A doctor torn between serving the poor and a lucrative career in US

Migration of doctors and nurses from poor countries to rich ones elicits a great deal of ethical debate

It was not an unusual death. Kunj Desai, a young doctor in training at University teaching hospital in Lusaka, Zambia, had seen many that were not so different and were equally needless.

Still, this was the one that altered all his plans. “A guy came in, and he had a stab wound,” Desai recalled, “and his intestines got injured.” The operation was delayed, and the wound became infected. “Whatever he was eating would come out of his belly,” Desai said. A carefully managed diet would have helped the man heal, but there were no dietitians at the hospital nor any IV drips of liquid nutrients with which to feed him. “He withered away to probably about 100 pounds when he died.”

The man was in his 30s, and his wife and children would have to fend for themselves. It was 2004, and Desai had worked at the chronically understaffed and underfinanced hospital for a year and a half. The hospital blood bank was often out of blood, and the lab was unreliable.

The patients were often so poor that Desai would pay for private lab tests out of his own pocket. Desai came home in tears one day after being unable to save a premature baby boy.

When the man with the stab wound died, the accumulation of preventable deaths – at what was, he kept reminding himself, the best public hospital in the country – finally became too heavy to bear.

“We were pretending to be doctors,” Desai, who is 35, told me when we first met. This was in the cafeteria of University hospital in Newark, N.J., and Desai was still in his surgical scrubs after a 30-hour shift. He talked about what he saw in Lusaka in the somewhat stream-of-consciousness way that war veterans sometimes speak about the battlefield. “What was I really doing?” he said. “Making myself feel happy? No.”

As an idealistic, energetic young doctor, Desai imagined he would spend his career in Zambia, serving those in desperate need. But over the months at the hospital, he found himself fantasising about another life – as a doctor in America. And in 2004, after he finished his internship, Desai quit his job at the hospital and began studying for the exams for a training position at an American hospital. Even while he did so, he told himself that after his stint in America, he would return to Zambia. His fellow Zambians, he knew, suffer from some of the gravest health crises in the world, not least of which is that Zambia’s doctors tend to leave the country and never come back.

Two years from now, Desai will be a fully qualified surgeon in America. He has a wife and a young daughter (he had neither when he moved to the US), and once he’s qualified, he can expect to make a very good living – the median salary of a surgeon in New Jersey is $216,000.

In the main hospital in Lusaka, where Desai worked, a surgeon makes about $24,000 a year.

The uncomfortable question that Desai put to the back of his mind when he arrived in the US has begun to resurface and trouble him: Will he really fulfill his promise to himself and his country?

As we sat in the cafeteria, I suggested that if he did return to Zambia, he might be seen as something of a returning hero. He looked at the table and said: “The heroes are the guys that stayed. They didn’t quit, and they didn’t run away.”

In a globalised economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America’s best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the US to work for American companies. And the US, with its high salaries and technological innovation, is also the world’s most powerful magnet for doctors.

The migration of doctors and nurses from poor countries to rich ones elicits some highly emotional responses, not to mention a great deal of ethical debate. Writing in the British medical journal The Lancet in 2008, a group of doctors, several of them from Africa, titled their paper “Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime?” They concluded that it should. Other critics have used terms like “looting” and “theft.”

Show of dishonesty

Some of the anger is directed toward the doctors who leave. The managing director of University teaching hospital in Lusaka, Lackson Kasonka, suggested to me that doctors who received government financing for their educations and then left exhibited “a show of dishonesty and betrayal.” (Desai is not in this group; his parents, who immigrated to Zambia, paid for his medical education in India, where they were born.) Peter Mwaba, the most senior civil servant in Zambia’s ministry of health, said that doctors overseas should not “hold their country to ransom” by staying away until things, in their minds, sufficiently improve.

The public health challenges in Zambia are intimidating: Life expectancy is 46, more than 1 million of Zambia’s 14 million people are living with HIV or AIDS and more than 1 in 10 children will die before they reach 5. To cope with this, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the US. If Desai decides to stay in the US, the world’s richest country will have gained a bright young doctor.

The loss to Zambia will be much greater.

The medical brain drain from poor countries gets a fair amount of attention in international health circles, and initiatives both private and public are trying to resolve the shortage of doctors. The teaching hospital in Lusaka where Desai trained, for example, is one of 13 sub-Saharan medical schools receiving support from a US-financed $130 million program to generate more and better graduates. 

