Justice, Development, And The Brain Drain
By Professor Michael Blake (University of Washington)
September 13, 2016 Picture: Tim A Hetherington/Reuters.
This article is part of The Critique’s September/October 2016 Issue “The Bright Continent: Illuminating The Challenges, Opportunities & Promises Of A Rising Africa”.
The result of this is that highly-skilled residents from developing societies have freedom to leave their countries of origin – and they are, increasingly, willing to make use of that freedom. This phenomenon is found in any number of fields; Devesh Kapur notes, in a related discussion, that African sports fans often prefer to watch European soccer, since the most talented African soccer players will emigrate to play in European leagues. The most ethically troubling cases, though, are found with medical personnel. The countries of sub-Saharan Africa, with less money to invest, have found themselves pouring resources into training medical professionals – only to see those professionals use their desirable skills to emigrate to Europe, Australia, and the United States. The outcomes have been deeply disquieting. In 2001, Zimbabwe graduated 40 pharmacists from its University system – and lost 60 to emigration. In 2000, Ghana trained 250 nurses, but saw 500 more leave. These patterns, of course, have led to continued medical shortfalls in the African continent: in Japan, there are 105 physicians per fifty thousand residents, while in Malawi, that same group must make do with only one.
These facts are generally grouped together under the heading of the “brain drain”; developing countries seem to be losing their most skilled and talented individuals, with the benefits of those individuals’ labors going to countries already well-situated. This set of circumstances should give us some pause. The histories giving rise to these facts are complex, and there is no simple story about either how the brain drain emerged or how it might be combated. Nonetheless, it is possible to at least ask about the moral character of these facts: why are we as disquieted as we are, and what should this disquiet lead us to do? I am not am empirical scholar, and this problem is a profoundly empirical one; I can, however, try to offer at least some clarity about the ethical norms that ought to govern our responses here. I will, then, try to answer three questions about the brain drain and Africa, in decreasing order of confidence. The first is: what is ethically troubling about the brain drain? What, that is, should make us think that this set of circumstances is a matter of injustice, rather than inconvenience? The second is: what may we rightly do, in response to the brain drain? I will ask, here, what we might do that is both ethically permissible and likely to be effective as a response to the facts on the ground. The final question is: what is the near future likely to hold, for Africa? This question, of course, is an empirical one, about which even empirical specialists disagree; nonetheless, we might at least identify some broad trends that might affect how likely the migratory patterns discussed here are to continue. I will end this essay without any hopeful conclusions. While there are some hopeful signs in Africa, which might undermine the push factors leading to the brain drain – notably, Chinese investment and increased integration into commodities markets – there are equally powerful negative signs as well. We are likely, I believe, to face the ethical problems of the brain drain for many years to come.
I. What is wrong with the brain drain?
Many of us are disquieted by the gap in physicians between Malawi and Japan. It would be one thing if the Malawian populace simply didn’t want to become physicians; that sort of difference tends not to lead to quite as many ethical worries. (There are, after all, more sumo wrestlers in Japan than in Malawi, but no-one cares.) This, however, does not seem to explain the difference; people do, indeed, want to be physicians – and to use their services – throughout the world. We might, though, still accept this difference, if medical services were something that a person could go without. Hollywood, for instance, has more filmmakers than Seattle; while Seattle might frown at this, there does not seem to be any moral reason for us to worry about this sort inequality. Our disquiet can be understood, though, with the thought that a physician is not a luxury good; if we accept that human rights include things such as the moral right to avoid dying young of an easily preventable disease, then access to a physician seems part of what we can expect, morally speaking, to be a part of a human life. Medical practice is thus different, morally speaking, and we are right to worry about this sort of inequality even if we do not want to worry about all sorts of inequality. More importantly, though, it seems as if the reason for the inequality here speaks to something unjust in the very background of the world. It is not an accident, after all, that the African continent – which was looted and colonized throughout the nineteenth and much of the twentieth century – is the site with fewer doctors than Japan. There is little agreement about the precise causes of the wealth of nations. It is, though, more than a coincidence that the countries facing brain drain are the formerly colonized ones, and the countries gaining brains are their former colonizers.
