To return or not to return

Dr Joseph K MathewEmergency & Trauma Physician

Alfred Health

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Global problem

• Genuine medical migration (90 %)

– Universal Declaration of Human Rights of 1948 says “Everyone has

the right to a standard of living adequate for the health and well-being

of himself and of his family”

– To refuse emigration would be a violation of the individual’s autonomy

– Dissatisfaction with services in their country

– Better salaries

– Training opportunities

– Working conditions

– Resources 2

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Global numbers

Government sponsored (8-9%)

– “Bonded”

– Financially supported

– Scholarships

– Majority from Middle East African nations

– Larger developing countries like China, India & Brazil have lesser

government sponsored long term trainees

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Global numbers

Freelancers with special interests (1-2 %)

– Special interests in research

– Development of new specialty

– Development of state to state and institution to institution

understanding

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Australian numbers

Australia differs in the proportion of these doctors it takes from

lower-income countries:

– Only 40 per cent,

– Compared with 75 per cent in Britain

– 60 per cent in the US.

In Australia the largest source of foreign-trained doctors

– Britain (8.6 per cent of the workforce)

– India (4 per cent)

– New Zealand (3.2 per cent) and

– South Africa (2.3 per cent) 5

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How it affects

• Results in a “large number of people having their access to health

care withdrawn”

• "There is a growing global concern about the large variation among

the world's nations in the availability of physicians and the negative

impact of the scarcity of physicians on health equity,"

Professor Fitzhugh Mullan - NEJM

• "If a country has a fragile health system, the loss of part of its

skilled workforce can bring it close to collapse"- WHO 2006 7

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Ethical issues

• “How is it decided if one person’s autonomy to make a choice that affects them is a

greater or lesser right than a much larger number of people’s right to health care?”

• Brain drain

• 70% train in public medical institutions –subsidised medical education

• What is socially justifiable in today’s globalized world is currently a topic of much

debate and controversy

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Personal story

• MBBS 1991-95, Christian Medical College, Ludhiana.

• Mission hospitals in the north and south of India

• Living in the wild (medicine in the rural areas of India, Rwanda,

Afghanistan, Uganda, higher Himalayas)

• Interest in Emergency Medicine- specialty not in India

• The next best thing - Surgery -Masters in general surgery (MS,Upper

GI surgery)

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Personal story

• Interest in developing emergency medicine & integrated trauma

services

• Involved in the setup of the first paramedic service and the first

mobike ambulance service AMARS in India

• Personal decision to train in Emergency and Trauma Reception &

resuscitation

• Train in Integrated trauma services

• A period of intense searching to find the right place to train

• Applied to Australia specifically due to the perceived robustness of

training and the Alfred’s reputation in Emergency &Trauma care.

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Personal Story

Strong involvement with key stake holders in India

– Christian Medical college,Ludhiana

– Neurotrauma Society of India

– State governments (Kerala, Punjab)

– Central government ( Cabinet Minister of Health,DGHS)

– SATRR programme (2008)

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My concept

• To evangelise ( integrated emergency & trauma care)

• Training people from the same institution & same state

• To lead by example.

• Seeing is believing

• To develop a working model which provokes change

• Change has to come in the public sector

• Implementation of integrated emergency and trauma services

• Implementation of a public insurance system which makes a

socially equitable access system possible(eg ,TAC)12

India - demographics

• Population-1,205,073,612 (July 2012 est.)

• Hospital bed density-0.9 beds/1,000 population (2005)

• US, Britain, Canada, Australia and the Gulf - 100,000 Indian

doctors (10 %) of the country's medical talent.

• 1 doctor for every 10,000 Indians, compared with the 548 doctors in

the US and 249 in Australia.

• Shortage of 600,000 doctors and one million nurses, (Indian

planning commission)

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India - the paradox

• Rural vs urban divide (70% vs 30%)

• Medical access ( wealthy vs middle class vs poor)

• Private health vs public health

• Majority 80% have only the means to access public health

• Public health - difficult (1% of the GDP)

• Lack of emergency medicine as a concept

• Lack of integrated trauma care as a concept

Measures countries implement

• Compulsory rural term post graduation

• Implementing better salaries

• Implementing restrictions to travel if trained in public medical

institutions

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State of Emergency Medicine in India

• Accepted as a specialty in 2010

• Majority emergency medicine programmes - in the private world.

• Still “pay upfront” based system

• Rollout of emergency paramedic systems

• More awareness of emergency medicine and trauma care

• Prevention systems still lacking

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Road blocks/Obstacles

• Major impediment- lack of recognition of foreign medical degrees

• Lack of political will

• Lack of support systems

• Lack of “ follow through”

• Lack of communication among multiple western efforts and home

grown efforts

• Identifying emergency care and trauma care as key elements in the

current health scenario

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The pros of going back

• The opportunity of a lifetime to change health care in a certain

district/state/country

• Developing a new concept

• Registries/research

• “Being at home” - AMONG YOUR OWN PEOPLE

• Personal legacy

• The magnitude of change & impact -huge

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• “Advocating for international health facilitators to truly engage with

the communities. You have to know the culture that you’re getting

into and have the linguistic competence to actively work with

people. But more importantly, you must be aware that each culture

has its own way of engaging in terms of their health, healthcare,

and getting well”.

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Cons of Going Back

• The real chance of being a glorified triage doctor

• The frustration of not being able to do what you have been trained

to do

• Spending a lifetime and not being able to change what you want to

do

• Central issue- family & their displacement, especially

kids(unquantifiable)

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Can we stay here and help

• Woodpeckers attitude - multiple failures ,but eventually it will get

through- just need to keep pecking

• Involvement in multiple programmes related to international work

and specifically your own country e.g: Australia -India grants

• Facilitating knowledge transfer in personnel building and capacity

building

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Would you ever go back

• Waiting for the opportunity to apply the knowledge and the skills for

maximal impact

• Building relationships/planning a move

• Plan for maximal impact

• Keep on negotiating and trying for the right opportunity

Current India fatality rate due to road trauma – 29/100,000 population

In India, road crashes are the

commonest cause of death for

people under the age of 35.

The estimated cost of road

crashes in India is 1% of the

Gross National Product

Road Trauma in India

Evidence indicates that people

with life-threatening - but

potentially treatable - injuries are

up to six times more likely to

die in a country with no

organized trauma system than

in one with an organized,

resourced trauma system [i].

[i] Mock CN, Adzotor KE, Conklin E, Denno DM, Jurkovich GJ. Trauma

outcomes in the rural developing world: comparison with an urban level I

trauma center. Journal of Trauma 1993;35:518-23.

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THANK YOU

ध�यवाद

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