November 05, 2004

The road to perdition

There's one crisis in our crisis-ridden country that I feel compelled to write about, setting aside the urge to comment on the electoral victory of George W. Bush, the man the rest of the world's peoples love to hate.

The brain drain in the health professions, specifically in nursing and medicine, has been going on since the 1960s as far as I can tell. Definitely, by the time my UP Medicine class of about 145 students graduated in 1979, more than half were destined to go abroad, at first to train, then to establish their practice and stay on. (I bet many of them got to vote in the last US presidential elections.)

So the news that the Philippines has the dubious distinction of being the top exporter of nurses in the world is old hat. We used to be the No. 2 exporter of doctors, but maybe India has taken over considering the cost of medical education and the economic crunch that Filipinos have been living under for two and a half decades.

What has got people sitting up to take notice is the fact that physicians are going back to school to become certified nurses. We're not just talking about fresh medical graduates either. Medical specialists who have been practicing five or more years are abandoning their hard-earned professions to work as nurses, mostly in the US and UK.

It doesn't take an economist to figure out why. One estimate is a stark US$400 working as a doctor in a Philippine state hospital versus $4,000 doing duty as a nurse in US hospitals (with immigrant status for family members to boot). I wager $400 is even on the high side since resident physicians, those doctors who are still undergoing specialty training, would be getting much less.

Consider the powerful cultural factors at play in making the switch from doctoring to nursing, but are easily swept aside by the economic imperatives: the general perception, correct or not, that becoming a nurse after having studied or worked hard as a doctor, constitutes a denigration of one's professional status.

There is an implied intellectual superiority that derives from the assumption that it takes more brains to be a doctor than a nurse when in fact, in most instances, the more accurate premise is that it takes more money to go to medical school and thus the higher status has more to with socioeconomic class than anything else.

In our still macho society, the shift to nursing constitutes a double demotion on the part of male doctors. In the hierarchy of the health professions, the doctor is still the decision-maker, the leader of the health team, if not the undisputed "boss," while the nurse takes down the doctor's orders and implements these.

The implications of the continuing brain drain deserve to be confronted especially when our political leaders, the bureaucrats at DOLE, the recruitment agencies as well as owners of mushrooming nursing schools all over the country peddle the lie that the country has a net gain in exporting our human resources.

They extol rather than decry the fact that we are spending scarce social capital on future doctors and nurses, only to lose them to richer societies that can afford to give them decent salaries and a modicum of respect, if not reward, after all the hard work and personal sacrifice.

This is the stark reality. The country has reached the point where there is now a developing scarcity in medical human power even in the cities, in tertiary care hospitals (i.e. those providing more specialized and expert medical care), and in the private sector.

It used to be that scarcity was relative. It followed that doctors and nurses tended to be hospital-based, both to earn more as well as to be able to avail of the newer medical technology and convenience any health professional educated in the Western tradition looks for.

It was to be expected that rural areas would have a difficult time attracting doctors and nurses to practice there because of the expected low paying capacity of its population, mostly farmers and small- to medium-size merchants. There were always vacancies in rural health centers and even secondary government hospitals especially in such far-flung areas like Samar, the Cordilleras and western Mindanao.

Metro Manila, on the other hand, had a surfeit not only of doctors, but of world-class physicians, you just had to be able to afford them or have the patience to queue up in the interminably long lines at the Outpatient Department of the University of the Philippines-Philippine General Hospital (UP-PGH).

Thus, the crowding in the cities where not only the money is better, the schools for the children are more prestigious, the shopping malls are more complete and the general socioeconomic environs cum cultural life more upscale than anything a small town, much less a barrio could ever hope to offer.

But now, the telltale signs of a worse crisis to come are truly worrisome. Hospitals in Mindanao and Negros Oriental are facing closure because of a lack of doctors and nurses.

UP-PGH, that venerable institution which produced the top-notch specialists practicing in the major urban centers of the country as well as top-rated US medical centers, is having difficulty attracting fresh graduates to fill up the slots in what used to be highly competitive residency programs.

The high turnover of nurses has accelerated in the last decade with the huge number of nursing schools unable to churn out graduates fast enough to fill in the slots their more-honed predecessors left.

No doubt about it, what has been a long-running crisis in our low priority, under-financed and decaying health care system will soon become a full-blown emergency. It's just another example of how the myopic, or rather, head-in-the-sand attitude, of our political leaders promises to lead us to even greater perdition as a country.

That's the fearsome scenario our young doctors and nurses are running away from, and who can blame them.

Nov. 5-6, 2004


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