With these facts in mind, we might ask why we are right to think that there is something morally wrong with the brain drain. We are, I think, right to hold that there is a moral wrong here; indeed, I think we might make the case that there is an injustice – a moral wrong of the sort of character that legitimates state coercive intervention. We might make this case in three ways: with reference to the simple human rights of the inhabitants of Africa, with reference to distributive justice between states, and with reference to the moral imperative of development.
The first form of argument is perhaps the simplest, and notes that the absence of a sufficient number of physicians can lead to a predictable and large number of avoidable deaths. Lucas Stanczyk discusses this phenomenon with reference to avoidable deaths during childbirth; every tenth woman in Malawi will require a caesarian section, but with a minuscule number of physicians available, many of those women will die during the birth process. Without even looking to notions like fairness or international distribution, we can simply say: this is morally wrong. It is particularly wrong, of course, when the world actually has enough physicians in it to give everyone adequate medical care. To use the Japanese contrast again: many physicians in Japan work in secondary care – dermatology, cosmetic surgery, and the like. These practices are not unimportant; they do, however, save lives less frequently than primary care in Africa would. One way of showing that the brain drain is wrong, then, is simply by showing that it robs people of the rights to which they are entitled, in a world that could have been arranged so as to allow those rights to be protected.
A second way of defending the proposition that the brain drain is morally wrongful looks instead to the issue of distributive fairness. We tend to think that some distributions of material goods are unjust, within the territorial state; there are some ways of dividing things up between the rich and the poor that are morally wrong. Many of us – by no means all – think that something similar holds true internationally. If we do, though, then there seems to be something rather awkward about the migration of people whose skills were expensively developed. Those countries already disadvantaged, who have little enough to invest, put money into their own citizens – only to see that investment returned in benefits for the globally well-off. One financial estimate held that the emigration of medical personnel represented over two billion dollars transferred from Africa to wealthy destination countries. If this is true, then it does not take much work to show that this is morally hard to accept. The wealthy states of the world have, on this account, systematically underinvested in their own medical educational infrastructure, confident that they could simply absorb the medical education paid for by the world’s poorer societies. This seems, if the notion of distributive fairness has any pull on us in this context, deeply unfair.
“The wealthy states of the world have, on this account, systematically underinvested in their own medical educational infrastructure, confident that they could simply absorb the medical education paid for by the world’s poorer societies”.
Some would go further, of course, and argue that there is something unfair here about the distribution of people, rather than simply the distribution of money. The medical personnel leaving Africa represent financial investments, of course, but they are also persons – often, the most active and well-trained people in a given society. Gillian Brock, for one, sees this as an independent reason to worry about the brain drain. If development is an imperative of justice, she argues, then we have a reason in justice to do whatever is required to ensure that the path of development is made to run smoothly. Development, though, is not simply a matter of moving money around; it is a matter of developing responsive institutions, which are able and willing to do what development requires. This, though, means the development of people who are able to push for those institutions; who are neither so impoverished that they are unable to raise their voices in activism, nor so entangled with state bureaucracy that they have no incentive to do so. Brock’s analysis, then, sees the development of a professional middle-class as a requirement of economic development, and so as an imperative in its own right. What’s wrong with the brain drain, on this analysis, isn’t so much that it exacerbates existing poverty – although it does that – but that it ensures that the future shall be impoverished as well.
I have reservations about all of these arguments; I think there are difficulties involved in making them do the work their advocates have made them do. Nonetheless, they are powerful reasons to think that the brain drain is, indeed, ethically problematic, to say the least. Let us take for granted, then, that the brain drain is something we have reason to regret, so much so that we ought to work hard to undermine it. How, though, can we begin to do that?
