Unbelievable is simply the only word that can describe this article in the Lancet. Citing problems with retention of doctors in under-treated populations in Africa, Mills et al. argue that direct recruitment of doctors by groups in the West should be criminalized and the individuals perpetrating it prosecuted in the International Criminal Court.
The authors present clear and compelling data to support the assertion that there is a brain drain of health care workers from Africa. Further, they show that this brain drain is exacerbating an already severe doctor shortage in Africa. Thus, the brain drain will have inevitable consequences for Africans, not the least of which is that a lot of people are going to die.
I do not dispute any of these findings. (Kerry Howley, writing in the LA Times, does, however.
He She argues that the brain drain is not the real source of health care shortages. Read the whole thing.)
What I find absurd is the solution that they propose.
Although the active recruitment of health workers from developing countries may lack the heinous intent of other crimes covered under international law, the resulting dilapidation of health infrastructure contributes to a measurable and foreseeable public-health crisis. There is now substantial evidence of state and organisational involvement in active recruitment of health workers from developing to developed nations.
There is no doubt that this situation is a very important violation of the human rights of people in Africa. In recent years, international law has developed the notion of international crime to strengthen the accountability of individuals for serious violations. One indication of the gravity of acts and that they deserve treatment as international crimes that has been developed by the International Criminal Court is that they create social alarm.
Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm: the practice should, therefore, be viewed as an international crime. Recruitment of health workers from Africa is an structured initiative led by recruitment organisations, but clearly sanctioned by countries that then accept these placements, such as Australia, Canada, Saudi Arabia, the UK, the United Arab Emirates, and the USA. Active recruitment is considered unethical under many national policies, leads to negative health outcomes, and undermines the right to health as asserted in the Universal Declaration of Human Rights, various International Covenants, and numerous declarations and legally binding treaties including the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women. (Citations removed. Emphasis mine.)
When the international community permits for-profit companies to actively entice overworked and often underpaid workers away from the most vulnerable populations, it is contributing to the deterioration of essential health-care delivery. Improvement of the health of the world’s poor is a challenge that the international community is failing to adequately address. Current international treaties and commitments are severely compromised if we are unwilling to adhere to their principles and prevent obvious harms to poor people. Clear, enforced regulation is needed to prevent recruitment companies from enticing health workers away from their local work, and developed countries should adequately compensate less-developed countries for the human resources they have lost and continue to lose.
Let’s set aside the practical issues of whether it is even feasible to withhold information from these individuals about the benefits that can be gained from moving to the West. Let’s set aside trying to justify a standard that a crime is something that “creates social alarm.” (How the Rule of Law is to be maintained under such a standard is utterly beyond me.) Finally, let us set aside that international organizations and agreements consider it unethical to help someone improve their lot through recruitment.
What I am aghast at is the cavalier attitude that this article expresses towards the rights of the health care workers in question. In indicating that the health care worker “poaching” violates the rights of Africans, in what way are they construing the rights of the health care workers? Have they concluded that the nations in question are entitled to their own health care workers? Are they implying that the health care workers are a nation’s property?
True, they do include the obligatory homage to the health care workers’ rights:
We, of course, recognise that while there is a right to health for everyone, there are also health-workers’ rights to consider. Health workers should have freedom of movement and choice of where they live and work, just as any workers should.
However, this admission contradicts what they say about the rights of African citizens demanding care. Let me make this clear. The authors assert that the individuals in Africa have a right to health care. On the other hand, they assert that the health care workers have right to mobility and the right to pursue a career under any circumstances they find most fortuitous. Does the health care workers right to mobility not include the right to converse with and interact with any organization they choose? The authors seem to suggest that the health care workers should exist is some sort of socially beneficent darkness in which they have rights but no knowledge by which they could appropriately exercise them.
Defenders of this proposition might respond: it is not the rights of the health care workers we would like to curtail. We just want to limit the deleterious behavior of other individuals in the West who would steal them away. Let me give you three reasons this definitely has to do with the rights of the health care workers:
- First, the notion that they are “stolen” or “poached” or “lured” implies that their natural location is in their country of origin. This implies ownership of those individuals by the state.
- Second, each worker has the potential to have a considerably better life in the West. For every active impediment that they place in the way of achieving whatever aspirations they desire, they are in essence placing a fine on them. Worse it is placing a fine on them for an utterly arbitrary reason: where they were born.
- Third, the exchange of information between the recruiter and the recruited is a transaction. Transactions include two willing participants. You cannot penalize one without affecting the other.
This whole debate reveals why the notion of health care as a positive right is preposterous. Health care is provided by the labor of individuals. As a consequence, it is a product with a non-infinite supply. In asserting that health care is a right, you assert the right to appropriate the produce of the labor of others. You positive right contradicts their liberty.
The American concept of [rights]…is officially stated in the Declaration of Independence. It upholds man’s unalienable, individual rights. The term “rights,” note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with–and that anyone who violates a man’s rights is: wrong, morally wrong, unsanctioned, evil.
Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That’s all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald’s, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights–and only these.
Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want–not to be given it without effort by somebody else.
The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.
To take one more example: the right to the pursuit of happiness is precisely that: the right to the pursuit–to a certain type of action on your part and its result–not to any guarantee that other people will make you happy or even try to do so. Otherwise, there would be no liberty in the country: if your mere desire for something, anything, imposes a duty on other people to satisfy you, then they have no choice in their lives, no say in what they do, they have no liberty, they cannot pursue their happiness. Your “right” to happiness at their expense means that they become rightless serfs, i.e., your slaves. Your right to anything at others’ expense means that they become rightless.
Caveat #1: I am not saying that health care is not highly desirable and that we should take steps to ensure the creation of more of it. Quite the contrary, I think that by treating it as a non-good that will always be there when we need it, we have diminished its supply. When a good is desirable, you need to pay more to get it. People tend to assume that because health care is important, it will just appear by spontaneous generation when they need it. This clearly is not true.
Caveat #2: Nor am I saying that health care delivery in Africa — particularly with respect to HIV/AIDS — is not a very serious issue that deserves immediate international attention. I probably differ from the hardcore libertarians and Objectivists with respect to this issue. Most would argue that since it is not our moral bad, we have no horse in that race. We have no moral imperative to act. While I don’t feel ethically obligated to save everyone suffering in the world, I think it is bad policy to let millions die without doing something. It would very likely lead to instability and unfortunate consequences for all of us down the road. Call it enlightened self-interest.
What I am saying is that this policy would necessarily curtail the rights of the health care workers in Africa. Further, the only policy that I know that would help solve this problem without violating someone’s rights is to organize the incentives so that health care workers find it desirable to stay in Africa. That’s right. In order to fix this problem, we are going to have to pay for it. The frustrating part is that the authors mention this very strategy:
To encourage the retention of health workers, governments and policy makers need to use incentives and to address the reasons for migration: low salaries, inadequate resources, long hours and heavy workloads, a threat of infections and violence, and lack of career development.
Why they couldn’t have written a piece suggesting this solution and only this solution is genuinely perplexing to me.
Organizing incentives such that is better for health workers to stay is not only the only reliable way to solve this problem, it is the only ethical way to solve this problem.
Hat-tip: LA Times