The Sudanese Medical Exodus

Someone in Khartoum said to me that Sudan has no middle class. Was he right? Is Sudan a socialist idyll, where contentment, fraternity and rational distribution flourish under a red-hot sun?

Well no, Sudan is in fact real country, not some rosy proletarian fantasy. My friend went on to declare that Sudanese society consists of just two classes; there are the elites, sitting up high on top of their mountain, and then ‘everyone else’ living down beneath their feet. Now I don’t think that either of us believed literally in this two-class hypothesis. But whether there are really two or twenty-two social strata in Sudan is not so important for the purposes of this post. Rather it is the feeling which prompted my friend, a doctor, to make his comment. It is this same feeling, of disaffection and disempowerment, which drives one of Sudan’s continuing tragedies, the exodus of health-workers. This blog explores this topic firstly through some facts and figures, to get an idea of the scale of things, and then secondly through considering what social status means across different societies and what some of the ‘push and pull’ factors there are for doctors in Sudan.

1 – In Facts and Figures: Education & Emigration

It wouldn’t be an exaggeration to say that almost every medical student or doctor to whom I spoke on my elective expressed a wish to leave Sudan and to work or study abroad. Most people knew someone who had already left and gone to the UK, US, Europe or to one of the states on the Arabian Peninsula such as Kuwait, UAE or Saudi Arabia. Indeed the issue is so widely acknowledged that one of the Sudanese newspapers even carried an editorial on the topic whilst I was there (Sudan Vision 26th September 2012).

So what is the real scale of this? (Here follows five short paragraphs involving one or two statistics which aim to clarify the scale of the ‘exodus’.)

In a study published in 2005, Mullan lists an ‘emigration factor’ for Sudan of 11.1, i.e. 11.1% of doctors who qualified at home now work abroad in either the UK, US, Canada or Australia (Mullan, NEJM 2005). This proportion is likely to be much higher in reality. Mullan does not consider migration eastwards across the Red Sea, or indeed to Ireland where there are reportedly 600 Sudanese doctors registered with the Irish Medical Council (Ali et al 2012). However, using this estimate of 11.1% yields a minimum figure of 1250 practicing doctors who have left Sudan (anyone who wants to see my working is welcome!). Add to this figure those doctors working on the Arabian Peninsula, in Ireland and those within Sudan who have left the profession before retirement-age for whatever reason and you’re looking at a high number of doctors lost to the Sudanese medical system.

Statistics from 2008 show that Sudan had a total workforce of 10,000 doctors serving a population of 35 million people, which yields a workforce density of 0.28 physicians per 1000 population (which is fairly low) (WHO Global Atlas of Health Workforce). For comparison, the UK has a total of around 160,000 doctors serving a population of 62 million, yielding a workforce density of 2.6 physicians per 1000 population (OECD 2011; Global Atlas of Health Workforce2010).

To increase Sudan’s ‘physician density’ (taking into account an annual population growth rate of 2%), Sudan would need to have a net increase of at least 200 doctors per year (i.e. a positive balance between the number of newly-graduated doctors entering the system and those emigrating or retiring out of it) (UN Data).

This might sound fairly easy and indeed there are grounds for optimism from a statistical point of view. There are reportedly 2-3000 medical graduates each year from around 30 Sudanese medical schools, following two decades of rapid growth in the medical education sector (Fadlalla et al 2012; Ali 2009).

However, there are no available data on the rate of medical migration i.e. how many doctors leave each year, so it is impossible to predict the speed with which physician density in Sudan may increase.

Furthermore an increased number of medical graduates doesn’t automatically equate to more doctors. The percentage of government resources spent on health has decreased between 1995-2010, whilst total government resources are diminished following the separation of South Sudan (WHO Global Health Expenditure Atlas). Indeed I met graduates who had waited for up to a year for a House Officer position. So whilst more graduates might help to fill Sudan’s hospitals, they can also lead to a greater pool of young professionals looking for work, and considering emigration.

