The loss of frontline health workers dying of Covid around the globe, is being compounded in the hospitals of developing nations by trained medical staff leaving to help in the pandemic effort abroad, according to experts.
With new Covid waves in Africa, and with Latin America and Asia facing unrelenting health emergencies, the number of health worker deaths from Covid-19 in May was at least 115,000, according to the World Health Organization. Its director-general, Tedros Adhanom Ghebreyesus, acknowledged data is “scant” and the true figure is likely to be far higher.
In richer countries, the share of foreign-trained or foreign-born doctors and nurses has been rising for two decades. But the pandemic’s double blows of death and migration are leaving behind knowledge gaps in already fragile health systems, where poor pay and conditions are driving staff to leave, say advocates and health workers.
Global health specialists are launching initiatives to protect medical staff, and incentivise them not to be enticed abroad.
Women in Global Health, an international network advocating for equality, has jointly launched what it calls “a new social contract for women in the health and care workforce”. The Gender Equal Health and Care Workforce Initiative, a partnership between the WHO, Women in Global Health and the French government, aims to strengthen policy investing in and protecting workers.
“Health workers are exhausted, many want to leave. We cannot afford to lose one single worker at this time,” says Dr Roopa Dhatt, executive director of Women in Global Health. “Investing in women is the best investment we can make for all our futures and the future of health security.”
The world is reliant on women to deliver health and care services, Ghebreyesus told the Generation Equality Forum, where the first round of commitments to the initiative was announced on 1 July.
Women account for about 90% of nurses and midwives, close to 50% of all doctors, and make up 70% of all health and care workers worldwide.
“This reliance demands that we ask ourselves tough questions on workplace conditions and equity, including how we value and reward women in the health and care workforce,” Ghebreyesus said. “And how we guarantee that workplaces are free from discrimination, violence, sexual exploitation and abuse.”
As governments – including those of Mexico, Pakistan, the Democratic Republic of Congo and Liberia – commit to the gender policy initiative, Dhatt said that millions of health and care workers were unpaid or underpaid and had no access to Covid vaccines.
“We must provide incentives for women to stay,” said Dhatt.
The global south has long supplied many of the human resources for health systems in the northern hemisphere. And as the UK, the US and Europe have struggled under the weight of their respective pandemics, demand for imported medical expertise has intensified.
Across the world’s wealthiest countries, nearly 25% of doctors and 16% of nurses were born abroad, according to a brief from the Organisation for Economic Co-operation and Development (OECD). Published in May, it examined how rich countries have sought to attract staff from developing countries in response to the pandemic.
It acknowledged that nations from where staff were being enticed “were already facing severe shortages of skilled health workers before the Covid-19 pandemic”.
The UK launched its own incentive – a fast-track Health and Care Visa in 2020 to attract more health workers from developing countries – even as the government drastically reduced its foreign aid budget from 0.7% to 0.5% of national income, against OECD advice and putting global health systems at risk, according to academics.
The Philippines is the largest contributor of nurses to wealthy countries, OECD data shows. India provides the highest number of doctors, and the second-highest number of migrant nurses.
Mitigating push factors for professionals to leave their countries requires policy to “reinforce international cooperation, notably overseas development assistance and technical assistance, to help less advanced countries build up a sufficient health workforce and to strengthen their health systems”, the OECD brief said.
The Filipino Nurses Association UK has raised concerns about the disproportionately high rate of deaths among NHS and social care staff from the Philippines, saying that the nationality had the highest mortality of all ethnicities, at about 20%. The group set up a special helpline for Filipino health workers and their families as a result. In the US, more than 30% of nurses who have died of Covid were Filipino, though they make up just 4% of the country’s registered nurses, according to the National Nurses United union.
In the Philippines, two prominent specialists died of Covid in March 2020: paediatric surgeon Leandro Resurreccion III and Salvacion “Sally” R Gatchalian, the president of the Philippine Paediatric Society.
Gatchalian helped create the Philippines Coalition Against Tuberculosis and led a children’s TB initiative, while Resurreccion was lauded for having returned from Australia to dedicate himself to the Philippines’ health service.
Highly skilled researchers are scarce in low- and middle-income countries, said Glenda Gray, president of the South African Medical Research Council, adding: “Any loss of scientists, either through death or migration, is a concern.”
