The Hinged World: Doctors and Diseases on the Move

1. The Hinged World:Doctors and Diseases on the Move Fitzhugh Mullan, MD The Murdock Head Professor of Medicine and health Policy George Washington University St. George’s University 30th Anniversary Symposium November 10, 2007

2. A Linked World and Medical Migration • Disease Mobility • Economic Disparities • War/HIV/Corruption • Human Ambitions • Aging of the Population in the West/North • Health Educational Policies in the West/North

3. The South

4. Pulls to the North and West • Training Opportunities • Practice Opportunities • Better Remuneration • Better Technology • Family Opportunities

5. Push Factors from the South • Lack of Post Graduate training Opportunities • Insufficient Practice Opportunities • Poor Remuneration • Security Concerns • HIV/AIDS

8. Life Expectancy Crisis

9. Workers Save Lives

10. More Wealth, More Workers

11. Health Worker Migration

12. Characteristics of Physician Workforces of US, UK, Canada, and Australia.

13. Regional Emigration Factors in 8 Regions of the World

14. Emigration Factors of Selected African Nations

15. Emigration Factors of Selected Caribbean Nations

16. Emigration Factors of Selected Indian Sub-Continent Nations

17. The North

18. Supply of Active Physicians (MD & DO) and Ratio to Population Actual 1950-1990 and Projected 2000-2020 Physicians Per 100,000 Population Population is U.S. civilian population including possessions

19. Applicants to Allopathic Medical Schools and Enrollment Source: AAMC

20. Number of Residents in U.S. Allopathic Training Programs from 1993-2007 Source: AMA

21. Number of Residents in U.S. Allopathic Training Programs According to the Type of Medical School Attended from 1993-2007 Source: AMA

22. DEFICIT WITH NO ADDITIONAL USMGs or IMGs ~2020-2025 Deficiency ~200,000 physicians (~20%) Demand Supply You are Here Source: RA Cooper

23. Background/Climate Era of medical school expansion New schools – allopathic and osteopathic Increased class sizes Branch campuses AAMC predicts  17% increase in enrollment by 2012 AACOM AAMC predicts  25% increase in enrollment by 20011

24. Source: AAMC

25. Current allopathic schools Planned allopathic schools

26. Current osteopathic schools Planned osteopathic schools

27. Northern Strategic and Moral Role in Global Workforce Stability

28. Health Workforce Stability • Bedrock of health system development • Requirement for HIV treatment and prevention • Prerequisite for public sector health reform • Essential for global health security

29. Health Worker Migration as a Business Proposition • The MD/RN degrees as passports • The privatization of education • The global health professional education “industry”

30. The Success Quandary of Developing Nations • Established Example – The Indian Subcontinent • Emerging Examples -- Nigeria, South Africa, Ghana

31. Previously Proposed Responses • Ethical Recruitment Codes • Emigration/Immigration Regulation • Bonding/Community Service • “Reparations”

32. Emerging Stability Strategies • Domestic Post Graduate Training • Salary Support • Ancillary Support • Car Loans • Housing • Schooling • Creative Use of Mid-levels • WHO/PEPFAR Task Shifting Project

33. What To Do At Home • Move rapidly toward self sufficiency in physician training in the North…5,000 more first year medical school positions in the US • Keep cap on government support for GME positions

34. What To Do Abroad • Support capacity building and twinning in developing countries • Track immigration and set benchmarks of good practice • Promote “reverse flows” • Create and support a US Global Health Service

35. African Proverb • The best thing to do is to have planted a tree twenty years ago • The next best thing to do is to plant a tree today