2 – The Faces and Feelings: Status and entitlements

Photo of London by Jason Hawkes

So much for the facts and figures, what about people and their motivations? One of the doctors I worked with was a fairly typical example, bright, competent and independent – a pretty good doctor to have in your health system. And she wanted to leave. Her brothers worked in the UK, cousins in the US, an uncle in Kuwait and several friends were now in Saudi Arabia. We discussed her own options outside Sudan; the US medical licensing exams (STEP 1, 2 & 3) are hard and require an extended period of intense studying (on top of making a living). The visa requirements for entry to the UK have tightened over the last few years, and include rigorous English language-, and a different set of medical-, exams. It’s easier to get a visa and a license to practice in another Arabic country, but career progression is slower, as employment contracts for junior doctors often include a commitment to an extended period of work at a junior level.  So wherever a prospective émigré chooses, they must jump, spin and study their way through a whole series of hoops, hurdles and exams without a guarantee of success (e.g. gaining a visa or a job) at the end. So why go through it?

This is where we come back to my friend’s feelings about social relations. On the one hand, students and doctors wanted me to share in their strong affection for their people, country and it’s potential. On the other, they felt strongly that staying in Sudan themselves meant accepting for some years a life of limited opportunity and social stasis.

Without getting too theoretical, there are many ways to analyse a person’s societal status. In simple terms, you might consider the size of their bank balance, house or car. At the more sophisticated end is Amartya Sen’s Entitlement theory which was developed in the context of famine. Here, an individual’s status is effectively defined by their ‘entitlements’ which include all the means they can access, whether legal, financial, moral or whatever-else, to use in getting what they want (Sen 1981). Simplifying and applying this beyond a famine setting to society in general, a person’s status might be defined by all the means and opportunities they have to improve their professional or domestic situation – their chances of gaining a better quality of life.

Graduating from medical school in Sudan does not mean the same things as it does in the UK. In Britain, I don’t think it would be too controversial to say that medical qualification signifies an individual’s accession to a comfortable middle-class status. UK medicine (whatever doctors might grumble), is a well-rewarded profession. It carries a decent salary, robust degrees of domestic comfort and job security, and opportunities for career advancement. It also generally means admission to one of the medical unions, such as the British Medical Association (BMA) or the Medical Defence Union (MDU) which act to protect doctors’ interests. So for UK doctors, entitlements (as defined above) come in all shapes and sizes; financial resources, career mobility (i.e. you can progress up the career ladder) and legal support.

And isn’t this the way it should be? On the one hand, quite apart from the fact that doctors are all delightful people, they actually provide a very valuable service to their community. Shouldn’t they be afforded the advantages proportionate to this social worth? On the other hand, aren’t doctors merely performing their job like another other honest citizen and so should be paid on the same scale? Does a doctor working nine-to-five in an air-conditioned clinic have a harder job than the man who works day and night washing cars? It would be an abuse of doctors’ position to demand more money, no? In fact this second stance is perhaps not too far away from where things are in Sudan.

A hard-working car-washer can reportedly earn more in a month than a junior doctor (around US$500 or ~SDG£95/day). After their first year as a House Officer, Sudanese doctors must then take a pay cut and work without a contract as a ‘General Practitioner’. Career progression to the post of registrar depends on studying hard, saving-up the entrance fee for a further set of exams (e.g. the UK MRCP or MRCS exams) and doing enough shifts to stay afloat. Whilst Sudan does have its own “Medical Specialisation Board”, openings for postgraduate training are acknowledged to be limited and poorly funded. So it’s quite possible to get stuck at this level for several years (although once at the Consultant level remuneration can increase exponentially as opportunities for private sector work arise).

Since they may be unable to get a foot on the property ladder at this stage, doctors often live in hospital accommodation – which may be subsidised or even free – unless they can live with family. Whilst this might be a cheap, convenient and communal option, it is not (to put it one way) exorbitantly luxurious. Neither are the parking nightmares lived by UK healthcare staff a feature in Sudan, since relatively few doctors have cars.

As for legal rights, medical organisations do not function as trade unions and so do not engage in any political action. In 2010-11 doctors’ strikes were organised independently over unpaid salaries, working conditions and accommodation. These were met bluntly with threats, arrests and imprisonment, with no subsequent action taken by the government to address doctors’ grievances (McDoom 2010; Sudan Radio Service 17 March 2010; Sudan Tribune, 18th March 2010, 3rd June 2010, 17th May 2011). The government response to this was perhaps tempered by remembrance of the 1985 revolution overthrowing Sudanese President Jafaar Al-Nimieri, which involved professional unions of doctors, lawyers, bankers and academics.

