Stemming the Flow

Health worker brain drain to industrialized nations has been receiving attention, but less often discussed is the depletion of developing country research talent

By Sheri Fink, MD, PhD*

Several years ago, Dr. Veronica Mulenga, a Zambian physician, was offered a two-year research training fellowship at Miami University. She gained her research skills in well-run, state of the art facilities. The situation when she returned home was markedly different. "A lack of equipment, erratic supplies of reagents, even drugs," says Mulenga, now a consultant pediatrician at the University Teaching Hospital in Lusaka, where she conducts clinical research on critically important treatment parameters in HIV-infected children. While Mulenga has toughed it out in less-than-ideal conditions, she says many of her colleagues have made a different decision: they are no longer working in the country. "They become frustrated with the systems they come back to—poor administration, poor objectives," she says. "Quite a lot of people return and then leave again because of frustration."

This phenomenon, often referred to as brain drain, is attracting increasing international attention, with conferences, declarations, and programs dedicated to stemming the departure of professionals from their posts in resource-poor countries. Most of these efforts have focused on healthcare workers after the massive scale-up of AIDS treatment programs in developing countries laid bare the shortage of qualified clinicians needed to implement them. However, relatively little attention is being paid to what many view as an analogous and related phenomenon of brain drain in the health research sector. Available evidence suggests that a significant proportion of biomedical and clinical researchers from developing countries leave their countries of origin or never return after training abroad. The result is a shortage of qualified scientists needed to investigate health problems of national importance, track illnesses, evaluate clinical programs, collaborate with international researchers, improve health systems, inform public policy, and train succeeding generations of researchers and technicians.

Large-scale problem

The US has the largest number of working scientists and engineers of any country, but over a third of those who hold doctorates and well over a quarter of those with masters degrees are foreign-born. According to US census figures from 2000 analyzed by the National Science Foundation (NSF), they hail, in large part, from low- and middle-income countries (National Science Board; Science and Engineering Indicators 2006). This trend may well continue. NSF surveys indicated that about three-quarters of all foreign-born doctoral students planned to stay in the US after receiving their science or engineering degree. The situation is similar in other developed countries.

Clearly, brain drain is one of the reasons that developing nations are home to relatively few highly trained researchers. More than two-thirds of the world's researchers live in developed countries. Staggeringly few researchers live in the least developed countries—only 4.5 researchers per million inhabitants. That compares with 374 researchers per million inhabitants in other developing countries and 3272 per million in developed countries (United Nations Educational, Scientific, and Cultural Organization, Science Report 2005). Often researchers from developing countries have received government support for their higher education and so their departure also represents a loss of investment for their countries.

Weighing the effect

Some social scientists have argued that the migration of researchers from developing to developed countries can have positive implications for their home countries. Well-paid professionals send money home, and they help set research agendas in powerful nations and within development agencies. In fact, experts suggest that the cyclical movement of researchers between countries might actually lead to 'brain gain' for poor countries through the sharing of knowledge. Further, the prospect of enjoying economic opportunities abroad might encourage children in poor countries to obtain higher education.

Some commentators have even questioned the need for qualified researchers to be well-represented across the globe—building research infrastructure requires significant investments, and specialized research programs cannot exist everywhere.

However, a strong domestic research and development capacity in science and technology is tightly linked to economic development. The leaders of highly industrialized nations understand this, and the loss of their own trained researchers concerns them. In recent years the European Union has undertaken several major efforts to plug the brain drain of European biomedical researchers flowing to the US. In some countries, including China, India, and the Gulf States, political leaders are endeavoring to build the research workforce with the understanding that it will contribute to sustained development.

When it comes to developing countries, there are many reasons why indigenous researchers are needed at home. "We're in a better position to know conditions that are very common here and that matter to us and therefore need to be researched," says Mulenga. The capacity to set national research priorities—and devote funds to them—can be critical for developing countries because many of the major medical problems affecting their populations have traditionally escaped the interest of northern research institutions. This problem has been termed the '10/90' gap, reflecting studies in the 1980s and 1990s showing that less than 10% of global health research money was being used to investigate 90% of the world's health problems.

