Where have all the flowers gone?
Subject: Medical students (Education)
Medical students (Management)
Medical education (Analysis)
Author: de V van Niekerk, J.P.
Pub Date: 05/01/2011
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0256-9574
Issue: Date: May, 2011 Source Volume: 101 Source Issue: 5
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 257352886
Full Text: Paraphrasing the nostalgic and political folk song by Pete Seeger, embellished and sung by many other famous artists, South Africa can ask 'Where have all our (medical) graduates gone'? And why have they gone?

The World Federation of Medical Education recognised that medical migration was increasing worldwide, as were the numbers of medical schools, many of doubtful quality. It therefore developed international medical education standards in 2003 with the objective of quality improvement, noting that 'shared international standards will facilitate exchange of medical students, and ease the acceptance of medical doctors in countries other than those in which they trained'. (1)

Regrettably, most medical migrations occur from economically less well-off countries to the 'haves' (2)--what my colleague Kay de Villiers years ago called 'the transfusion from the anaemic to the plethoric'. Figures from 2000 published in the report by the Southern African Migration Programme (SAMP) (3) showed that South Africa had 27 551 doctors locally and 7 363 abroad. Their survey revealed the extreme dissatisfaction of many health professionals, a sentiment that cut across profession, race and gender. Some countries in our region, Angola, Mozambique, Tanzania, Zambia and Zimbabwe (and many other African countries), had many more doctors abroad than in the country!

While we focus mainly on medical migration, it is salutary to note that the total number of entries into South Africa increased from 1 million in 1990 to 5.1 million in 1996 and 7.5 million in 2005, mainly from the rest of Africa! (3)

The most recent major source of medical migration from South Africa is a study (4) by Peter Arnold, a South African medical graduate who left to practise in Australia immediately after graduating in 1961. He became president of the General Practitioners' Society in Australia and chaired the Federal Council of the Australian Medical Association. His South African background, later qualifications in politics, philosophy and economics, and chairing of the committee responsible for registering foreign doctors in New South Wales were excellent qualifications to produce this fascinating and insightful book, which I draw on liberally. The book is thoroughly researched with an extensive literature review, and it is profusely illustrated with graphs and figures. However, it is the insights into and understanding of South Africa's unique political and ethnic makeup that make it such interesting reading, and a must-have source for those interested in medical migration.

Approximately 2 000 of South Africa's medical graduates have migrated to Australia. This is equivalent to approximately two years' output from South Africa's medical schools. Roughly one in every 30 doctors practising in Australia graduated in South Africa. Arnold provides evidence of why this can be considered to be a unique migration.

Australia is quintessentially a country peopled by migrants. Of the Anglophone immigrants, the professionals were a minority. The migration from South Africa has differed, as a high proportion have been professionals, including doctors. Skilled migration generally involves 'journeys of advancement', whereas South African emigration is unique as people did not leave primarily for professional, career or financial advancement. This migration of professionals, which commenced on a small scale in the early 1950s, has progressed in ever-increasing waves, triggered by political upheavals in South Africa. This study (4) and the other studies (2,3) indicate that this large-scale medical immigration is set to continue.

There have been four distinct medical migrations from South Africa to Australia. These relate to, among other things, timing, reasons for leaving, reasons for choosing Australia, professional achievement before and after migrating, and family reunion. The earliest migration, with its clear characteristics in all these respects, was heavily Jewish. The latest migration, with its quite different characteristics, is predominantly Afrikaner. Running over all six decades, fluctuating with political upheavals in South Africa, has been the steady flow of non-Jewish, non-Afrikaner whites, and since 1990 there has been a much smaller migration of non-white, mainly Indian doctors. While this immigration is unique for Australia, it is not unique to Australia. Canada has also experienced a similarly significant immigration of South African professionals.

The vast majority of South African doctors who emigrated to Australia since 1948 had decided to do so for reasons relating to their individual positions in South Africa's strange racial/ethnic hierarchy. Motivation for this migration has largely been primarily due to push rather than pull factors. Almost none chose Australia because it offered a better income, unlike the primarily economic inducements that have attracted sub-Saharan, Asian and South American medical graduates to the USA.

South Africa's medical migration is therefore closely tied to our political environment. An important recurring theme is how we treat our respective ethnic groups and value our professionals. More recently the seriously deteriorating public health facilities and services and high levels of crime have played an increasing role. With close to 40% of its many medical graduates having left the country, South Africa leads other African countries in the volume of its medical brain drain. The health sector has been especially hard hit by the brain drain from South Africa. Unless the push factors are successfully addressed, intense interest in emigration will continue to translate into departure for as long as the demand exists abroad --and there is little sign that this will let up. (2)

J P de V van Niekerk

Managing Editor

jpvann@hmpg.co.za

(1.) World Federation of Medical Education. Global standards for quality improvement. http://wiki.ifmsa. org/scome/images/WFME_Standards_Basic_Medical_Education.pdf

(2.) The haemorrhage of health professionals from South Africa: Medical opinions. http://www.queensu.ca/ samp/sampresources/samppublications/policyseries/Acrobat47.pdf (accessed 10 March 2011).

(3.) Migration Health MIDSA Report--December 2009. http://www.queensu.ca/samp/MIDSA_Report_Dar%20es%20Salaam.pdf (accessed 10 March 2011).

(4.) Arnold P. A Unique Migration: South African Doctors Fleeing to Australia. Alexandria, NSW: SOS Print & Media Group, 2011.
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