Physician Brain Drain a Critical Issue for Developing Countries

nurse anne bell of nashville

Image by venusnaturalis via Flickr

Reuters reports today (Kavita Chandran and Tan Ee Lyn) that the

. . .health crisis in developing countries is . . . being exacerbated by the West as countries relax stringent immigration regulations to attract doctors and nurses from less developed countries to boost their own flagging health systems while saving money on expensive training.

The consequences of this “brain drain” are grave as it leaves gaping holes in the healthcare systems of developing countries where diseases such as AIDS, tuberculosis and malaria run rampant and children die daily from diarrhea.

I’ve written a number of times that we seriously underestimated the depth and impact of the globalization of health care and how entangled and interdependent we are with the health problems plaguing the rest of the planet. So at the risk of being a PITA I want to repeat my message.

  1. Our public discourse in health care is often too insular, too self-serving and thus irrelevant when it comes to the rest of the world;
  2. The world, and health care with it, is changing in dramatic ways;
  3. We are not paying enough attention to the above two points.

Step back for a moment and consider the overwhelming preponderance of words, time and money we spend in taking apart the U.S. health care system. Now think about how much of that talk goes toward building an understanding of our dependencies on the rest of the world for that care. Or for that matter, how much of the world’s health care, in turn, depends on us.

Not much. In fact we tend to polarize our thoughts into strict them-and-us compartments that essentially diminish any appreciation of the depth of those inter-relationships.

It also shows in our ignorance of health care systems in other countries (especially so when we boast of the superiority of either theirs or ours); in our odd blindness to the fact that, demographically speaking, the world is already living in our own house; and in our easy dismissal of international health comparisons not favorable to us. We are, to be blunt, isolationist, and to many on the planet, arrogant,when it comes to health care.

Keeping the world at an arm’s length is no longer possible or desirable. Much like an “American” car or anything you can buy at Wal-Mart, health care is fast becoming the product of a complex world-wide process. While the health care services Americans receive may appear to be local, each drug, patient record, and operating room is the culmination of a complicated international exchange we need to better understand.

Every health care issue confronting today has underlying global aspects. The U.S. health care is discovering itself inextricably caught up in international diplomacy, the throes of globalization, and even the murky dealings of illegal transnational organizations.

We’re witnessing the emergence of a new order, with its corresponding growth opportunities, intractable problems, and chaotic flash points. For example, the drug industry: new drug biologics, research, testing, manufacturing, pricing, distribution, profits, and counterfeiting — all are derivatives of active public and private global networks. International coordination and information exchange is clearly critical in controlling infectious diseases such as SARS, avian flu, or HIV.

“Medical tourism” (international hospital competition) increases every year. More of our physicians are either foreign-born or being trained in other countries– indeed our entire health care infrastructure is increasingly dependent on foreign labor. Research into other countries’ health care practices will usher a new wave of alternative and complementary care into mainstream medicine. And, of course, health care IT. Electronic claims transaction, systems installations and software testing, call centers with advanced technology –- you name it — and its major components are more and more often located offshore.

Borders are increasingly, or already, irrelevant to health care. We are either getting flattened, or doing it to others. Adapting to that emerging reality is critical. But we seem to be missing the signals. Even in the grand ideas fermenting in the speeches of our presidential candidates we see little recognition of what is going on around us. So we need to start interrogating the global connection of every health care problem we face.

The message has to get out: the globalization of health care is not an optional sub-specialty anymore. It is front and center required reading.

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Global Trends 2025: Six Disruptive Technologies

Thomas Fingar

Image via Wikipedia

Thanks to Computerworld we learn that Thomas Fingar, deputy director of the Office of the Director of National Intelligence, the body that oversees all U.S intelligence agencies, spoke this month before a gathering of intelligence analysts on ‘Global Trends 2025′,  a forecast prepared by U.S. intelligence agencies. In his remarks he discussed six emerging disruptive technologies that will have a major impact on the U.S. and the world. Health concerns, of course, are front and center.