II. What can be done?
Before we can figure out how to solve the brain drain, we would have to be more precise – both about who it is that is doing the solving, and what a solution would have to imply. On the latter question, I would argue that the notion of a “solution” here implies a pathway forward that is both ethically permissible and likely to actually reduce the facts that made us feel the brain drain to be ethically impermissible. This notion of a solution is, I believe, the only one we should feel comfortable about using; something is not an ethical solution, if it depends upon our doing what is independently unjust. The former question, though, is susceptible to multiple answers; we might imagine that multiple parties can perform actions designed to make the brain drain less problematic.
We could start by asking what the wealthier countries of the world might do by way of addressing these issues. One response, of course, is simple: it might stop offering preferential treatment in admission decisions to those people with scarce and desirable skills. This solution is certainly open to those of us who think that states have some discretion about who to admit to residency; even those of us who think that states should generally be open to all comers have tended to think of this policy as permissible, under the right empirical circumstances.
Even if we accept this proposal as morally permissible, though, we have reason to worry about its ability to actually solve the problem. Those people who want to leave a place, and who have the energy and money required to do so, will often choose to leave even if they are not offered a legal means to do so; sometimes people will choose to be undocumented abroad, rather than a professional in their country of origin. It is, in this context, worthwhile to note that the single most prominent factor cited by African nurses to explain their emigration was not money, but safety; they sought to live in a country without as much endemic violence as their country of origin, and might well choose to migrate even if they were not able to practice their trade. This results in the phenomenon called “brain waste,” in which the expensive skills inside someone’s head are simply wasted, as they choose a life in which those skills will not be permissibly used.
There are other worries here, too, which ought to be counted in the calculus of permissible responses. The first is that a refusal to allow immigration tends to undermine remittances, which remain a powerful engine for development; the net flow of remittances in 2015 rose to over $431B, easily dwarfing the amount of official aid. Remittances cannot do everything – they cannot, for instance, replace institutions – but it is a mistake to think they can do nothing, and a policy that undermines them must be shown to produce more benefits than the costs it entails. A reduction in the quantity of foreign professionals, further, would have the effect of reducing the number of educated, middle-class people of color in the destination country, which can tend to exacerbate racism and prejudice in that country. The existence of a critical mass of African doctors, to put it bluntly, may have some effect that undermines the force of racism within the society in question. A policy that undermines professional migration, then, might have some hidden costs, even if it has benefits as well.
“The existence of a critical mass of African doctors, to put it bluntly, may have some effect that undermines the force of racism within the society in question”.
More interesting, perhaps, is the question of what could be done by the country of origin to prevent the loss of its own citizens. There are any number of proposals here, which run the gambit from the fairly blunt – Cuban-style embargoes on emigration, for instance – to the more subtle, as in schemes delaying professional certification until a number of years of national service are undertaken. What these schemes have in common is the thought that a country is entitled to its own citizens, that it has invested in them, and so has the right to the skills it has helped to create. If permissible, these schemes would perhaps be the most effective means by which the brain drain’s effects might be mitigated. A country could simply refuse, for some stated period of time, to allow its citizens to practice their medical craft abroad; instead, those skills would have to be used for the benefit of their own fellow citizens at home.
What, though, makes us think that any such scheme is permissible? There are many arguments that have been put forward. One simple idea is that there is no sharp distinction between the person and the skill, and the skill is created in a society that has a right to joint ownership of that skill. (A Cuban journalist once complained that the United States had stolen Rolando Arrojo’s fastball – which had been taught to him in Cuba, and to which Cuba still had title.) A more plausible version of the account is that citizens of a reasonably just society have duties of loyalty to that society, and they do not have the right to pick up and leave at a moment’s notice; they are, instead, bound to do right by that society and its investment, before choosing a new society in which they might practice their craft. On this account, we are temporally extended agents, and we have obligations to those fellow citizens with whom we have built a society; we cannot simply abandon our fellow citizens, any more than we could a spouse, simply because someone else can provide us with more. Brock’s own argument, finally, argues that the general obligation to build just institutions can insist that we remain where we are, to avoid undermining the limited moves towards justice that can be made in a less developed society. We have, on this account, an obligation to work for justice, and we are uniquely well-situated to make this part of the world as just as it could be – which means that we might have to stay for some time where we are, instead of striking out on our own.