As support grows for AIDS, tuberculosis and malaria programs, the scales may be shifting but they are still far from balanced according to experts at the Council on Health Research for Development (COHRED), a Switzerland-based international organization devoted to building health research capacity in resource-poor countries. Critical under-investment in health research relevant to problems common in low- and middle-income countries persists. Developing country problems such as malnutrition, childhood disability, and the impact of local environmental degradation on health have received little attention from researchers in industrialized nations, according to COHRED director Carel IJsselmuiden of South Africa. These areas of research will remain neglected, he says, "unless there is some kind of national ability to decide on priorities, conduct research, and find appropriate partners in the north to do it with you."

Sometimes developed and developing country medical research interests coincide, such as with HIV/AIDS and tuberculosis. Here again, the existence of highly trained researchers in developing countries offers distinct advantages. As collaborators they can facilitate the conduct of research in their home countries, settings with a high prevalence of infection and an epidemiological context where new drugs, diagnostics, or vaccines could one day prove most useful. "When it comes to the people you're studying, you're in a better position to know them, know their culture and the ways they understand things," says Mulenga. That helps indigenous researchers ensure that prospective volunteers receive the information they need to provide truly informed consent.

Involving these researchers also increases potential volunteers' trust in the research program, says Pat Fast, director of medical affairs at IAVI. "We want populations and governments to trust that research is conducted appropriately, both from an ethical and a scientific standpoint, so if the research provides a vaccine it will be quickly accepted," she says. "That's best done by having researchers from the country or region conduct the research."

Push and pull

Brain drain occurs due to push factors that drive researchers out of their jobs or native countries, and related pull factors that entice them into other jobs and other nations. Budding scientists often leave their countries to pursue advanced studies and many of them fail to return home. A study released by AfricaRecruit in May 2006 found that nearly half of around 600 African diaspora healthcare professionals listed higher education as the top reason for their migration. The next most common reason was the prospect of professional career advancement, which is often limited in home countries. "There's a major deficiency in career structures," says IJsselmuiden. "Even if you are a good researcher and there is political stability, it's still difficult to move up." Promotion is often based on seniority and factors other than merit. "There's more emphasis on who you are and where you came from," he says.

Career advancement is also hindered by poor working conditions in some developing countries. According to the African Health Researcher Forum (AfHRF), African countries on average spend less than 0.5% of their national health budgets on research, an exceedingly tiny amount given that only 1% of total gross domestic product is allocated to health in the first place (Lancet 360, 1665, 2002). Researchers who trained in the sparkling, high-tech laboratories of North America are not used to the spartan infrastructure they'll face back home. Shortages in supplies and equipment, poor management, and an insufficient number of technicians take a toll on researcher productivity, says Professor Job Bwayo, principal investigator at the Kenya AIDS Vaccine Initiative in Nairobi. "They do very well when they're outside, actively involved in research," he says, "but as soon as they come back they lose that because the environment doesn't encourage their research." Studies have offered evidence supporting Bwayo's assertion. Developing country researchers based outside their countries of origin have a significantly higher rate of scientific publication compared with those based inside.

The low priority that some countries place on research is reflected in a common complaint among scientists—that policymakers tend to ignore or dispute their findings. Recently a team of Ugandan and US scientists as well as two other independent research groups found that male circumcision can dramatically decrease HIV transmission. This exciting finding is being further investigated and its potential implementation intensely discussed. Even so, President Yoweri Museveni of Uganda reportedly was skeptical of the conclusion. "By and large the government doesn't know what [researchers] are doing," says IJsselmuiden. "It doesn't get translated into useful knowledge for policymakers to work with." This, too, contributes to brain drain. "If you do research and don't see action taken, you want to go somewhere else."