  1. Biogerontechnology involves technologies that improve lifespan. Think of Dorian Gray. If people are living longer and healthier lives, it will challenge nations to develop new economic and social policies for an older and healthier population.
  2. Energy storage systems, such as fuel cells and ultracapacitors, would replace fossil fuels.
  3. Crop-based biofuels and chemicals production, which will reduce gasoline dependence.
  4. Clean coal technologies can improve electrical generation efficiency and reduce pollutants.
  5. Robots have the potential to replace humans in a number of industries, ranging from the military to health care.
  6. Internet pervasiveness will be in everyday objects, such as food packages, furniture and paper documents. It will also streamline supply chains, slash costs “and reduce dependence on human labor.”
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Globalizing Charitable U.S. Health Care: The Taxman is Coming

IRS building on Constitution Avenue in Washing...

Image via Wikipedia

The BNA Health Care Policy Report ($$ Subscription) tells us that Steven Grodnitzky, a manager in the IRS exempt organization division recently said that they are

starting to look into the globalization of U.S. health care systems and the tax ramifications for exempt systems that provide advisory services to foreign governments, mostly in the Middle East, to help them construct, establish, and operate new state-of-the-art hospitals and health care facilities, he said.

Some of these exempt health care systems have created subsidiaries that are paid fees to provide these services, he noted. The organization does not own, operate, or control the foreign operation, its role being rather to help get these foreign operations up and running by providing advice, expertise, and training, he added.

As with other exempt entities, the issues are whether these subsidiaries are really charitable and whether they are promoting public health or educational purposes. “This is an area we are starting to see and hear about,” he said.

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The World Wants Obama

The race here in the US may be tight but the rest of the planet- well at least 22 other countries – wants Obama to be the next President.

All 22 countries in a BBC World Service poll would prefer Democratic nominee Barack Obama elected US president instead of his Republican rival John McCain. Obama is preferred by a four to one margin on average across the 22,000 people polled.

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Steve Talbott: We are Losing the Battle for Digital Privacy

An EPC RFID tag used by Wal-Mart.Image via Wikipedia

Steve Talbott’s book Devices of the Soul: Battling for Our Selves in the Age of Machines is difficult reading, both for the truths embedded in it, as well as the tedious exaggerations he deploys in his scathing critique of digital technology, the internet and mostly all things virtual. Yet there is much to consider here, especially in his short, but poignant, chapter on digital privacy.

Some excerpts so you can get the drift of what he sees coming:

The battle for privacy, waged upon the fields of data, will be lost. . .

. . . the ideal of privacy gains substance only in those primary contexts where we know each other well enough to care. . . Lacking such contexts, we cannot win; we will be assimilated to the realities of our technology, where one data bit looks just like another and there can be no special protection for any of them.

Issues of personal respect don’t arise between packets of data, nor between information processing programs.

Rather we will have an endless contest between privacy-protecting software and privacy-invading software.

Within the global information system every piece of data is perilously close to being globally exposed . . .

If privacy is to emerge as a meaningful public value, it will be in the context of community involvement. Where else can we learn what needs respecting about each other, if not from a knowledge of the other person in particular and of the requirements of a healthily functioning community in general.

Here’s a simple principle to consider: if you are clearing the way for a new form of data transaction, or proposing some new mechanism for data privacy, then spend at least three times as much effort working towards a means for strengthening community outside those data contexts. Otherwise, you may well be helping to destroy the essenial milieu for any privacy worth having.

So how do we think about Talbott’s arguments when it comes to health care? Several challenges quickly come to mind.

  • How do we sensitize large institutions that manage medical information to the concerns of the community? In other words, how do we get medical institutions to care?
  • The emergence of ubiquitous computing in health care — RFID tags, remote sensing, medical surveillance and the like — presents special challenges when it comes privacy. Where is the community context for this technology?
  • What about privacy in the 2.0 world, where health information divulged in one social media, is collected for say commercial use in another?