There are, of course, worries about all of these arguments. Some have thought that the arguments here tread uncomfortably upon the thought of self-ownership; if we own ourselves, on this thought, then how can others legitimately claim to own our skills? Others – myself included – have worried about the fairness of making the duty to build a just world fall so sharply upon the skilled residents of the impoverished society. We have a shared obligation to make the world less unjust, of course – but does that mean that we can impose any obligation upon a given individual, if that obligation would make the world more just? I tend to believe, instead, that we often have a right to do what isn’t ideal, and that people have the right to build lives with others that are not the lives that make the world the best place it might be. I have also argued that the state has less of a right to coerce people into staying than arguments like Brock’s allow. The state must justify its coercive powers to individuals, and I don’t think the sort of coercion these arguments permit is likely to survive the process of justification. Most centrally, though, I believe the norm that we ought to be allowed to leave any country, even our own, is a valuable norm, and one worth preserving, even if in some particular case the suspension of that norm would be of benefit. If we start making the sort of exceptions allowed here for good states, I am convinced, we would in practice announce that the norm was susceptible to exceptions – and this will, in short order, announce that the norm isn’t as central as we thought it was. We are better off, instead, thinking that the right to leave one’s own state – like the right to be free from torture – is an absolute, or near-absolute, value.
“The norm that we ought to be allowed to leave any country, even our own, is a valuable norm, and one worth preserving, even if in some particular case the suspension of that norm would be of benefit”.
There exist, of course, any number of other possibilities for how to address the brain drain. We might focus on financial penalties for accepting migrants – as in the Bhagwati tax. We might examine the extent to which there is an emergency justification for temporarily preventing emigration – but we have to question, here, what counts as an emergency, when the circumstances discussed have been in place for many decades. We might, instead, urge destination states to increase medical training expenditures, so as to prevent the sort of regressive financial transfer discussed above. We might, as a recent proposal had it, ensure that medical training in sub-Saharan Africa is more focused on African diseases, rather than the broad medical training that is more easily transferred to European and American contexts. All of this, though, amounts to marginal steps; none of these is likely to lead to a world in which we do not face the sorts of problems discussed above. My own view is that we have, in the brain drain, a case not simply of a thorny moral problem, but a genuinely unsolvable one – in the sense that we have, here, no effective and permissible means by which we might solve a clear injustice. Some moral problems, that is, have responses that will solve them, but which require us to do difficult things; we know how to get to the just world, and only have to find the courage to do what is required. The brain drain, though, is not that sort of a problem. The present case is unjust, and the solutions that are on offer are likely to be either only partial solutions, or unjust in themselves.
There is, of course, a hope in cases such as this that the problem will just go away on its own. Circumstances might change, such that the problem might cease to be a problem requiring independent examination. Could African emigration be such a case?
“We have, in the brain drain, a case not simply of a thorny moral problem, but a genuinely unsolvable one”.
III. What does the future hold?
I would emphasize, once again, that I am not an empirical scholar; what I can offer here is at best a guess. Nonetheless, I want to offer some considerations – both positive and negative – that might help us get a sense of what is likely to happen in Africa that might affect the brain drain as discussed above.
There are, to begin with, some clearly positive signs. There have been, to begin with, some real – if limited – gains in economic development and democratization in Africa in the past decade. Economic development, in particular, has benefitted from an enormous investment from Chinese nationals; Chinese entrepreneurs have invested billions of dollars into African infrastructure, with the result that African natural resources and commodities are now being shipped to China at a furious rate. This has had an enormous impact on African integration into global commodities markets, and had significant effects on the economy of Africa more broadly; put most simply, the roads now get repaired, at least when that benefits Chinese industry, and those roads work for the advantages of all residents. The impact of Chinese investment has not been uniformly positive: there are worries that China’s poor record on human rights is now being exported to Africa, and China has offered financial support to some regimes that have decidedly mixed records on human rights. Nonetheless, it is at least possible to think that Chinese investment has laid the groundwork for an African continent better able to keep its own medical professionals, by reducing the sorts of underdevelopment that tended to prompt their exit. There have been, moreover, some real gains in democratization in Africa. If Amartya Sen is right that democracy tends to undermine famine, by providing electoral checks on truly appalling state policy, then the increased respect for democratization also counts as a positive indicator for Africa’s future.
