the hinged world: doctors and diseases on the move fitzhugh mullan, md the murdock head professor of...
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The Hinged World:Doctors and Diseases on the Move
Fitzhugh Mullan, MDThe Murdock Head
Professor of Medicine and health PolicyGeorge Washington University
St. George’s University30th Anniversary Symposium
November 10, 2007
A Linked World and Medical Migration
• Disease Mobility
• Economic Disparities
• War/HIV/Corruption
• Human Ambitions
• Aging of the Population in the West/North
• Health Educational Policies in the West/North
The South
Pulls to the North and West
• Training Opportunities
• Practice Opportunities
• Better Remuneration
• Better Technology
• Family Opportunities
Push Factors from the South
• Lack of Post Graduate training Opportunities
• Insufficient Practice Opportunities
• Poor Remuneration
• Security Concerns
• HIV/AIDS
Physician Density per 100,000 Population
530
417
350 340
280
220 220 206 190164
69 6013 2
0
100
200
300
400
500
600
Cuba
Russian
Fed
erat
ion
U.S. C
ities
Franc
e
U.S. A
vera
ge
United K
ingdom
Poland
Brazil
North D
akota
China
Republi
c of S
outh A
frica
India
Ghana
Moz
ambiq
ue
Health Worker Migration
Characteristics of Physician Workforces of US, UK, Canada, and Australia.
Country Physicians per 100,000 population
% IMGs in MD workforce(total IMGs)
% IMGs from lower income countries
% IMGs from other three countries
US 293 25.0 (208,733)
60.2 6.5
UK 231 28.3 (39,266) 75.2 2.5
Canada 220 23.1 (15,701) 43.4 22.3
Australia
271 26.5 (14,346) 40.0 33.5
Regional Emigration Factors in 8
Regions of the World
Global Regions
Sending country MDs in recipient
Countries by sending region
Sending country MDs in sending
regionEmigration
Factor
Sub-Saharan Africa 13,272 82,100 13.9
Indian Sub-Continent 78,680 656,876 10.7
Caribbean 8,010 87,443 8.4
Middle East and North Africa 27,010 489,464 5.2
Central and South America 12,103 707,416 1.7
Europe and Central Asia 44,988 2,741,717 1.6
East Asia and Pacific 39,910 2,808,400 1.4
North America 14,519 1,076,398 1.3
NationMDs per 100,000
Sending country MDsin recipient countries
MDs in sendingcountry
Emigration Factor
Liberia 1.7 78 55 58.6
Ghana 8.8 791 1,842 30.0
Zimbabwe 5.7 266 736 26.5
Tanzania 2.3 270 822 24.7
Zambia 5.8 164 647 20.2
South Africa 69.3 6,993 30,740 18.5
Ethiopia 2.7 359 1,971 15.4
Uganda 4.3 195 1,175 14.2
Nigeria 24.0 4,053 30,885 11.6
Sudan 12.4 622 4,973 11.1
Emigration Factors of Selected African Nations
Emigration Factors of Selected Caribbean Nations
NationMDs per 100,000
Sending country MDsin recipient countries
MDs in sendingcountry
Emigration Factor
Jamaica 82.5 1,589 2,253 41.4
Haiti 24.0 1,067 1,949 35.4
Dominican Republic 193.0 3,262 15,670 17.2
Cuba 586.7 2,069 66,567 3.0
Trinidad & Tobago 92.2 23 1,004 2.2
Emigration Factors of Selected Indian Sub-Continent Nations
NationMDs per 100,000
Sending country MDsin recipient countries
MDs in sendingcountry
Emigration Factor
Sri Lanka 39.7 3,027 7,963 27.5
Pakistan 59.7 12,813 96,900 11.7
India 46.6 59,523 503,900 10.6
Myanmar 33.5 1,545 14,356 9.7
Bangladesh 22.5 1,718 32,498 5.0
Nepal 4.5 54 1,259 4.1
The North
219,897259,443
323,799
453,165
601,237
776,301
906,278 988,100
299.2297.4277.4
236.9
195.9
155.6
141.6142.2
0
200,000
400,000
600,000
800,000
1,000,000
1950 1960 1970 1980 1990 2000 2010 2020
Su
pp
ly (
Th
ou
san
ds)
Supply of Active Physicians (MD & DO) and Ratio to Population Actual 1950-1990 and
Projected 2000-2020Physicians Per
100,000 PopulationPopulation is U.S. civilian
population including possessions
Applicants to Allopathic Medical Schools and Enrollment
Year No. of Applicants