Health care, as I have said many times, is the poster child for digital privacy issues.

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My 10 Top “Out-of-the-Box” Questions for Health Care

Very early depiction of Cygnus atratus, given the title

Image via Wikipedia

The method to much of my blogging madness has been to read widely in areas on the fringes or loosely connected to health care, and then try to think about the relevance (to health care) of the ideas, metaphors or insights the works may generate. I then take some of these conceptual rocks (or questions) and throw them into the web’s health care pond and look at the ripples. All this, I readily admit, is my personal strategy for dealing with intellectual entropy and boredom.

I believe a little redundancy will help in my effort to create bigger ripples – some of the boulders I’ve lobbed in are quite large. So here for your review are my “10 Top “Out-of-the-Box” Questions for Health Care.”

  • Globalization: Why are we so insular and provincial when it comes to health care? Can health care become an important factor in re-establishing America’s ‘Soft Power’ in the world? (more..)
  • Privacy 2.0: Are we paying enough attention to the changing nature of health care privacy in the Web 2.0 world? (more…)
  • Everyware: How do we as citizens contend with ubiquitous computing surveillance (ambient, RFID etc) when it comes to health care? (more …)
  • Black Swans: Is what we don’t know about health care far more relevant than what we do know? (more…)
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Will the “Moment of Complexity” Be Coming to Health Care?

A Möbius strip, an object with only one surface and one edge; such shapes are an object of study in topology.

Image via Wikipedia

(Cross posted at World Health Care Blog)

Mark C. Taylor‘s intriguing book, The Moment of Complexity: Emerging Network Culture, is one of those brilliant boiling pot examinations of social theories and philosophy which forces one to think and re-think where we are heading in this new flat world. Of course, when confronted with such intellectual challenges, my initial thoughts are always to line up the questions good authors generate and put them to the test in health care — my personal anchor to all things real and important.

The processes of globalization and proliferation of information technology, according to Taylor, is “creating a new network culture whose complex logic and dynamics we are only beginning to understand.”

Falling between order and chaos, the moment of complexity is the point at which self-organizing systems emerge to create new patterns of coherence and structures of relations.

Poised between too much and too little order, the moment of complexity is the medium in which network culture is emerging.

Taylor is studying that site between chaos and catastrophe, where boundaries are shifting, power relationships are becoming quite shaky, but order has not been overthrown – at least not just yet. And in theory it is never quite eliminated because “separation is always incomplete, for we remain entangled with that from which we struggle to escape” as Taylor puts it.

So a question that this theoretical assault raises for health care could be this: Will there be a “moment of complexity” where the ‘grid’ that structures health care — the systems, hierarchies, roles, science, authority and the rest of it — gets, well . . . torqued. As he describes,

Whereas walls divide and seclude in an effort to impose order and control, webs link and relate, entangling everyone in multiple, mutating, and mutually defining connections in which nobody is really in control. As connections proliferate, change accelerates, bringing everything to the edge of chaos.

One could argue that the brewing excitement in US health care — the crisis of health care costs, the catastrophe often proffered by futurists and economists, the explosion of health 2.0 and beyond, the perplexity of the public will — all speak to our hapless entry into this unnerving social space: health care’s very own ‘moment of complexity.’ The future may well indeed already be here.

One of the problems of being in this space, says Taylor, is the issue of whether the noise, the information glut, and the “confusion and debilitating sense of vertigo” it engenders will overwhelm the controls. For health care, that possibility could have both liberating and devastating consequences.

One response is to simplify and strengthen the stranglehold of the authority structures that govern and control medical practice and information distribution. Yet, if complexity is inevitable, then these attempts although well intentioned, will be more or less futile. No, the question really revolves around focusing our intellectual attention to this changing landscape, its “fluid dynamics” and how we adapt to its effects.

