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.”
Texas anti-abortion law shows ‘terrifying’ fragility of women’s rights, say activists | Global development
The new anti-abortion law in Texas is a “terrifying” reminder of the fragility of hard-won rights, pro-choice activists have said, as they warn of a “more aggressive, much better organised [and] better funded” global opposition movement.
Pro-choice campaigners have seen several victories in recent years, including in Ireland, Argentina and, most recently, Mexico, where the supreme court ruled last week that criminalising abortion was unconstitutional. Another is hoped for later this month when the tiny enclave of San Marino, landlocked within Italy, holds a highly charged referendum.
But Texas’s law, which bans abortions after about six weeks, once embryonic cardiac activity is detected, and does not make exceptions for incest or rape, has sent shock waves around the world, making pro-choice activists realise they can take nothing for granted.
Sarah Shaw, head of advocacy at MSI Reproductive Choices, said: “Even though we have seen little gains here and there, in some places, we can never, ever be complacent because we’re only ever really hanging on to these rights by the skin of our teeth.”
She said the Texas law was “really terrifying” because of the emboldening message it sent to other anti-choice governments and organisations, with the fact it had happened in the US giving it “a huge weight and legitimacy”.
“This is all happening in the context of a rising, much more aggressive, much better organised, better funded and much more legitimised opposition movement than we’ve ever seen before,” Shaw said.
Pro-choice campaigners say they have faced increasingly vocal opposition from organisations that started on the US religious right but have spread to other countries, such as 40 Days for Life, a group that distributes graphic and misleading leaflets to women outside UK abortion clinics.
Heartbeat International, a conservative US Christian federation, funds and coordinates a network of anti-abortion “pregnancy resource” centres, many of them in sub-Saharan Africa, to provide women with what it calls “true reproductive help”.
“It’s a transnational movement now,” said Shaw. “What we’re seeing is them [US organisations] exporting their playbooks and their money overseas.”
Attacks on abortion rights usually happen in countries where other human rights are under threat, according to analysts. Last year, more than 30 countries, many of them led by authoritarian strongmen or rightwing populists, including Belarus, Uganda, Hungary, Egypt and Donald Trump’s US administration, signed a non-binding anti-abortion document known as the Geneva consensus declaration. The text was also seen as being anti-LGBTQ, as most of the signatories had not legalised same-sex marriage and several prosecute their LGBTQ+ citizens.
Among the signatories was Poland, which is one of only three countries to have significantly rolled back abortion rights since 2000, according to the Guttmacher Institute. The other two are Nicaragua and the US.
In October last year, Poland’s constitutional tribunal ruled that terminations due to foetal defects were unconstitutional. Three months later, a near-total ban on abortions was imposed. Abortion is now only legal in the case of rape, incest or a threat to the mother’s health.
Meanwhile, human rights observers have said that a Nicaraguan law punishing abortion without any exceptions, passed in 2006, has simply forced women to seek unsafe backstreet terminations.
Marge Berer, coordinator of the International Campaign for Women’s Right to Safe Abortion, said setbacks were all too common, with breakthrough moments often followed by backlashes.
“My experience of this is one step forward, two steps forward, or one step back, 10 steps back,” she said. “And much of it, if not all of it, depends on who is the head of the government of the day.”
Berer, who has been involved in the pro-choice movement for almost 40 years, said the overall picture was brighter than it had been then: fewer deaths from unsafe abortions, and many more countries where terminations are legal.
But, she added, she was not hugely optimistic about the future. “There’s so much misogyny in the world. And I don’t know how anybody is going to make that go away,” she said. “For me, that’s the real problem. It’s that when misogyny takes over on a policy level, it’s very nasty.”
However, there is more hope among activists in Latin America, where the marea verde, or green wave, has swept through first Argentina and, last week, Mexico, where the supreme court struck down a state law that imposed prison terms for having an abortion. While it did not automatically legalise abortion, the decision is thought to set a binding precedent for the country’s judges.
Eugenia López Uribe, regional director of the International Planned Parenthood Federation, said the legal change was the result of “40 years of hard work” by campaigners, with mass demonstrations, backroom lobbying and “a mainstreaming” of women’s rights in public discourse.
She said the ability of the Catholic church to tell people what to do when it came to abortion and contraception had been greatly reduced. “What we know from different surveys … is that in reality Catholics … feel that this is a private decision that you have to do with your own conscience.”
As women in Texas bear the brunt of the law brought in by the governor, Greg Abbott, their Mexican allies across the border were planning to take the fight north, she added.
