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Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad

The United States is increasingly relying on foreign-born health workers to fill health care gaps, particularly in providing primary care. In her recently published book, Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad (Dartmouth Press, 2012), Dr. Kate Tulenko, senior director of health systems innovation at IntraHealth, argues that this practice has dire economic and social consequences, threatening the quality of medical care in both source countries and the US. The following is an excerpt of the preface to Insourced.

Read more about this issue in this recent interview with Tulenko.

The following post is an excerpt from Insourced: How Importing Jobs Impacts the Healthcare Crisis Here and Abroad by Dr. Kate Tulenko (Dartmouth College Press, 2012).

In developing countries, a child dies every four seconds. A major reason for such needless death is the lack of enough doctors, nurses, and other healthcare providers to prevent and treat illness. The global healthcare-worker shortage has been called the greatest humanitarian crisis of our time because it cuts across every crisis, from disease outbreaks to national disasters to wars, and hamstrings our ability to respond. As a mother, a pediatrician, and a health-policy expert, I feel deeply the urgent need to address this issue.

During my time at the World Bank, I saw people out of work in the United States while good jobs sat empty in their communities. I saw health workers being imported from countries that could ill afford to lose them. But no one seemed to be making the connection between the two problems and offering solutions. Many wealthy countries have their own shortage of healthcare workers, and rather than paying to train their own young people to work in these fields, these countries, led by the United States, are importing healthcare workers from poor countries. This practice has severely distorted and damaged healthcare systems in those countries and has created perverse incentives to produce healthcare workers for export rather than to meet the needs of their own people.

Concentrating on a short-term solution, the United States and other wealthy countries are failing to address the reasons they do not have enough healthcare workers and ignoring the damage they are doing both at home and abroad. So I have pursued the topic by researching and writing this book during vacation time, early-morning writing sessions, caffeinated evenings, and an extended maternity leave.

As a resident, I served on the American Academy of Pediatrics’ Section on International Child Health, which works to improve the health of children in developing countries. The vast majority of child deaths are in developing countries, and about half of those deaths occur in Africa. Most newborn deaths in the United States are due to unpreventable birth defects or severe prematurity, for which even the most advanced medicine can offer little help

It took a while to dawn on me that in both streams of my career, I was working on the same issue: the shortage of healthcare workers in developing countries and in the United States.

In 2002, after completing my pediatrics residency, I had an opportunity to join the World Bank. The World Bank is one of the largest nongovernment funders of healthcare programs in these countries, and joining its health team was an incredible chance to make a difference.

Once I started traveling it became difficult to schedule my shifts in the emergency room, so I started working with hospitals and clinics in underserved communities in the Washington DC area. These facilities often had trouble filling their permanent positions, so they were happy to have me come in on short notice on a weekend here and there. I supplemented this with on-call work in a variety of clinics and hospitals in medically underserved communities in rural Maryland and Virginia. If you drive an hour and a half in almost any direction from Washington DC, you find yourself in a rural community with a healthcare worker shortage. Often, the community has just one or two pediatricians.

I worked in Carroll Hospital Center, in Carroll County, Maryland, attending high-risk deliveries and caring for the children in the pediatric ward. The hospital was short three pediatricians, and the lone staff pediatrician was alternating night shifts with local clinic-based pediatricians, many of whom had little experience with critically ill children. It turns out this type of substitute work is a $2 billion-a-year Band-Aid solution to the severe shortage and maldistribution of healthcare workers in the United States. The other Band-Aid solution is importing tens of thousands of foreign-trained healthcare workers each year.

From 2006 to 2008, during my time at the World Bank, I had the rare privilege of working in Barbados. I had to suffer through a lot of jokes and comments from my colleagues about "hardship travel" and writing reports on the beach. But it was deeply serious business. The Caribbean has the highest rate of HIV/AIDS outside Africa – Haiti, Jamaica, and the Bahamas all have HIV rates near or above two percent.

Barbados, however, has shown incredible leadership in openly addressing its HIV/AIDS crisis, creating special programs to prevent the spread of the disease as well as to diagnose and treat anyone on the island with HIV. Even so, the response of Barbados and the other Caribbean countries has been hindered by their healthcare-workforce shortage. Unable to pay their healthcare workers anywhere near as much as they can earn United States, and unable to afford the technology that makes medical practice more rewarding and intellectually stimulating, the Caribbean has seen large numbers of its doctors and nurses emigrate. One estimate is that three times as many Caribbean-educated nurses are working outside the Caribbean as in their home countries. In addition to my stint in Barbados, as I encountered country after country in which the fundamental problem was the shortage of healthcare workers, I was surprised to find that no significant World Bank grants or lines were addressing that problem.

Finally I found a consultant, tucked away in a corner of the World Bank, who was studying this issue. Dr. Demissie Habte was the former dean of the Addis Ababa University, Faculty of Medicine in Ethiopia, and the former director of the renowned International Center for Diarrheal Disease Research, in Bangladesh. Drawing on his experience as both medical-school dean and manager of a large healthcare system, he was developing approaches to address the healthcare worker shortage in developing countries. Together we wrote the first draft of a proposal for a World Bank program that would work on solutions to the global health workforce crisis. That work eventually led to the World Bank's African Health Workforce Program, which I coordinated, to assist countries in making better use of their healthcare workers and in training more.

With what I had seen as a clinician and learned as a global health-policy expert, it wasn't difficult to see how the two problems relate. The issues are complex and require complex analyses and solutions. But promising steps, at least in my experience, can come in surprising ways.


Insourced cover