Taylor argues that education is the currency of the realm in network culture. If that is the case, then how we train our physicians, nurses, allied health professionals, technicians and the rest will be of critical importance in confronting this emerging challenge.

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Health Care Challenges in the “Post-American World”

The Post-American World

Image by ~C4Chaos via Flickr

(Cross-posted at the World Health Care Blog)

Fareed Zakaria argues in his new book “The Post-American World“, that the problem America faces in the new emerging international sphere is not so much domestic decline, but rather more “the rise of the rest.” By this he means that countries all over the world “have been experiencing rates of economic growth that were once unthinkable.” This is resulting in shifting of the balance of power, the movement from a unipower world with America at the center, to a world of “many actors, state and non-state” where there is no center. The challenge in such a world, according to Zakaria, is “how to stop the forces of global growth from turning into the forces of global disorder and disintegration.”

In this new “Post-American World”, Zakaria asks “will international life be substantially different in a world in which the non-Western powers have enormous weight?” Will Washington be able to “adjust and adapt to a world in which others have moved up?” And can we thrive in a world we cannot dominate? In America, “new thinking about the world is sorely lacking” and our isolationism has left us quite unaware of the world beyond our borders.

We also suffer from a “dysfunctional politics”, Zakaria writes, one characterized by gridlock and partisanship, which prevents us from beginning “a generous effort to engage the world.” The future is already here.

The task for today is to construct a new approach for a new era, one that responds to a global system in which power is far more diffuse than ever before and in which everyone feels empowered.

And organizing coalitions has become a primary form of power. Real solutions require,

creating a much broader coalition that includes the private sector, nongovernmental groups, cities and localities, and the media. In a globalized, democratized, and decentralized world, we need to get individuals to alter their behavior.

Now here is where health care begins to enter into the “Post-American” picture.

While Zakaria complains that health care costs “have risen to  point that there is a significant competitive disadvantage to hiring American workers,” — and will not be an easy fix — he strongly believes that “America will remain a vital, vibrant economy, at the forefront of the next revolution in science, technology and industry — as long as it can embrace and adjust to the challenges confronting it.” The United States “has been and can be the world’s most important continuing source of new ideas, big and small, technical and creative, economic and political.”

In fact two of the industries he cites as examples are nanotechnology and biotechnology.

So where does Zakaria’s analysis leave those of us in health care. Here are a few thoughts.

  • Health care reform in the US is not just a domestic priority but an international one as well. It is both part of the problem and part of the solution to America’s future position in international affairs.
  • As I have argued a number of times before( here, here, and here ) American health care can become a stronger component of our international ‘soft power’ because it is a valuable and desired center around which international coalitions can be formed.
  • The world (and the US) has yet to full advantage of the emergence and development of Health 2.0. What an opportunity for a technology which emphasizes social networks to bring the world a bit closer together around a major concern of all countries– health care.
  • The time to bring America’s involvement in world health care to the next level is now.

Health care can help to renew America’s legitimacy to act, in Zakaria’s words as an “honest broker’ in world affairs. It is time for US health activists to think global and take leadership in this important challenge.

China Asks: “My friends, What Do You Want From Us?”

Thanks to C’est La Vie.

–This article is quoted from cbc forums, in response to the protests against China Olympic Games.

What do you want from us?

When we were called “sick man of Asia”, we were called peril.
When we billed to be the next superpower, we’re called the threat

When we closed our doors, you smuggled drugs to open markets.
when we embrace free trade, you blame us for taking away your jobs.

when we’re falling apart, you marched in your troops and wanted your fair share.
when we’re putting the broken pieces together, “Free Tibet” you screamed! “it was invasion.”

So we tried communism, you hated us for being communist.
So we embraced capitalism, you hate us for being capitalist,

Then we have a billion people, you said we’re destroying the planet.
Then we limit our numbers, you said it was human rights abuses.

When we were poor, you think we’re dogs,
When we loan you cash, you blamed us for your debts.

