[afro-nets] Pakistani Physicians and the Repatriation Equation

[Jawad Asghar <jawad@alumni.washington.edu>]

Pakistani Physicians and the Repatriation Equation
--------------------------------------------------

New England Journal of Medicine
Volume 356:442-443 February 1, 2007 Number 5
http://content.nejm.org/cgi/content/full/356/5/442

Saad Shafqat, M.B., B.S., Ph.D., and Anita K.M. Zaidi, M.B., B.S.

In Pakistan, students who are accepted into 
medical school are congratulated ­ only 
half-jokingly ­ on three counts: that they will 
become doctors, that they will become certified 
by the American Board of Medical Specialties, and 
that they will soon be living in the United States.

Pakistan has contributed approximately 10,000 
international medical graduates (IMGs) to the 
United States,1 even though it faces a shortage 
of physicians.2 Take the case of Aga Khan 
University Medical College in Karachi. By 2004, 
it had produced 1100 graduates, 900 of whom had 
gone on to graduate medical training in the 
United States ­ despite the fact that doing so 
costs up to $20,000 (a fortune for most 
Pakistanis) and means leaving the comforts of one's home and culture.

The United States represents an overpowering 
lure: a rigorous system of graduate medical 
education, a merit-based structure of 
professional rewards, and a culture of academic 
nurturing. And, of course, material rewards. In 
Pakistan, an intern earns approximately $150 per 
month (the same salary as an unskilled, 
illiterate worker), whereas a U.S. intern can 
afford to live independently ­ and expect a 
better quality of life after residency.

Information from Pakistani medical institutions 
indicates that only about 300 of the 10,000 
U.S.-trained Pakistani physicians have resettled 
back home. Why did this minority choose to 
return? Aga Khan's experience is instructive: the 
majority of the medical school's 40 or so alumni 
who have repatriated from the United States have joined its faculty.

Motives for returning include aging parents and 
family ties, a desire to raise children in a 
familiar culture, and an emotional need to be 
home. But for many Aga Khan returnees, the 
attributes of the university and its hospital 
were key: teaching, research, and clinical care 
are patterned after the U.S. model, and salaries 
permit a comfortable lifestyle. Ultimately, 
attractive career prospects have to be the draw.

The challenge is local capacity to absorb highly 
trained physicians. U.S.-trained physicians 
represent a small fraction of Pakistan's 116,000 
doctors,2 but they return with ambitions to set 
new standards for clinical practice, education, 
and research and to influence academic medicine, 
health policy, and public health. To do so, they 
must negotiate local circumstances for which they 
are unprepared: exhausting clinical demands, an 
impoverished population, an environment in which 
malnutrition is a significant cause of death, 
collapsed health care delivery systems, and 
patients who respond to an unjust society with 
mistrust. Inevitably, they also face 
questions >from local professionals about the 
appropriateness of U.S. training for practice in Pakistan.

Discussions with expatriate physicians indicate 
that many more wish to return but cannot find 
suitable jobs. Like many poor countries, Pakistan 
has both severe shortages of health care 
professionals and a high level of unemployment 
among physicians ­ a paradox caused by inadequate 
and inappropriate investment in local health care 
systems. Elite medical academies in developing 
countries are frequently derided as manufacturers 
of a product that, out of place in its 
environment, enters a workforce supply chain 
leading to the West.1,3 The answer, however, is 
not to lament the irrelevance of these 
institutions but to advocate for more ­ for they 
can attract back highly trained professionals who 
have the potential to assume leadership roles. 
Repatriated Aga Khan graduates have won grants 
from major international agencies, established 
nonprofit research organizations, joined 
hospitals serving refugee populations, and led 
disease-control programs. Such academic 
institutions can play pioneering roles if they 
reorient their priorities to match their 
countries' needs ­ producing professionals with a 
strong public health ethic, establishing rigorous 
graduate programs in which trainees are paid good 
wages, and developing relationships with alumni 
that can help sustain rewarding careers in challenging environments.

Exhorting physicians to serve in environments to 
which their skills are ill-suited will not lure 
IMGs home. Barriers to immigration in individual 
countries are almost meaningless in a globalized 
world. For example, as immigration laws in 
Western countries are tightened, Pakistani 
physicians are seeking jobs in the Middle East. 
We believe that developed countries that import 
physicians to meet their own demands have a moral 
obligation to invest in improving health care 
systems in countries that train substantial 
segments of their workforce. Such investments 
provide employment opportunities for the diaspora 
of health care professionals, benefiting health 
in developing countries.

As a first step, the U.S. medical community can 
support IMGs who want to repatriate. U.S. 
academic medical centers could work with 
institutions in developing countries to develop 
training programs oriented toward global health,4 
availing themselves of growing funding 
opportunities for such endeavors.5

One approach is to offer motivated IMGs mentoring 
to equip them with skills needed in their home 
countries. The scheme could be formalized through 
international cross-appointments for mentor and 
mentee at each other's institutions and a 
bilaterally recognized role for the mentor. Such 
initiatives are desperately needed; properly 
done, repatriation of IMGs can help diminish vast 
disparities in health care.

Source Information

Dr. Shafqat is an associate professor of 
neurology, and Dr. Zaidi an associate professor 
of pediatrics and microbiology, at Aga Khan 
University Medical College, Karachi, Pakistan.

References

1. Mullan F. The metrics of the physician brain 
drain. N Engl J Med 2005;353:1810-1818. [Free Full Text]

2. Working together for health: the World Health 
Report 2006. Geneva: World Health Organization, 
2006. (Accessed January 11, 2007, at 
<http://www.who.int/whr/2006/whr06_en.pdf>http://www.who.int/whr/2006/whr06_en.pdf.) 


3. Bundred PE, Levitt C. Medical migration: who 
are the real losers? Lancet 2000;356:245-246. [CrossRef][ISI][Medline]

4. Institute of Medicine. Who will keep the 
public healthy? Educating health professionals 
for the 21st century. Washington, DC: National Academies Press, 2003.

5. Gupta R, Hotez P. Rethinking global health 
training in North America. Medscape General Medicine. August 24, 2006.


--
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
mailto:jawad@alumni.washington.edu
http://www.DrJawad.com
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