All this, though, comes along with some significant structural difficulties – ones that are likely to make the brain drain a fact of life for a generation to come, if not more. The first of these is the mirror image of the discussion above of democratization. One diagnosis for African underdevelopment is the simple fact that African states got their borders not based upon independent bonds of affiliation or loyalty, but because of the interests of the colonizing power. (As Edward Miguel puts it: “Does ‘The Central African Republic’ sound to you like a name people chose for themselves to express their national identity, or one imposed by a colonial bureaucrat?”) This means, though, that there is no pre-existing solidarity, of the sort that tends to give a moral reason to refrain from the worst sorts of corruption. In the absence of that solidarity, it is possible for the leadership of the state to simply buy enough military might to immunize itself against any challenge from the people, and get to work selling off the country’s resources for private gain. Democracy can work against this phenomenon, but even that requires some notion of solidarity; democracy requires the willingness to lose, and continue to play the game of politics, and that tends to be absent in cases where there is no felt loyalty to the political society in question. There is, in other words, a structural recipe here for ongoing violence in Africa, and seventy percent of African states have had at least one year’s worth of warfare in the past decade. This is, perhaps, changing – the slow, but real, march of democratization in Africa is testimony to that – but it is a factor whose roots emerged a century ago, and whose legacy is likely to continue into the future.
There is, further, the simple fact that the agricultural policy of wealthy states is unlikely to change any time soon. There is a great hypocrisy in the fact that the United States, for instance, preaches free trade and free markets, but dumps billions into its agricultural sector, undermining the agricultural workers in developing countries. This is not, I should emphasize, an independent cause of the brain drain. I want only to note that this sort of hypocrisy helps exacerbate the inequality that gives rise to the brain drain, and is unlikely to go away any time soon. The simple fact is that politicians are aware that foreign nationals don’t vote; agricultural subsidies help domestic nationals, at the cost of harming foreign nationals, but those who are harmed are in no position to do more than weakly protest what has been done to them. We might imagine that the domestic nationals will stand up and demand the end to this hypocrisy – and we have seen some limited activism towards that – but this requires domestic nationals to actively campaign against their own interests; this sort of moral courage, quite frankly, is rare. We might, instead, imagine that an elected leader would attack this hypocrisy, even against the wishes of her constituency – but we have to face up to the fact that the leader’s continued employment depends upon avoiding this sort of conflict. We might, then, think that there is a structural reason to think that the inequality between Africa and the United States will continue into the indefinite future. Electoral democracy draws a line between the domestic citizen and the foreign citizen, and it is the will of the former that ultimately determines who shall be put in place to make policy.
One final structural worry is worth highlighting here: the burdens of global climate change will fall with disproportionate force upon Africa. These are burdens that were, it goes without saying, not chosen by African states. The use of carbon by the United States and China, which enabled them to develop flourishing economies, has given rise to possible significant increases in global temperatures. These increases are not, however, distributed in an equal way. The United States, Japan, and Northern Europe, for example, will experience a significant but limited rise in average temperature, against a moderate starting point. Parts of the African continent, however, will experience a significant rise, against an already high starting point – which will make life in parts of Africa, notably the Sahel region, nearly impossible. Our focus has been on skilled migration, not climate refugee flows – but the latter affect the former; those who migrate, as has been mentioned above, consistently mention safety in their country of origins as a key reason for migration, and climate change is likely to lead to both increased refugee flows and increased military conflict in Africa. The result is that we are likely to see, in the decades to come, migration pressure that begins with climate change, and which will lead to increased desire for emigration generally; this pressure is likely to make the problems of the brain drain only that much more acute.