In fragile health systems, lost knowledge when a community health worker or highly trained medical expert dies can have a long-term impact. And research suggests physician migration costs low and middle income countries $16bn (£11.5bn) annually and lost medical knowledge contributes to excess deaths.
With emigration rates of doctors and nurses as high as 50% from some African and Latin American countries, it can mean that more doctors born in these countries are working in the OECD area than in their countries of origin.
Africa’s research community lost renowned HIV scientist Gita Ramjee to Covid in March 2020.
“Gita was fundamental and inextricably linked to the endeavours to find solutions to prevent HIV in women. She was tireless in this pursuit, her tenacity will never be forgotten,” Gray said. Winnie Byanyima, executive director of UNAIDS, said Ramjee’s loss was “when the world needs her most”.
“The psychological impact of deaths, infections and [increased workloads] prompted many doctors to request leave and, in the event of management refusal, some resorted to resigning from governmental hospitals,” Egyptian physician Abdel Hamid Mahmoud said.
Johan Fagan, an ear, nose and throat disease specialist at the University of Cape Town in South Africa, said policies such as the UK’s fast-track visa would spur further migration.
“These countries aren’t training enough of their own healthcare professionals and are exploiting the workforce in developing countries,” Fagan said. “In a pandemic, this has a significant impact on our health systems and how we’re able to deliver care.”
Algerian Dr Al Arabi Bin Hara predicted a new exodus of skilled workers from his country, saying: “Last year and at the beginning of this year, there was the smallest number recorded in doctors’ immigration because of the closed borders as [a result] of the measures imposed by the pandemic.
“The post-Covid phase will witness a mass flight of doctors, as long as the situation remains as it is and the suffering continues.”
What hurts, said Bin Hara, is that hospitals and clinics in Europe – particularly in France – were attracting Algerian doctors with critical specialisations.
In Zimbabwe, a country with one of the highest doctor emigration rates, Dr Charles Moyo said Africa would face a healthcare crisis if the tide of health worker losses was not stemmed.
“The healthcare system is already strained by limited resources and by Covid. If more manpower is lost, the entire healthcare system could collapse,” he said.
The International Council of Nurses (ICN), which has backed the Gender Equal Health and Care Workforce Initiative, celebrated the World Health Assembly’s adoption of the WHO’s updated global nursing and midwifery strategy, which presents policy priorities to support midwives and nurses.
ICN chief Howard Catton said the message was clear, adding: “We must invest now in nursing education, leadership, jobs and practice, and we need member states to own their new strategy and implement it now.
“Of course, the tragic irony is that if we had done this before, we would have had a better protected healthcare workforce, and fewer of our colleagues would have died.”
EU not evacuating staff from Kyiv
The EU will not evacuate its staff from Kyiv, the bloc’s foreign affairs chief Josep Borrell said on Monday before the meeting of EU foreign affairs ministers, who will have a video conference with US secretary of state Anthony Blinken. “Blinken will explain the reasons for this announcement, we are not going to do the same thing, […], we don’t have to dramatise, the negotiations are going on,” Borrell said.
‘I’ve already sold my daughters; now, my kidney’: winter in Afghanistan’s slums | Global development
The temperature is dropping to below zero in western Afghanistan and Delaram Rahmati is struggling to find food for her eight children.
Since leaving the family home in the country’s Badghis province four years ago, the Rahmatis have been living in a mud hut with a plastic roof in one of Herat city’s slums. Drought made their village unliveable and the land unworkable. Like an estimated 3.5 million Afghans who have been forced to leave their homes, the Rahmatis now live in a neighbourhood for internally displaced people (IDP).
There are no jobs. But the 50-year-old has hospital fees to pay for two of her sons, one of whom is paralysed and the other who has mental illness, as well as medicine for her husband.
“I was forced to sell two of my daughters, an eight- and six-year-old,” she says. Rahmati says she sold her daughters a few months ago for 100,000 afghani each (roughly £700), to families she doesn’t know. Her daughters will stay with her until they reach puberty and then be handed over to strangers.
It is not uncommon in Afghanistan to arrange the sale of a daughter into a future marriage but raise her at home until it is time for her to leave. However, as the country’s economic crisis deepens, families are reporting that they are handing children over at an increasingly young age because they cannot afford to feed them.