So overall, many of the entitlements that define UK doctors’ status are rather different in Sudan – whether this is in terms of a salary, a house, a car, job security, professional training and promotional opportunities or legal protection. So are doctors so different from car-washers in Sudan?

Perhaps the defining status symbol is a travel visa. Ultimately, medical knowledge and skills provide greater weight to a visa application than a bucket and sponge. Whilst migration may be difficult for Sudanese doctors, it remains possible. And the significance of a visa application is that it is the first step in reaching out towards the opportunities that exist in other countries.

Solutions (?) & Conclusions

The Sudanese Minister for Health, Dr Bahar Idris Abu Garda, is understandably keen to retain doctors within the health system. International solutions have been proposed including tightening immigration restrictions in countries such as the UK, ethical recruitment policies (i.e. not advertising NHS or BUPA vacancies in Africa) and paying compensation for training costs and labour value to the government of an immigrant. Such ‘solutions’ are likely to be little more than fripperous baubles, glittering briefly for those who glance at this issue, but lacking any impact on the root problems.

Surely the only real solution (and the hardest to achieve), is to begin lowering the mountain, to create opportunity, increase social and professional mobility and to close the gap between the elites and ‘everyone-else’. In other words, it would be better to try and make people want to stay, rather than just preventing them from leaving.

Maybe this starts with greater and more structured investment in the health system. There have been significant achievements already; undergraduate medical education has grown rapidly over two decades. Now postgraduate training and employment capacity need the same level of attention.

Quite how this is to be achieved is difficult to conceive, given Sudan’s reduced national income (since the secession of South Sudan), its high defence spending and the burden of international debt. But the green shoots of regeneration are present in the new cohorts of medical graduates and doctors coming through, with their desire to improve their country. The best response is not to decrease opportunities to leave, but rather to increase opportunities for those who stay.

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References

Agwu, K. Llewelyn, M. (2009) Compensation for the brain drain from developing countries. The Lancet (373) 1665 – 1666

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609609272.pdf

Ali, Z. (2009) The third international conference on medical education in Sudan: lessons about undergraduate medical education. Sudanese Journal of Public Health. 4 (4) 411-413

www.sjph.net.sd/files/vol4i4/SJPH-vol4i4-p411-413.pdf

Ali, Z., El-Higaya, E., Ibrahim, N., Elmusharaf, K., Shadad, A., Elshafei, M. Ahmed, M. (2012) Migration of Sudanese Doctors: Dynamics and Opportunities – Conference Report. Sudanese Medical Association UK and Ireland. 9th June 2012.

www.slideshare.net/SMAUKI/sma-uk-ireland-galway-conference-report-2012

Chen, L.C., Boufford, J.I. (2005) Fatal Flows — Doctors on the Move. New England Journal of Medicine. (353)1850-1852
www.nejm.org/doi/full/10.1056/NEJMe058188

Commission on the Social Determinants of Health (2010) Closing the gap in a generation: Health equity through action on the social determinants of health. WHO. WHO/IER/CSDH/08.1

http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf

Fadlalla, M., Jaffar, R., Abdalgadir, N. (2012) Strategic analysis of the surgical internship in Sudan. Sudan Journal of Medical Sciences. 7 (1) 35-40

www.ajol.info/index.php/sjms/article/view/78155

McDoom, O. (2010) Sudanese security forces beat doctors in protest march. Reuters.

http://uk.reuters.com/article/2010/06/03/idUKMCD332528._CH_.2420

Mohammed, G.K. (2007) Financing health care in Sudan: Is it a time for the abolishing of user charges?  Sudanese Journal of Public Health. 2 (1) 38-47

www.sjph.net.sd/files/vol2i1p38-47.pdf

Mullan, F. (2005) The Metrics of the Physician Brain Drain. New England Journal of Medicine.  (353) 1810-1818
www.nejm.org/doi/full/10.1056/NEJMsa050004#t=article

OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing

www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en;jsessionid=9tamks2ta7noa.delta

Sen, A. (1981) Poverty and Famines: An Essay on Entitlement and Deprivation (Oxford, Clarendon

Press)

Sudan Radio Service (17 March 2010) Doctors Strike in Northern Sudan.