Salary differentials also play major a role in brain drain. Researcher salaries are notoriously low in some developing countries. Steven Wayling manages research training grants at the Special Programme for Research and Training in Tropical Diseases (TDR), a scientific collaboration founded in 1975 and co-sponsored by several UN agencies and the World Bank. Wayling says that some physicians accepted into TDR's PhD training programs have declined to participate. "They say, 'I know I can't earn money as a researcher, so I have to stay in clinical practice and support my family.'"

The need to earn a living wage drives some trained scientists to give up research and take other jobs in their countries, sometimes called 'internal brain drain.' The term is controversial because it is often used to describe researchers who jettison government research in favor of positions with international research initiatives or commercial enterprises. "Researchers who would be able to spend time on [research aimed at benefiting local health systems] are drawn out to projects funded by outside donors," says IJsselmuiden, and he views that as a "major international problem." Mulenga says this extends beyond scientists to research technicians. "Here we have quite a number of NGOs from the US who are running a lot of health projects," she says. "These have managed to attract quite a number of skilled technicians from government laboratories into NGOs."

The pull factor of international recruitment is an often-cited factor in clinician brain drain, especially the efforts of European countries and the US to compensate for critical nursing shortages. Recruitment of researchers may not be as targeted, says IJsellmuiden, but "there's lots of open competition going on. There's no inhibitor for attracting good quality African, Asian, or Latin American researchers into your organization." Special visa categories in the US promote the immigration of highly skilled professionals, including biomedical scientists.

Brain gain

While the UK has issued a ban on recruitment of nurses from developing countries, experts caution against analogous bans against researchers from developing countries. "It's OK for someone in America to go to Europe, whereas it's not OK for an African to go to Europe?" asks Wayling. "It's like two standards." Some researchers move to escape war and persecution in their home countries. Whatever the reason for migration, many experts believe it is important for researchers to circulate, share knowledge, and expose themselves to different learning environments throughout their careers.

Numerous studies have found that the majority of expatriate professionals wish to return to their own countries, and an even greater proportion wish to contribute to them in some way (Science 310, 1602, 2006). They often report that they do not know how, and their native countries have failed to reach out to them. "Those scientists should be supported and encouraged to come back and participate in the research of their own countries," says Bwayo. He says scientists working abroad have been steeped in a "culture of research" they can share back home by mentoring and teaching the next generation. A number of programs have been established to help expatriates share their skills in their home countries. These include AfricaRecruit, UNDP's TOKEN project, and 'diaspora networks' of professionals from various countries. The governments of Singapore, China, and some Eastern and Western European countries are promising top salaries to lure their expatriate scientists back home.

Steps to counter brain drain are also being taken much earlier, beginning with the initial education of a scientist. Training programs, which used to involve several years abroad in Europe or the US, are increasingly offered by developing countries such as Brazil, Nigeria, Kenya, Mali, Thailand, Malaysia, and the Philippines. Researchers who do train outside their countries—with support from their governments or international donors—often must agree in advance to return home and work for a certain minimum period. Using this method has allowed countries such as Thailand to build up a globally-competitive talent pool while investing in research institutions. Some funding agencies, including TDR, carefully select trainees based less on personal ambition and more on potential to contribute to their countries. "Anyone who applies already has to have a permanent job in a research institution," says Wayling. "They have a position to return to and a career path." TDR supports many of the steps on that career path. Trainees can apply for US$40,000 re-entry grants to help them set up research programs back home. Support is made available to strengthen institutions. Ultimately, many of the graduates win competitive research grants from TDR and other funding agencies. The funds allow them to upgrade their equipment, supplies and facilities, and increasingly to train their own scientists and those from other developing countries. Not surprisingly, TDR boasts a near-100% retention rate of the 1500 or so PhDs it has supported over the past several decades.

