Canada a prime destination as MDs flee South Africa

Patrick Sullivan

CMAJ 1999;160:1615-6

Although there is growing concern about the brain drain that is drawing Canadian physicians to the US, Canada's problems are minor when compared with South Africa's. And ironically, Canada appears to be one of the main reasons for our Commonwealth partner's brain-drain epidemic.

Violence like this is driving many MDs from South Africa

Not only is Canada already home to 1338 known graduates of South African medical schools, but it is actively trying to recruit more of them. The November 1998 issue of the South African Medical Journal (SAMJ) contained 23 pages of employment-related ads, and 11 of the pages were filled with job offers from Canada, the United Kingdom, New Zealand and Australia.

The 10 Canadian ads ranged from a family practice for sale in Prince Rupert, BC, to a post in Kindersley, Sask., that offered a $25 000 "practice establishment grant." South Africans were also invited to practise among the "craggy cliffs, deep fjords and snow-capped mountains of Newfoundland and Labrador."

Over the years, the ads appear to have been successful. According to the CMA's Masterfile list of all doctors in Canada, BC (378 South African-trained physicians) is the destination of choice within Canada, followed by Ontario (305), Saskatchewan (263), Alberta (195), Manitoba (124) and Newfoundland (46). At the low end are Prince Edward Island and the Yukon Territory, with 1 each.

South Africans now account for 9.7% of all international medical graduates practising here; only the UK, with 31.7% of the foreign-graduate total, has provided Canada with more doctors. The immigrants from South Africa range from Toronto Hospital CEO Alan Hudson, a neurosurgeon who graduated from Cape Town University in 1960, to 1995 and 1996 medical graduates now practising in small-town Saskatchewan and Alberta.

For South Africa, the news is equally bleak in New Zealand, where 1 of every 14 practising doctors was trained at a South African medical school.

Unfortunately, the situation is unlikely to improve in a country facing ongoing political and financial problems, as well as unprecedented levels of crime and violence. In a recent editorial, SAMJ Editor Daniel Ncayiyana pointed out that in 1998 South Africans witnessed "accelerated decay of academic hospitals plagued by thefts, loss of experienced nursing, continued loss of medical expertise and drastic shrinkage of services. . . . Mayhem and slaughter continued on our roads and in interpersonal violence in the townships. The government lost complete control of the crime situation in gangland areas, the rand [South African currency] floundered and interest rates skyrocketed to over 23%. Well, 1999 just has to be better."

Perhaps it will be better, but South Africa isn't taking any chances. It has already asked the World Medical Association (WMA) to develop an international declaration on medical migration in an attempt to discourage the poaching of physicians by wealthy countries. When the WMA met in Cape Town in 1996, Deputy Prime Minister Thabo Mbeki criticized the aggressive recruiting being done by countries like Canada. This WMA declaration has yet to be developed.

So why do physicians leave South Africa? Dr. Isra Levy, the CMA's director of health programs, says the decision to leave is "intensely personal" for all physicians. A 1986 graduate of Witwatersrand University, he estimates that more than half of the 200 graduates in his class have already left.

"There have been very different reasons for leaving over the years," he said. "My assessment is that in the 1980s people were leaving for reasons of ideology and because of their political beliefs, and also to get First World experience. Now, at least according to what I hear anecdotally, reasons for leaving have far more to do with violence."

Levy, who came to Ottawa from South Africa to study community medicine, thought he would return home, but he never did. Does he have any regrets? "I still have family and friends there and I still have a strong emotional attachment to the country. I have emotions, but regrets? I don't think so. Today I have a strong attachment to this country."

Professor Dave Morrell, who chairs the South African Medical Association's (SAMA) Committee for Fulltime Practice, says there appears to be an increase in the number of doctors leaving the country, but as yet there is no substantiated information on why this is happening. The government says 813 physicians have emigrated from South Africa since 1986, but that number is widely acknowledged to be a joke. For instance, the South African Journal of Science reported recently that 45% of the medical graduates produced by Witwatersrand University in the past 35 years — more than 2000 physicians — have left the country. The SAMJ says the actual emigration figure is probably twice the government's official estimate, since many doctors emigrate "unofficially."

"The loss of only 1 South African doctor to another country is an issue of serious concern," says Morrell. "However, it is a fact that our doctors are highly regarded abroad and that they are usually offered excellent opportunities elsewhere."

Morrell says the SAMA is not opposed to South Africa's own importation of physicians from other countries, but "we believe that a country's health services should offer sufficient incentives to retain its own doctors, who know the people, their culture, language and the peculiar diseases best."

As for potential reasons why doctors leave South Africa, he points first to violence. "Even in practice, doctors are exposed to violence and intimidation," he says. "These are circumstances they find difficult to reconcile with their role as caregivers."

Other issues include the deterioration of conditions in training and at academic hospitals, and difficulties in filling posts because of a moratorium on new appointments in the public sector.

Unfortunately, things are unlikely to improve quickly. A survey of South African doctors paid for by the Canadian International Development Agency found that only 65% of respondents are "unlikely to leave" within the next 5 years.

South Africa, the country that gave the world its first heart transplant in 1967, is now in the midst of what appears to be a losing battle to retain its well-trained doctors. As Professor Max Price, the dean of health sciences at Witwatersrand University, explained in the SAMJ, the overall picture is "very depressing."

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© 1999 Canadian Medical Association