www.sudanradio.org/doctors-strike-northern-sudan

Sudan Tribune (18 March 2010) Sudan’s Bashir threatens to fire doctors on strike over pay.

www.sudantribune.com/spip.php?article34458

Sudan Tribune (3 June 2010) Police in Sudan clash with doctors pushing for nationwide strike.

www.sudantribune.com/spip.php?article35276

Sudan Tribune (17th May 2011) Sudanese doctors go on strike.

www.sudantribune.com/spip.php?article38935

Sudan Vision (26th September 2012) The Brain Drain.

http://news.sudanvisiondaily.com/details.html?rsnpid=214526

UN Development Programme (2011) International Human Development Indicators. Sudan Country Profile. http://hdrstats.undp.org/en/countries/profiles/SDN.html

WHO (2006) Health System Profile: Sudan. Regional Health Systems Observatory – Eastern Mediterranean Regional Health System Observatory.

http://hinfo.humaninfo.ro/gsdl/healthtechdocs/en/m/abstract/Js17310e/

WHO. (2012) Global Health Expenditure Atlas. W 74

Available at www.who.int/nha/country/sdn/en/www.who.int/nha/atlasfinal.pdf

Websites

BUPA – www.bupa.co.uk/

General Medical Council (UK) – Postgraduate Education – www.gmc-uk.org/education/postgraduate.asp

Home Office – UK Border Agency – www.ukba.homeoffice.gov.uk/visas-immigration/

Sudan Medical Specialisation Board – www.smsb.gov.sd

United Nations Data. Sudan Country Profile – http://data.un.org/CountryProfile.aspx?crName=SUDAN

United States Medical Licensing Examination – www.usmle.org/

WHO. Global Atlas of Health Workforce.

http://apps.who.int/globalatlas/DataQuery/default.asp

WHO. Sudan Country Profile

www.who.int/countries/sdn/en/

World Bank. Data, By Country – Sudan.

http://data.worldbank.org/country/sudan

WHO. Global Health Expenditure – Table of key indicators, sources and methods by country and indicators

http://apps.who.int/nha/database/StandardReport.aspx?ID=REP_WEB_MINI_TEMPLATE_WEB_VERSION&COUNTRYKEY=84559

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‘Saving lives on holiday?’ or ‘What is a medical elective?’

The seven weeks in Khartoum will be my medical elective, part of my final year at medical school.  Such placements have been part of medical curricula in the UK since the 1970s. But what are they like?

Should an elective be a chance to have a bit of a holiday and save a few lives for fun? Or a courageous, single-handed slog against all odds for the good of mankind? I rather suspect (and hope) that it’ll turn out to be neither of these. So in that case, again, what exactly is an elective? And what’s the point of it?

If you were to ask me, I’d say that an elective is probably a little like a cross between a gap year and a regular medical placement: A short clinical attachment (i.e. 2 months based in a hospital) abroad or in the UK, which is normally self-selected and self-organised.

Like any of the modular placements which make up training for medical students (e.g. paediatrics or cardiology), an elective provides some important educational opportunities. Various authors have identified several of these medicinally-based benefits, including the improvement of knowledge, skills and confidence, the accumulation of resource- ‘awareness’, and the development of some insight into future career choices*. Overall, in this clinical vein, you could see an elective as a chance to enrich your academic soul through exposure to favourite medical specialties, different teaching or supervision, and new therapeutic experiences.

But like a gap year, it’s also supposed (I think) to be a bit fun! Depending on your destination, your elective is your ticket to leave behind the familiar scenes of the past five years and immerse yourself for a couple of months in a new place, culture, language, and health system. If you play your cards right, you can spend those weeks somewhere you’ve always wanted to visit – whether that’s for reasons of history, culture, family connections, or simply because it’s five minutes away from the world’s best beach! Put this way, wouldn’t it be good if most career paths included an elective period?!

But hang on a minute, is that all there is to it? Education + Enjoyment = Electives? If that was really the whole equation, couldn’t we just substitute in a couple of lectures, a few ward sessions and a holiday for the elective? Be a lot easier to organise wouldn’t it? There must be something more to it, and sticking with the E’s, I’m going to suggest the last component might be called ‘Edge’.

