The result is that Africa and to a lesser extent India now effectively subsidize medicine in the U.S. and Britain. Ghana, Malawi, and Zimbabwe are among 16 African nations with more doctors practicing outside their countries than in them. In recent years the number of nurses leaving Malawi for jobs has outstripped the number graduating from nursing school. The medical brain drain is a problem being discussed by the G8 forum of the world's richest countries, the WHO, and Harvard University, among others.
But enticing doctors and nurses to stay home may not be the answer to the health care crisis in poor countries. I asked Nils Daulaire, the head of a U.S.-based group called the Global Health Council, what can be done about the fact that there are only, for example, roughly three doctors for every 150,000 people in Malawi.
"Can we get it down to two? Or one?" he said. Daulaire was only half joking. Doctors, he says, are not the solution for the world's poorest people. Even if they do not emigrate, doctors stay in the cities. In Malawi half of the country's doctors work in just one of four hospitals in major cities, although Malawi is about 85 percent rural. With a handful of exceptions, doctors in poor countries become doctors for the same reason most people all over the world do: to make a good living. If Malawi or India does succeed in recruiting a doctor for a health post in the countryside, chances are that a patient looking for him there will not find him. He will be in the capital, treating patients who can pay.
Even doctors who do treat villagers, moreover, rarely spend time teaching them about nutrition, breast-feeding, hygiene, and using home remedies such as oral rehydration solutions. They don't help villages acquire clean water and sanitation systems or improve their farming practices—ways to eliminate the root causes of disease. They don't work to dispel myths that keep people sick. They don't combat the discrimination against women and low-caste people that is toxic to good health. Doctors also present a powerful institutional lobby that can block the real solution for places like Jawalke: training villagers like Sarubai Salve and Babai Sathe to do all these things.
"Doctors promote medical care because that's where the money is," says Raj Arole. "We promote health." The distinction is crucial to Arole, 75, a doctor himself, and the founder, along with his wife, Mabelle (who died in 1999), of the program, known as Jamkhed, that trained Salve and Sathe. The Aroles graduated top in their class from one of India's most prestigious medical schools, Christian Medical College in Vellore, Tamil Nadu. "They were trying to impose an education that would make you a good doctor in France or Germany," says Arole. But the Aroles had a different goal: to promote health among the poorest of the poor. They worked at a mission hospital, then did their residencies and studied public health in the United States.