No. Accepted Applied: Accepted Ratio
No. Enrolled Mean GPA of Applicants
1980 36,100 17,146 2.1 16,590 3.32
1992 37,408 17,464 2.1 16,289 3.24
1993 42,808 17,362 2.5 16,307 3.26
1994 45,364 17,317 2.6 16,287 3.28
1995 46,591 17,357 2.7 16,253 3.31
1996 46,967 17,385 2.7 16,201 3.34
1997 43,018 17,313 2.5 16,165 3.38
1998 40,998 17,374 2.4 16,170 3.40
1999 38,449 17,424 2.2 16,221 3.43
2000 37,092 17,538 2.1 16,301 3.44
2001 34,859 17,456 2.0 16,365 3.45
2002 33,625 17,592 1.9 16,488 3.46
2003 34,786 17,539 2.0 16,538 3.47
2004 35,735 17,662 2.0 16,648 3.47
2005 37,373 17,987 2.1 17,003 3.48
2006 39,108 18,442 2.1 17,370 3.48
2007 42,315 18,858 2.2 17,759 3.50
Source: AAMC
Number of Residents in U.S. Allopathic Training Programs from 1993-2007
0
20,000
40,000
60,000
80,000
100,000
120,000
93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07
Academic Year
No
. of
Res
iden
ts
All residents First-year First-year with no prior graduate training
Source: AMA
68,57869,27168,45667,13166,64665,66165,82067,31667,08567,11166,89368,64767,52470,218
6,6296,4745,6755,8385,3274,6584,1753,8693,6783,3673,2883,3333,2643,296
28,17627,63626,72026,57725,78325,40324,70726,41425,98126,10225,25725,60124,07923,291
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07
Academic Year
No
. o
f R
esid
ents
U.S. Allopathic U.S. Osteopathic Foreign
Number of Residents in U.S. Allopathic Training Programs According to the Type of Medical School
Attended from 1993-2007
Source: AMA
100
150
200
250
300
350
400
$0 $10,000 $20,000 $30,000 $40,000 $50,000
GDP per Capita (1996 dollars)
Act
ive
Phy
sici
ans
per
100,
000
. o
f Pop
ulat
ion
SupplySupply
Demand
Demand
DEFICIT WITH NO ADDITIONAL USMGs or IMGsDEFICIT WITH NO ADDITIONAL USMGs or IMGs
DeficiencyDeficiency~200,000~200,000physiciansphysicians
(~20%)(~20%)
~2020-2025~2020-2025
You are HereYou are Here
Source: RA Cooper
Background/Climate
• Era of medical school expansion• New schools – allopathic and osteopathic• Increased class sizes• Branch campuses
• AAMC predicts 17% increase in enrollment by 2012
• AACOM AAMC predicts 25% increase in enrollment by 20011
Source: AAMC
Current allopathic schools
Planned allopathic schools
Current osteopathic schools
Planned osteopathic schools
Northern Strategic and Moral Role
in Global Workforce Stability
Health Workforce Stability
• Bedrock of health system development
• Requirement for HIV treatment and prevention
• Prerequisite for public sector health reform
• Essential for global health security
Health Worker Migration as a Business Proposition
• The MD/RN degrees as passports
• The privatization of education
• The global health professional education “industry”
The Success Quandary of Developing Nations
• Established Example – The Indian Subcontinent
• Emerging Examples -- Nigeria, South Africa, Ghana
Previously Proposed Responses
• Ethical Recruitment Codes
• Emigration/Immigration Regulation
• Bonding/Community Service
• “Reparations”
Emerging Stability Strategies
• Domestic Post Graduate Training
• Salary Support
• Ancillary Support– Car Loans– Housing– Schooling
• Creative Use of Mid-levels
• WHO/PEPFAR Task Shifting Project
What To Do At Home
• Move rapidly toward self sufficiency in physician training in the North…5,000 more first year medical school positions in the US
• Keep cap on government support for GME positions
What To Do Abroad• Support capacity building and twinning
in developing countries
• Track immigration and set benchmarks of good practice
• Promote “reverse flows”
• Create and support a US Global Health Service
African Proverb
• The best thing to do is to have planted a tree twenty years ago
• The next best thing to do is to plant a tree today