Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad

Contents

Contents Foreword by Laurie Garrett / ix Preface / xiii Acknowledgments / xxv Introduction / 1 1 Shortage in the Land of Abundance / 10 2 How the United States Created Its Healthcare-Workforce Problem / 40 3 The Path to America / 66 4 The Damage Done / 91 5 The Fox and the Hydra Failed Attempts to Address Insourcing / 116 6 Successful Efforts to Curb Insourcing / 138 7 The Way Forward / 150 Notes / 181 Index / 197 Foreword It’s hard to imagine any realistic conversation about global health that doesn’t begin with the question: “Where are the healthcare workers?” In 2004 Lincoln Chen and Tim Evans told us1 that the world was facing a profound deficit of some 4.3 million health professionals; for sub-Saharan Africa alone, the deficit was 1 million. Since then the pressures on the global health labor force have only increased, and training of doctors, nurses, dentists, pharmacists , lab technicians, midwives, medical supplies experts, hospital administrators, optometrists, and every other type of health professional remains woefully inadequate. The most acute shortages of skilled health personnel are in countries facing the gravest public health challenges. For example , in rural Mozambique, where hiv rates exceed 10% of the adult population and famine shadows the people with shocking regularity, the few physicians available have a patient load of 6,496 patients per md, about twenty times the burden doctors face in the capital city of Maputo.2 Any initiative to improve the well-being of Mozambique’s largely rural population must begin by asking who will actually implement programs of mass immunization , hiv testing, prenatal care, safe drinking water, or malaria prevention. The spectacular boom in global health financing between 2002 and 2009, jumping from roughly $5.6 billion to more than $20 billion, allowed the world to dream big: Eradicate malaria, provide universal access to hiv treatment, stop the spread of drug-resistant tuberculosis, and bring maternal mortality rates x Foreword in poor countries down to the levels found in North America. But as ambitious programs were rolled out, often in great haste, implementers realized the scale of the healthcare worker crisis. A mad scramble ensued, as skilled professionals were wooed away from their often dismal government jobs to work on externally supported health initiatives. The brain drain from one sector to another within countries might have been tolerable if it had not occurred amid two larger global forces: gross underpayment of public sector health workers , and pull from wealthy countries. A sad truism is that highly skilled physicians and nurses in most countries of the developing world and even emerging market nations can earn more money driving taxis or selling cars than they can by performing trauma surgery or treating malarial encephalitis. In Dr. Kate Tulenko’s book you will read the numbers —a state of affairs increasingly seen in rich countries, as well. A newly minted American physician now often faces decades of student loan payments, the interest and duration of which cannot be shortened by accepting a position in a rural county hospital or inner city clinic. All over the world the basic economics of salaries and cost of living drive skilled professionals either out of the health field entirely or else toward practices in populations that are already relatively well served. To put it crassly, the economic model favors Beverly Hills plastic surgeons over primary care physicians in rural Iowa. A former U.S. presidential candidate named Ross Perot famously referred to “that giant sucking sound” of American jobs allegedly sucked away to Mexico. In truth the massive “sucking sound” is that of health professionals enticed to abandon their home countries for higher paying positions in wealthier nations. As Tulenko details in this book, the lure often proves less glam- Foreword xi orous or rewarding than immigrating healthcare workers expect. But the numbers of those sucked away from their home countries to fill the ranks of healthcare workers elsewhere are enormous . In Lesotho doctors told me of losing nurses to Botswana; the Botswana losses are to South Africa. Walk the halls of England ’s National Health Service and hear nurses speaking Zulu and Xhosa—evidence that South Africa is losing personnel to wealthier Commonwealth countries. Years ago I was asked to testify on the healthcare worker crisis before the Senate Foreign Relations Committee. I told the committee members that it was unconscionable that the...