There are, of course, any number of ways in which these predictions might prove false. There are, moreover, any number of additional factors that will affect the brain drain. The rise of right-wing populism in both Europe and the United States is likely to affect migration, in ways that are difficult to predict. (It is worth noting that Donald Trump’s campaign platform promises to reduce both H1-B and J-1 visas into the United States; these are the primary visas on which professionals enter.) I am afraid, though, that my conclusions are largely negative in character. The brain drain is, indeed, ethically troubling; we are not wrong to be bothered by medical emigration from Africa. Our ability to meet the challenges of that brain drain, in an effective and morally sensitive way, is limited at best. The situation is, finally, unlikely to become significantly better in the years to come. We may hope that Africa’s future is bright, and that the emigration from Africa of her best and brightest eventually ceases. We are, however, far from that future, and I am not convinced we have yet found any means by which it might be found.
Footnotes & References
 Figures as of 2015; available at http://www.un.org/en/development/desa/population/migration/index.shtml
 Devesh Kapur, “Addressing the Brain Drain: A Partial Cosmopolitanism Approach,” forthcoming in The South African Journal of Philosophy.
 David R. Katere and Lloyd Matowe, “Effect of Pharmacist Emigration on Pharmaceutical Services in Southern Africa,” 60 American Journal of Health-System Pharmacy (2003): 1169-1170.
 Magda Awases et al., Migration of Health Professionals in Africa: A Synthesis Report (Brazzaville: World Health Organization, 2004).
 The relevance of this “shared and violent history” is explored in the later work of Thomas Pogge. See Pogge, World Poverty and Human Rights (London: Polity, 2002).
 Edward Mills et al., “The financial cost of doctors emigration from sub-Saharan Africa: human capital analysis,” British Medical Journal (2011); available at http://www.bmj.com/content/343/bmj.d7031
 Brock’s argument is developed in her chapters in Gillian Brock and Michael Blake, Debating Brain Drain: May Governments Restrict Emigration? (New York: Oxford University Press, 2015).
 Kieran Oberman, who generally condemns all forms of border exclusion, accepts the potential legitimacy of this sort of exclusion in “Can Brain Drain Justify Immigration Restriction?” 123(3) Ethics (2013) 427-455.
 Sue J. Ross et al., “Nursing Shortages and International Nurse Migration,” International Nursing Review 52(2005):252-262.
 Anna Stilz, “Is there an Unqualified Right to Leave?” in Sarah Fine and Lea Ypi, eds., Migration in Political Theory (Oxford: Oxford University Press, 2016).
 Fernando Tesón and Loren E. Lomasky, Justice at a Distance (Cambridge: Cambridge University Press, 2015).
 My arguments in this paragraph are developed in more length in my chapters in Debating Brain Drain: May Governments Restrict Emigration?
 Jagdish N. Bhagwati, “Taxing the Brain Drain,” 19(3) Challenge (July/August 1976) 34-38.
 Howard W. French, China’s Second Continent: How a Million Migrants are Building a New Empire in Africa (New York: Vantage, 2014).
 Amartya Sen, Development as Freedom (New York: Oxford University Press, 1999).
 Edward Miguel, Africa’s Turn? (Cambridge: M.I.T., 2009) 42.
 For discussions of this pathology, see Paul Collier, The Bottom Billion (Oxford: Oxford University Press, 2007) and William Easterly, The White Man’s Burden (London: Penguin, 2007).
 See generally Pogge, World Poverty and Human Rights.
 These ideas are discussed in Miguel, Africa’s Turn? For a discussion of the ethical challenge of climate change, see Stephen M. Gardiner, A Perfect Moral Storm (Oxford: Oxford University Press, 2011).
 Trump’s plan is available at https://www.donaldjtrump.com/positions/immigration-reform