Had Kunj Desai stayed in Zambia, his experience might have looked like that of his old friend Emmanuel Makasa. An orthopedic surgeon, Makasa is 38 and earns about $24,000 a year. He does some work in private clinics for extra money. Makasa is something of an authority on the emigration of doctors. “The human-resource crisis in Zambia has reached a disastrous stage with the health system at breaking point,” Makasa wrote in a 2008 paper in The Medical Journal of Zambia, though he has no harsh words for his colleagues who left. He studied at the University of Alabama, Birmingham, on a Fulbright scholarship and also took and passed the first of two exams the British require of international medical graduates seeking jobs there. He told me that he had been tempted to emigrate permanently.

But during his time living in the US and visiting Britain, he felt subtle racism. He hated the weather in Britain and found Zambian doctor friends living stressful lives in undesirable parts of the country. And he knew the difference a single surgeon in Zambia could make. So his American wife and their two daughters moved to Zambia at the end of 2010.

“There are very few doctors in this part of the world,” Makasa told me, “and if you left, yeah, it means you have a better life. Yes, you get more money. Yes, but you can’t enjoy a meal when you know your mother is hungry.”

In 2005, Makasa and his colleagues set up Doctors Outreach Care International, which provides medical care to underprivileged communities and is financed by corporate sponsors. “I don’t stay in Zambia because of lack of opportunities to go,” Makasa said. “I stay in Zambia because of what I think I can do in Zambia.”

Kasonka, the managing director of the hospital, said that he didn’t blame Desai for leaving to pursue his surgical education. As we spoke in his office, I told him that Desai wanted to become a laparoscopic surgeon. At that, Kasonka sat forward in his chair with interest.

Zambia, he said, had no surgeons performing this less-invasive surgery, though the Netherlands had recently donated a laparoscope.

“If I have to say something to Dr Desai, it is: ‘Hey, Dr Desai, I know you have now acquired extra skills in surgery including laparoscopy,”’ Kasonka said. “I have got a state-of-the-art laparoscope – please come back and practice.' You see, he will pack up his bags and come back.”

When I returned from Lusaka last May, I went to visit Desai at his home in Jersey City. His wife, Bhavana, a pharmacist who also is Zambian of Indian descent, and their 17-month-old daughter, Kaiya, greeted me at the door. Desai turned up a few minutes later, in scrubs, after a 14-hour shift.

Way to go home

Desai feels a strong need to help his country. “It is still my homeland,” he told me when we first met. “It is still where I plan to die. I have spots picked out where I plan to retire.” In our conversations and email, Desai seemed to be exploring a way to go home. He’s an only child who worries about abandoning his parents in their last years, and he wants Kaiya to grow up as a Zambian, not as an American. But he despairs of the public health system in Zambia and can’t stomach the idea of catering to the wealthy in the private sector. He talked of returning to open up his own private clinic, which would serve everyone, not just the wealthy. Or perhaps he could work for a foreign aid agency there, he said.

Desai’s enthusiasm for each alternative, however, seemed limited and fleeting – as if he recognized that his contradictory desires were never going to be fully resolved. “I’m so caught up in my day-to-day stuff,” he said. “It’ll be 30 years from now, and I’ll wake up, and I’ll be like, ‘Whatever happened to my idea of going back?”’

I wondered if he would be at all encouraged to change his plans based on what I found at the teaching hospital. We sat in front of my computer at his dining table. He drank a beer while I showed him photographs of the hospital and told him what I found there. He was pleasantly surprised by the images of the newly equipped ICU, the renovated operating theaters and dialysis machines, and he was disheartened by my photographs of packed wards and accounts of broken elevators. I showed him photographs of the Bosch power drill in action.

“Oh, it’s fantastic,” he said, laughing, appreciative of his former colleagues’ resourcefulness.

He noted that the power drill was in fact a big step forward from the manual drills he used when he worked at the hospital. When I told him about Kasonka’s new laparoscope and the managing director’s offer to give Desai full access to it if he chose to return, he was surprised.

But his surprise almost instantly gave away to skepticism. “Sounds great, but, yeah, we’ll go back, and how long will that work?” Desai found it hard to believe that the laparoscope and other equipment required for keyhole surgery would be properly looked after. He took a gulp from his bottle of beer. “The fundamental flaws and root causes are there.”