Yet, selling her daughters’ future was not the only agonising decision Rahmati was forced to make. “Because of debt and hunger I was forced to sell my kidney,” she tells Rukhshana Media from outside her home in the Herat slum.
Afghanistan is on the brink of “a humanitarian crisis and economic collapse”, according to the UN. The agency’s ambassador to Afghanistan has said it is “experiencing the worst humanitarian crisis of its contemporary history”. Drought, Covid-19 and the economic sanctions imposed after the Taliban seized power in August 2021 have had catastrophic consequences on the economy. Dramatic rises in inflation have resulted in soaring food prices.
The kidney trade has been growing in Afghanistan for some time. But since the Taliban took power, the price and conditions under which the illegal organ trade takes place has changed. The price of a kidney, which once ranged from $3,500 to $4,000 (£2,600 to £3,000), has dropped to less than $1,500 (£1,100). But the number of volunteers keeps rising.
Rahmati sold her right kidney for 150,000 afghani (£1,000). But her recovery from the operation has not been good and now, like her husband, she is also sick, with no money left to visit a doctor.
More than half of the country’s estimated 40 million population face “extreme levels of hunger, and nearly 9 million of them are at risk of famine”, according to the UN refugee agency, UNHCR. For a growing number of Afghans, selling a kidney is their only way to get money to eat.
“It has been months since we last ate rice. We hardly find bread and tea. Three nights a week, we can’t afford to eat dinner,” says Salahuddin Taheri, who lives in the same slum as the Rahmati family.
Taheri, a 27-year-old father of four, who scrapes together enough money for five loaves of bread each day by collecting and selling recycled rubbish, is looking for a buyer for his kidney. “I have been asking private hospitals in Herat for many days if they need any kidney. I even told them if they need it urgently, I can sell it below the market price, but I haven’t heard back,” Taheri says. “I need to feed my children, I have no other choice.”
In the past five years about 250 official kidney transplants have taken place in the hospitals in Herat province, with a very limited number being a family member donating their organ, says Asif Kabir, a public health official in the province. The cost of a kidney transplant is 400,000 afghani, plus the price of the kidney, according to Kabir.
But the true number of kidney operations may be far higher. A doctor working in one of the hospitals where most of the transplants take place, who spoke on the condition of anonymity, says: “Recently the number of people who want to sell their kidney has increased in Herat and most of them live in the displaced camps, in Herat’s slums. The customers also go to the displaced camps to find a cheap kidney.”
Sayed Ashraf Sadat, a civil society activist in Herat, was a member of a delegation assigned by president Ashraf Ghani to investigate the illegal kidney trade in May 2021.
“We found that the hospitals were not working according to the law. People are working inside and outside the country to encourage people to sell their kidneys. These people get them visas and send them to the other side of the border. There is more demand for kidney transplants outside Afghanistan. Countries like Iran need kidneys, and poor Afghans are forced to sell them.”
Sadat says the investigation he was part of identified two hospitals in Herat where kidney transplant operations take place; one of them said it had completed 194 operations and the other said 32, but more than 500 people were claiming to have sold their kidney, 100 from a single village in Herat. “This shows the kidneys were taken outside Afghanistan,” says Sadat.
“For example, a kidney is purchased for 300,000 afghani (£2,100) inside Afghanistan, and it is sold for more than £7,500 to £11,000 outside the country,” says Sadat.
“We found evidence that some are encouraged to sell their kidneys, taken outside the borders, and their kidneys are sold for 200,000 to 400,000 afghanis ,” says Sadat. “It seems that the doctors are involved in the illegal trade. But unfortunately, our investigation was stopped due to a worsening security situation.”
Two months have passed since Rahmati’s kidney operation, and the money has already gone to pay off medical debt. Her recovery from the operation continues to go badly.
“I am so sick. I couldn’t even walk because the wound has been infected. It is very painful,” she says, adding that the recipient of her kidney only paid for the operation fee, two nights in hospital and her first medicine bill.
On the day of the transplant, Rahmati was sick and the doctors refused to operate. “I couldn’t breathe properly, so the doctors took me down from the hospital bed, but I returned. I told them ‘I am happy with my own death, but I can’t tolerate seeing my children hungry and ill’,” she says.
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