Posted by Dan Schwarz
On Wednesday night, winding down my day, I skimmed the new WHO policy recommendations for improving health worker retention in rural areas1. Reading through the Executive Summary (I was way too tired to read the full report), I was, admittedly, a bit skeptical of the 16 recommendations, written from a desk in Geneva. Sitting on my wood-plank bed in rural Achham, with
no running water to brush my teeth before bed, no electricity make a cup of tea, and cockroaches and mice crawling around on the floor, I thought to myself that the document, while quite insightful, seemed to be just a bit off the mark; it seemed to miss some larger point about poverty and human rights. …Exhausted, I fell asleep mid-thought.
* * *
As fate would have it, the next morning, drinking tea and eating roti with our Hospital staff, our Medical Director informed me that he would be leaving for the US within 3-4 weeks. He had, at the last minute, been admitted to an American MPH program, which would help him in the next round of American medical residency applications. The fact that he had not mentioned this to me beforehand, or the fact that he is the only doctor we have at the Hospital right now, did not seem to be adequate deterrents to this, admittedly fantastic, professional opportunity.
Our doctor had just started at Bayalpata Hospital two months prior. His predecessor, another young Nepali physician, had left to attend to a “family emergency” and never returned. We received an email three weeks later informing us that he was moving on to other work (he did not say where, but curiously, he was in Kathmandu by then). Breaking the lock on his door in our staff quarters after hearing the news, we found a bare room; the “family emergency” had apparently been a little more pre-planned than perhaps he had explained initially.
Bayalpata Hospital - Ridikot
Our current doctor, who is packing his bags in the room next to mine as I write this (using a flashlight because the power is out), came to us without abortion or HIV clinical training. In order to be able to continue to offer these crucial services at Bayalpata, we had paid to send him to Kathmandu for further clinical training twice over the past two months, totaling almost one month of training leave. Effectively, he has worked just over 50% of the time that he has been employed. We’ve invested an immense amount of financial and material resources into preparing him to be our Medical Director, to work to provide the quality care that we strive to provide to the people of Achham. There are no other abortion or HIV treatment centers for at least four to five hours walk (and in many cases, those centers don’t have medicines), meaning that unless we are able to find a replacement physician who has already been trained in these services, there will likely be a gap in our offerings for at least several months. The women of Achham will have nowhere (literally) to get a safe abortion, and HIV+ patients will need to walk an extra several hours to get refills on their antiretroviral medications (which is not exactly very easy for many ill HIV+ patients).
But wait. All of this makes it sound like this guy is a malicious, scheming con-man, right? …Perhaps there’s more to the story. The WHO’s new recommendations rightly point to improving the lifestyle offerings for our health care workers, providing them housing options, better school systems for their children, continuing educational options for themselves, etc. But the problem is that, while this may sound phenomenal on paper when read in New York or Geneva, the truth is much starker out here where these health workers live and work.
This young physician spends his nights and early mornings (while on call in the wards) reading through stacks of bootlegged, photo-copied American medical text books (bought on the streets of Kathmandu), studying for
Model Hospital - Kathmandu
American and Indian licensing exams, with the dream of eventually one day getting a residency position at one of the top-tier teaching hospitals abroad. He is, as of yet, unmarried, but speaks hopefully of a future in which he will be able to offer his children a better life than he had growing up, in rural impoverishment in the east of Nepal.
And seriously, who can blame him? Isn’t that what we all want? Isn’t that the kind of story that makes up the protagonist of innumerable movies and novels throughout the ages? Let’s be even more blunt – isn’t that what I want? Isn’t that what you want? Indeed, as I sit here, with my two graduate degrees from fancy American institutions, a wealthy family to support me each and every day, and the assurance of continued privilege and opportunity in the years to come, it seems perhaps a little hypocritical to throw stones at our doctor’s aspirations. It’s very easy for me to volunteer to come to Achham, to work for “equity” and “justice,” but perhaps a part of that is because I know that I will always be one bus trip away from a plane ride home to the US, where my family and med school awaits me.
For our doctor, that plane ride, and that med school, is a lot further away than simply getting to the airport. …Indeed, given the immense logistical, financial, and educational barriers for him, it might as well be on another planet. But is it any less deserved than for me? Is it any less his right to leave
Bayalpata is located in a remote part of Far West Nepal where access to further education is limited
Achham and pursue his own future than it is mine? Is it any less his right to be happy and to have a nice home and laptops than it is mine, simply because he was born in a “developing nation” and we (in the West) can talk about him “supporting his country and people”? To me, it seems that that type of logic has some rather problematic double standards at its core. What makes it fair that people call the American guy who takes a year off from his Ivy League education to volunteer a ‘saint;’ while the Nepali doctor who leaves his country to pursue his education is considered a ‘problem’ that warrants long policy recommendations?
In rereading the WHO’s new recommendations on the retention of health care workers just now, it is clear that there is, indeed, some significant value to them. Each of the 16 goals that they outline would, were they effectively implemented, truly help in retaining health workers. I imagine that, for example, both of the two physicians that have left us in the past two months, might have been more inclined to stay if there were good schools, social opportunities, even a library. But the point that the WHO fails to highlight is that these goals are not just goals that should be implemented for the purposes of retaining health workers. No. Quite the opposite, these points are all small details of a much larger conversation about the equity of wealth distribution, the double standards of the rich-poor gap between the West and the rest of the world, and the fundamental rights of all people – regardless of their profession or education – to enjoy a healthy, prosperous life. Indeed, if we were to challenge the WHO about the title of this document, one could easily raise very legitimate questions about why health workers had any more of a right to these “retention” incentives than, for example, school teachers, or (as is much more common in Achham) illiterate farmers.
Bayalpata Hospital will continue to fight for a world in which these inequities do not exist. But along the way, our work will continue to be hindered by the stark truths of this world. We will likely not have a reliable or dependable long-term staff of highly-trained medical professionals until we first address the much more fundamental issues of poverty in this area, thereby providing our staff with better lifestyles, and more of a reason to be content to stay. But none of this is to say that we should condemn brain drain; quite the opposite, I think it is, in fact, one of our most potent reminders of how much work we have to do. We cannot, and will not, develop a sustainable health system, without first changing the landscape of human rights and the tolerability of poverty at large.
The Achham region is extremely poor with limited opportunities for work and income. In this picture local women stitch clothing on a rooftop to earn extra money for their households.
From Achham, thank you all for your continued support of our work. I hope that, when you might meet an immigrant physician wherever you happen to be right now, you will consider closely the heinous and unacceptable circumstances that have led to him or her arriving there, and more particularly, wanting to be there.
Citations:
1. WHO Global Policy Recommendations on “Increasing access to health workers in remote and rural areas through improved retention”; http://www.who.int/hrh/retention/home/en/index.html
Tags: Achham, Dan Schwarz, Far West, global development, global health delivery, healthcare, Human Rights, rural health, rural life, social justice
