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September 15, 2004

Individuals and Global Health Improvement—Reply

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2004;292(11):1303. doi:10.1001/jama.292.11.1303-b

In Reply: Dr Pust asks how clinicians in high-income countries can contribute to the attainment of the United Nations Millennium Development Goals and the improvement of health more broadly in low-income countries.

He is correct to draw attention to the dramatic contrast between the physician-citizen ratio in a country like the United States and in sub-Saharan Africa. However, it is important to acknowledge that the United States and other high-income countries contribute to the problem by employing and depending on medical and nursing graduates from many low-income countries.1 For example, between a third and a half of South African medical graduates emigrate.2 The situation may be even worse in poorer countries such as Zambia where, some years ago, it was found that only 50 of the 600 physicians trained by the medical school in Lusaka worked in the public sector health service.3 The situation is similar for nurses. In Malawi, two thirds of jobs in the public health system remain vacant, with more nurses emigrating in the past 4 years than the 336 who remain to serve a population of 11.6 million.4 Clinicians in countries such as the United States can play an important role by drawing public attention to the problems caused by migration of health professionals and pressing for the development of effective policy responses. These could include encouraging investment in domestic policies to improve the retention of health workers within low-income countries and reduce requirements for overseas recruitment by high-income countries, together with the development, implementation, and enforcement of ethical guidelines on international migration of health professionals.5