When we build our industries, you called us polluters.
When we sell you goods, you blamed us for global warming,
When we buy oil, you called that exploitation and genocide.

When we were lost in chaos and rampage, you wanted rule s of laws for us.
When we uphold law and order against violence, you called that violation of human rights.

When we were silent, you said you want us to have free speech.
When we were silent no more, you say we were brainwashed.

Why do you hate us so much? We asked. “No”. You answered, “we don’t hate you”.
We don’t hate you either Bud, do you understand us?? “of course we do”, you said, “We have CNN, BBC, and CBC”.

But why, we still feel, your western people are not happy with us.

What do you really want from us?

My friend, What do you really want from us?

Let’s Stop Playing the Healthcare Blame Game

More notes from the final day of the AHIP 2008 National Health Policy Conference:

US Senator Ron Wyden took the stage first thing this morning. He’s a frequent speaker at this conference usually focusing on his ‘Healthy Americans Act’ as a step towards real healthcare reform. He says the first 100 days for the new president will be critical for healthcare. Democrats — if they win — will need to put something on the table quickly. Congress is getting ready to act and Wyden does not want a repeat of the now infamous Clinton failure of 1994. This time there is an opportunity to do healthcare reform right. He wants a system where everyone has a basic private portable health insurance plan.

Recent history shows states cannot fix healthcare by themselves because the big drivers are federal, such as Medicaid and Medicare. And if we don’t fix the private market, the country will go single payer. Wyden wants a new private health insurance market that breaks the dependence on employer-sponsored coverage. His plan would still offer a choice of an employer plan. But his ‘Healthy Americans Act’ now before Congress would provide for an alternative to both single payer, and an over-dependence on employer-sponsored healthcare.

But how will health insurers respond to these proposed new changes? Cajoling his audience of health plan representatives, he argues that his approach would be one way to stop playing the healthcare blame game, replete with its usual designated healthcare villain of the day being held responsible for all that is wrong in healthcare. Health plans have all too often shared this distinction.

Andy Stern, President of Service Employees International Union, started his talk with an all-too-familiar tragic story of a healthcare disaster that end bankrupting an American family. He then switched gears to share the changes his own union has had to undergo to confront the new global economy. Healthcare, he believes, has also not reacted well to this new global economy. What we have now is a healthcare sector; what we need to build is a healthcare system. “Change is inevitable but progress is optional,” he lamented.

If there is one truth about healthcare reform, Stern believes, it is that the longer you wait, the worse it gets. And the US employer-based healthcare system is not sustainable for the economy of the future. It is dead and it’s time for hard choices. We need to move on to a more competitive approach. But he doesn’t think the country is ready, willing or able to go for a single payer system. We have to build a broader coalition on healthcare and negotiate a new blend in order to move on.

Stern warned that there is a big target painted on health insurers and the bullets are getting closer. Health insurers will have to walk in a new direction. People are ready for change. But where is the solution? “Be the agents of change”, he charged, “not the assassins of change”.

Gail Wilensky, Senior Fellow, Project Hope and a former Medicare chief, observed that even when we have expanded access to healthcare — such as the recent addition of drug benefits to Medicare, we still have problems with cost and quality. Medicare’s cost is unsustainable and its population is becoming more politically forceful. The program’s provider financial incentives are perverse and its spending constraints are ineffective when it comes to value and quality. It will be an immense challenge to moderate the Medicare’s cost growth.

Bruce Vladeck, Senior Health Policy Advisor, Ernst & Young, and also a former Medicare chief noted that the healthcare reform proposals put forth by the presidential candidates rarely mention Medicare or Medicaid. Problems with Medicare are the problems with the healthcare system generally speaking. He argues that Medicare costs — even with new efficiencies — cannot be sustained without new money. Politicians need to be more open and explicit about this hard fact. And he adds, that we must stop confounding the problems having to do with improving the quality of healthcare, with the problems of moderating the cost of care. It is a fantasy, he says, that improved quality will save serious money in healthcare.

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