“The ‘green wave’ hasn’t reached the United States so this is a very good opportunity for [it] to cross the border of the Rio Grande and go to the United States. We can make it go even further. We’ve been used to thinking about it in Latin America. Now is the time for North America.”
France attacks US over ‘stab in back’ submarine deal
France has called a US deal to develop nuclear-powered submarine technology with Australia and the UK, but not any EU countries, unveiled Thursday, a “stab in the back,” in the words of French foreign minister Jean-Yves Le Drian. The move is to see France lose out on a multibillion-euro submarine-technology deal with Australia. “This is not over. We’re going to need clarifications. We have contracts,” Le Drian added.
‘A forgotten disaster’: earthquake-hit Haitians left to fend for themselves | Global development
David Nazaire, a 45-year-old coffee farmer from Beaumont, a small village in rural southern Haiti, was getting ready to harvest when an earthquake struck his home and livelihood. Much of the farming infrastructure – as well as nearby homes, schools and churches – was damaged or completely destroyed. A month later, he and thousands of rural Haitians – those most severely affected by the tremor – are still waiting for relief, and are not expecting it to arrive soon.
“The earthquake didn’t destroy our crops, but it did take everything else,” Nazaire says, outside a neighbour’s house, now a pile of rubble beneath plastic roof tiles supported by the remnants of concrete walls. “We were just getting ready to harvest, but that’s lost now.”
The 7.2 magnitude earthquake that struck southern Haiti on 14 August killed more than 2,200 and left 30,000 homeless. But while foreign aid and builders have been trickling into urban centres such as Les Cayes, the capital of Sud province, and other quake-struck areas, many rural Haitians see an all too familiar abandonment.
“Haiti has always been divided between an urban professional class and the ignored rural communities,” says Estève Ustache, 58, a researcher on rural development attached to a Methodist church outside Jeremie, another quake-struck town. “You have to ask yourself, why do leaders and aid workers only travel to these rural areas in a helicopter? Because they know it would be nearly impossible to go otherwise.”
Haiti is the poorest country in the western hemisphere, where nearly half of the 11.4m population is food insecure. But the poverty in which rural Haitians – who make up two-thirds of the population – live is startling, even by the country’s own abject standards.
The drive to Tricon, a rural hamlet just a few miles from Les Cayes – the regional capital – takes more than an hour. The road has never been paved and heavy rains can leave it impassable. Communities live in shacks built partly from material scavenged in the city. The phone signal is unreliable, and aside from a handful of community-built wells, there is no water supply.
“Everything we have, we built ourselves,” says Moise Magaly, 49, who was tending to her bean crops when the earth beneath her began thrashing, throwing her to the ground and making her arm “go crack”.
Most in the community are gaunt, after a dry spell that led to crops of cassava, beans and corn failing to yield their usual harvest. Vetiver, a cash crop often used to combat soil erosion, has been over-farmed in the area, further damaging the land.
Magaly’s house was damaged in the earthquake, knocking out the walls but leaving the roof standing on top of wooden struts. Like almost everyone else in southern Haiti, the fear of aftershocks and another quake has kept her sleeping outside, vulnerable to the Atlantic hurricane season.
“I don’t know why no one comes for us,” Magaly says, clutching at her arm. “We’ve contacted the media and our representatives but we’ve heard nothing.”
Aid has arrived in the country, with the US delivering more than 60 tonnes of aid to quake-hit regions, while Britain has pledged £1m of support, including shelter kits and solar-powered lanterns.
But some working on the relief effort worry that as international compassion wanes, so too will the funds from donors.
“It’s a very poor area, where people don’t have the resources or the funds for materials to build their houses well,” says Kit Miyamoto, a structural engineer who runs a firm and foundation that works in Haiti and around the world to improve earthquake preparedness. “And this is a forgotten disaster because it happens out of the eyes of the world, which means there will be less funding.”
Miyamoto adds that rural homes, churches and schools were more affected than those in cities because many of them were built before 2010, when improved building codes were adopted nationwide after a catastrophic earthquake struck the capital Port-au-Prince, killing more than 200,000.
“Construction is different now, and people are more conscious of how to build in a way that does the little things right, and makes the difference,” Miyamoto says.
But despite growing awareness of resilient construction techniques, the relief effort remains hampered by the sheer isolation of the most affected communities, and some are giving up hope.
“No one has been here since the earthquake. Just like before, the only time we see an outsider round here is when they want our votes,” says Altema Jean Joseph, a 52-year-old farmer who grows vetiver, an ingredient used in expensive perfumes which, despite costing $25,000 (£18,000) a barrel, makes farmers only $4 a week. “So why would we expect them here? We’ll have to build back ourselves.”
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