Brain Drain and Ex-pats
Submitted by Saurabh (Harry) Jha, an Associate Professor of Radiology at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. Dr. Jha is also a member of the Applied Radiology Editorial Advisory Board, a writer, and a global radiology enthusiast. He can be reached on Twitter @RogueRad.
The last straw for Funmi Ogunlesi, MBBS, was a demand for a sick note. In some ways it was like every other demand for a sick note, but this person was particularly irate, particularly entitled, and particularly medically undeserving. Or perhaps Dr. Ugunlesi was particularly tired of signing sicknotes, on which she felt her medical degree was being wasted. She was already overburdened by the ever-increasing boxes that general practitioners had to tick. In a bold but well-thought-out decision, she resolved to leave Britain’s National Health Service (NHS) to practice medicine in her ancestral land, Nigeria.
Dr. Ogunlesi’s journey from London to Lagos defies gravity. At the 2022 Association of Radiologists in Nigeria (ARIN) meeting in Lagos, brain drain – the emigration of skilled professionals, such as physicians, from low- and middle-income countries (LMICs) to developed countries, was cited as one of the threats to Nigerian radiology. Brain drain isn’t unique to Nigeria. Doctors from the Indian subcontinent have long propped up Britain’s NHS at bargain prices. Americans also rely on foreign medical graduates, particularly to care for underserved populations and veterans. The healthcare infrastructure of developed countries is cemented by brain drain from LMICs.
Brain drain isn’t as simplistic as the West “stealing” resources from LMICs. The benefit is mutual. Those who leave have worked hard and want better lives for their family, better education for their children, and better professional opportunities for themselves. In short, they want higher rewards for their talent and hard work. Brain drain is a particular issue in tech-driven, capital-intensive fields such as radiology.
The typical scenario described at the meeting is that of young radiologists doing electives at academic centers in the US to develop expertise in advanced imaging. When they return to Nigeria, they get frustrated by routine imaging such as ultrasound and radiography. They long for the sophistication of 3T brain MRI. Their emigration is arguably motivated more by technological sophistication than financial remuneration. But brain drain is only one part of the story.
Shortly after becoming a doctor, Dr. Chinedum Anosike, Consultant Radiologist, Warrington and Halton Hospitals, UK, went to the UK to become a radiologist. He has a knack for teaching radiology. His children, settled in public schools, are destined for British universities. Dr. Anosike has complex feelings about brain drain. Having left Nigeria, he doesn’t wish to hector radiologists who also wish to leave the country. But he does think their expectations should be managed. For example, they should be aware that many hospitals in the UK restrict Nigerian radiologists to reading only radiographs and ultrasound scans.
His ties with Nigeria remained strong because his parents still lived there. The state of Nigerian healthcare became a personsal issue when his father had septicemia six years earlier. Dr. Anosike noted that progress in Nigerian hospitals is uneven. The standards in surgery and medicine are higher than in radiology. Yet, physicians, growing more reliant on radiology reads, were increasingly reluctant to dispense therapy empirically. Dr. Anosike doubled up as a radiologist to his father, and to other patients in the intensive care unit. He made several management-altering findings, including a lung abscess in one patient. His father, sadly, succumbed to sepsis.
Feeling a moral debt to fill the imaging expertise void, Dr. Anosike founded a teleradiology company , Accuread, with Dr. Hammed Ninalowo, an interventional radiologist who works at Euracare, Lagos. Accuread provides Nigerian hospitals with specialist reads, such as cardiac MRI for congenital heart disease. Accuread also double reads Nigerian radiologists, filling an educational as well as a clinical role.
Dr. Anosike’s team comprises twenty radiologists, mostly Nigerian ex-pats, who put in an extra three to six hours a day for paltry fees, which doesn’t seem burdensome to Dr. Anosike, who is still a fulltime NHS radiologist. High-quality reads are an ethical minimum for Dr. Anosike. He views the choice between quality and access in healthcare a false one. I might quibble with him on that point, but I understand the sentiment that one shouldn’t lower their professional standards just because they’re working in an low-to-middle income country (LMIC).
Farouk Dako ,MD, assistant professor of radiology at the University of Pennsylvania, Philadelphia, Pennsylvania, remembers fondly his boarding school days in Lagos. Dr Dako recalls a particularly amusing episode in school. On hearing the sound of artillery from a nearby barracks, his teachers, fearing an attack, fled, leaving the children to fend for themselves. Dr. Dako’s journey for higher education in the US was motivated more by a sense of adventure than by frustration with his homeland. He dreamt of becoming a public health physician at Johns Hopkins University. Though he became spellbound by radiology, he still views public health as his true calling.
Dr Dako’s father, Mamudu Dako, MD, is a successful physician treating underserved people in Lagos at the Dako Medical Center. But his obligations to Nigeria aren’t just filial. For Dr Farouk Dako, Nigeria is an extension of his academic mission. He wants to build a center for radiogenomics in Nigeria – a data repository which will give insights into disease and treatment subtleties for Africans. He views imaging as means to improving population health. Dr Dako encourages US radiologists to help Africa. But he cautions against the “Instagram Radiologist,” the type who travels to Africa principally for a selfie with a rhinocerous. Global work, he believes, requires commitment, and he discourages dilettantes. Ultimately, global radiology should become a bona fide academic discipline with measurable goals.
Udunna Anazodo, PhD, assistant professor in neurology and neurosurgery, atMcGill University in Montreal, Canada, has happy and painful childhood memories of Nigeria. Dr Anazodo enjoyed a charmed childhood until her father’s death, resulting in the plummeting of the family’s economic status. In a heavily patriarchal society where a woman’s status depends on her husband, Dr Anazodo’s mother, a highly educated woman, lost her job upon becoming widowed.
Poverty struck mercilessly. Dr Anazodo recalls starvation on a level that cannot be understood in the abstract. Months after her father’s death, she nearly died from a misdiagnosed viral infection. She immigrated to Canada, parting with a visceral hatred of Nigeria. With growing academic success, she increasingly viewed herself as privileged and lucky, and her perspective on Nigeria began to change. Years after the tragedies that struck her family, as a medical physicist with an expertise in PET/MRI at McGill University she began feeling a deep moral obligation for the country she once despised.
Dr Anazodo established an organization called CAMERA – the Consortium for Advancement of MRI Education and Research in Africa---to provide diagnostic imaging training opportunties across Africa. Along with Dr. Abiodun Fatade, CEO of Crestview Radiology, Lagos and colleagues from the CAMERA network, she opened a medical artificial intelligence laboratory in Lagos to initiate indigenous AI research in Nigeria. The lab’s first task is to aggregate annotated brain MR images for data scientists and epidemiologists. Africa is the ultimate free market for MRI scanners, with wide variation in scanner prices, quality of magnets, and radiology services. By employing AI applications, such as image enhancement, she hopes to bring equity to imaging services. With CAMERA, Dr. Anazodo also hopes to nurture home-grown radiologists, biomedical engineers, and physicists to fight brain drain. This is a long journey, but all great endeavors start with a first step.
Dr. Ogunlesi faced another type of frustration when she returned to Nigeria. It wasn’t the frustration of watching waste in a country of plenty but the frustration of not being able to deliver enough in a country of scarcity. She watched patients die from renal failure because of the shortage of dialysis machines. She watched her diagnoses go untreated. Still, Dr Ogulesi doesn’t regret her decision to return. She prefers the the frustration of not being able to do enough to the frustration of having to do too much that’s clinically irrelevant.