median salary of a surgeon in New Jersey is $216,000. In the main hospital in Lusaka, where Desai worked, a surgeon makes about $24,000 a year. The uncomfortable question that Desai put to the back of his mind when he arrived in the United States has begun to resurface and trouble him: Will he really fulfill his promise to himself and his country?
As we sat in the cafeteria, I suggested that if he did return to Zambia, he might be seen as something of a returning hero. Desai is a naturally polite and courteous man, but he is also disinclined to hold back from criticizing when he finds fault. In this case, his target was himself. He looked at the table and said: "The heroes are the guys that stayed. They didn't quit, and they didn't run away."
In a globalized economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America's best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the United States to work for American companies. And the United States, with its high salaries and technological innovation, is also the world's most powerful magnet for doctors, attracting more every year than Britain, Canada and Australia — the next most popular destinations for migrating doctors — combined.
The Council on Physician and Nurse Supply estimates that in 10 years, the United States could have a shortage of 200,000 doctors. Already, one in four doctors working in this country is trained in a medical school overseas (though this includes some American doctors who attended medical school outside the United States). American medical schools are producing more graduates, but many of them will become specialists who can command better pay. The demand for primary-care doctors is expected to stay high, perpetuating the demand for foreign medical graduates.
Even in the unlikely event that American medical schools produce more general practitioners, nothing but legislation would prevent American hospitals from cherry-picking the most promising young doctors the world has to offer, according to Laurie Garrett, a senior fellow at the Council on Foreign Relations. "If you can take from an applicant pool from the whole planet, why would you only take from Americans?" Garrett said. "For the foreseeable future, every health provider, from Harvard University's facilities all the way down to a rural clinic in the Ethiopian desert, is competing for medical talent, and the winners are those with money."
Some of the responsibility for the migration of health care workers lies with the immigration laws in the host countries. In 1994, Senator Kent Conrad, a Democrat from North Dakota, introduced legislation that empowered states to grant waivers to foreign doctors on J-1 student visas. They could stay in the United States after finishing residencies in American hospitals if they agreed to practice in communities where doctors were in short supply. The law, which has been continually renewed by Congress, has allowed more than 8,500 foreign doctors to gain jobs in rural communities, where patients often have to drive great distances to get medical care, and in underserved cities.
For a diabetic or someone with heart disease in rural Nebraska, this is unquestionably a good thing. They may be unaware, however, that their gain is a poor country's loss. The migration of doctors and nurses from poor countries to rich ones elicits some highly emotional responses, not to mention a great deal of ethical debate. Writing in the British medical journal The Lancet in 2008, a group of doctors, several of them from Africa, titled their paper "Should Active Recruitment of Health Workers From Sub-Saharan Africa Be Viewed as a Crime?" (PDF) They concluded that it should. Other critics have used terms like "looting" and "theft."
Some of the anger is directed toward the doctors who leave. The managing director of University Teaching Hospital in Lusaka, Lackson Kasonka, suggested to me that doctors who received government financing for their educations and then left exhibited "a show of dishonesty and betrayal." (Desai is not in this group; his parents, who immigrated to Zambia, paid for his medical education in India, where they were born.) Peter Mwaba, the most senior civil servant in Zambia's ministry of health, said that doctors overseas should not "hold their country to ransom" by staying away until things, in their minds, sufficiently improve.