A few other groups do similar work in Africa, Asia, and Latin America, including the Special Programme of Research, Development and Research Training in Human Reproduction (HRP) of the World Health Organization; the International Clinical Epidemiology Network (INCLEN), initiated by the Rockefeller Foundation; the NIH's Fogarty International Center for Advanced Study in the Health Sciences (FIC); and the Field Epidemiology Training Program (FETP), promoted by the US Centers for Disease Control and Prevention). Efforts range from training and supporting local scientists to facilitating access to scientific literature, communications, and exchanges, as well as promoting the uptake of research results by governments and the general public. The AfHRF and other developing country institutions are similarly engaged in building capacity, improving the quality of south-south and north-south collaborations, giving developing country researchers a voice in setting and implementing the global health research agenda, and empowering African scientific publishing.

Some developing country scientists say that collaborating with well-funded teams of foreign researchers has made it much easier for them to stay in their countries. KAVI's Bwayo says that international collaboration with IAVI has brought supplies, equipment, reagents, training, presentations at international meetings, and—just as importantly—salary support. "That's the one best thing that's been done," he says. "There's no incentive for us to go anywhere else." Likewise, there's no incentive to do anything else. Government researchers often supplement their meager salaries with more lucrative work in private medical clinics. The additional income from IAVI makes that unnecessary. "That income compares favorably with that of colleagues doing surgery or obstetrics," Bwayo says. "I don't have to moonlight. I don't have to spend time working in evening clinics... I can do research full time."

International collaborations have their share of problems and frustrations for national scientists. In some cases, the internationals run the show from start to finish-from designing the research to analyzing and disseminating the data. "They have their own research agenda, and locals don't participate in deciding what that should be," says Bwayo. "They only use the locals as a front to allow them to conduct research in the country." Some national scientists complain that international researchers tend to collaborate with the same set of "usual suspects," therefore limiting the potential to build capacity in younger generations of scientists.

Looking to the future

Northern and southern researchers have learned from these experiences, and many now recognize that mutual respect and capacity-building toward self-reliance are critical features of successful collaborations. "The most important thing that we all need to help with is to provide a career path for researchers who want to stay in their countries," says Fast. That involves building up both researchers and their institutions. "This is not something one research organization can completely achieve."

IJsselmuiden agrees. He points out that some developing countries maintain dozens of research contracts with a range of funding agencies. Most of these collaborations include a training and capacity development component, but the various efforts are uncoordinated. A more efficient and sustainable approach would be for donors to work together to support research infrastructure, including universities, local research councils, and perhaps regional centers of excellence. "Integrate vertical programming with horizontal system building," he says. "You build up programs that serve more than one research program." That way an epidemiologist trained in the context of an AIDS vaccine trial could transfer her skills to another research program once the original trial is completed. "More can be done to make sure health research [contributes to] a country's development, not just product development," IJsselmuiden says, and he hopes TDR will play a "brokering role" between donors interested in integrating their work in this fashion. The Commission for Africa Recommendation on Governance and Capacity Building recently called for $500 million a year over 10 years to build Africa's higher education institutions and $3 billion over 10 years to create centers of excellence in science and technology.

There are also steps that international finance institutions can take to counter brain drain, such as removing tight caps on recruitment and salaries. However, most experts are calling for commitment from political leaders, the local private sector, and national research systems themselves to support national researchers. Capacity-building in biomedical and clinical science must be included in national plans, and research institutions must commit to be accountable, transparent, and sensitive to national health priorities. Only with a self-sustaining research enterprise will developing countries be able to guide the research agenda rather than follow the agendas of whoever funds them.

Ultimately, though, the balance of brain drain to brain gain will depend on the individual decisions of researchers themselves. Job Bwayo, like Veronica Mulenga, has decided to focus his efforts at home. "I can make my maximum contribution to this country by working in this country," he says. "I don't ever want to leave." With AIDS taking an ever larger toll on the continent's talent, hopefully an increasing number of researchers will feel the same.

This article was researched and written in December 2006. Tragically, Professor Job Bwayo was murdered in Kenya on February 4, 2007. A full obituary will appear in the next issue of IAVI Report.

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*Sheri Fink, MD, PhD, is a freelance writer whose work has appeared in such publications as The New York Timesand Discover Magazine, and the author of War Hospital: A True Story of Surgery and Survival.