Shouldn’t an elective occasionally push you out of your comfort zone, turfing you out of the cosy certainties of medical school into the precipitous unknowns of the real world? Unlike medical school, where responsibility always lies with someone higher, electives students’ decision ‘to act, or not to act’ may actually mean something. This is where a hint of controversy touches the topic. How far should you as a student go? Where exactly is the edge here?

Whilst on elective, many factors may come into play to increase students’ autonomy. These might include a low staff to patient ratio, limited student supervision with unrealistic expectations of their performance, and a high value attached to clinical decisions (due for example to limited availability of lab tests or specialist opinion). Simultaneously, students may be more frequently exposed to situations and demands closer to the limits of their competence than ever before. Overall, it may occasionally appear as though they wield a new and giddy power over their patients.

Conceivably, an elective student’s decisions may concern whether to attempt a solo-appendicectomy (the answer is no!), which drug to use to treat cutaneous leishmaniasis, whether to act as lead assistant in an emergency caesarean section, or just simply whether to admit someone for observation. The difficulty is in knowing where the edge is, and which path to take in order to avoid pushing both your patient and yourself over it.

A major factor in these situations is presumably your attitude – how you see yourself and your role. I think it can be very difficult, with reasons both plausible and implausible stacking-up to justify you in pushing the boundaries. Isn’t your help better than no help? The chance of life better than the prospect of death? Isn’t it in fact a duty to bring painstakingly-acquired knowledge and skills to bear upon deprived patients and depleted medical systems?

However, whilst such propositions may be beguiling, aren’t they in fact little more than excuses for exercising this new-found power? Surely a more searching question to ask yourself is exactly what help your knowledge and skills would give to a patient’s chances of life?

I would guess that the best solution might begin with trying to keep any surging adrenaline at bay and then, placing your patient’s interests uppermost, quickly consider your capacities and limits. Remember that you’re a medical student! I’m not suggesting that students should never do anything new – they’d never get anywhere, let alone qualify – just that they should be doing things for the right reasons. The acid test is probably ‘if this patient was a member of your own family, would you make the same decision’?

Or is that all too simplistic and short-sighted? Should there in fact be different standards for different settings? If patients live under different realities and have different expectations of health care, then do Western standards just hold things back? Ultimately, I doubt that there’ll ever be a great deal of regulation or evaluation of all this. Different authors have commented on the scarcity of real data or studies of such situations. Until there is more, I guess it remains down to each individual student to evolve their own sense of professionalism, to decide where their own edge is.

After all of that, what will I be hoping to get out of my own elective? Perhaps a little of each of those three E’s! Some opportunities, lots of fun and some chances to learn more about medicine and where I fit into it. I would also like to get to know Khartoum and its people a little whilst I’m there. And why Khartoum in the first place? Well that’ll hopefully be for my next blog…

Will write again soon!

Pete

* If you’re interested then read Dowell, J., Merrylees, N. (2009) Electives: isn’t it time for a change? Medical Education. (43) 121-6

Also some interesting thoughts in the following letter, comment piece and article respectively.

–          Banerjee, A., Banatvala, N., Handa, A. (2011) Medical student electives: potential for global health? The Lancet (377) 555

–          Graham, N. (2010) Elective Ethics. Student BMJ (18) 65-67

–          Edwards, R., Piachaud, J., Rowson, M., Miranda, J. (2004) Understanding global health issues: are international medical electives the answer? Medical Education. (38) 688-90

Khartoum in English – Hello from me!

Summer reading

I’m currently a final year medical student at University College London Medical School.

In September I’m off to Khartoum, Sudan, to spend two months based in one of Khartoum’s main teaching hospitals. This is my medical elective (of which more later).

Whilst I’m there, I hope to keep feeding this blog at least once a week with any little snippets and morsels of what I’m doing, seeing and thinking (assuming anything vaguely noteworthy happens!).

I’m new to any form of blogging, but I’m pretty sure anybody can reply to my posts – so it’d be great to hear from anyone and everyone. Tell me about places you’ve been to, similar experiences you’ve had, things I should (or shouldn’t) eat, see or wear, ask me any questions, or chip in with your own thoughts. In short, stay in touch in whatever way you want!

Before I arrive in Sudan, I’m going try and get in a couple of posts – about medical electives in general, and about Khartoum in particular.

Will write again soon!

Pete.