What is to be done?
Nairobi International Airport – and it’s time for some difficult farewells. It helps that Nancy has her daughter Ruth waiting for her in England. ‘She is my consolation,’ she says.
Though it took more than one attempt, Ruth was able to join her mother because she was under 18. Nancy is fortunate. For many migrant workers the system cherry-picks their labour but rejects all excess ‘emotional baggage’ of family, partners, children – the elements that make for a warmer, rounder, more sustaining life.
Ruth is waiting with supper when Nancy gets home. Shortly the 19-year-old student will be doing work-experience at a local hospital. Last year she was offered a place to train as a nurse but had to forgo it for lack of funds. She needs to have lived in Britain for three years before she can pay the same fees as a local student. Otherwise the fees are exorbitant.
If Ruth gets trained in Britain and eventually takes those skills back to Kenya, then the flow of skills that started with Nancy coming to work in Britain will have gone full circle. ‘I will go back eventually,’ Ruth says. ‘But I think it would make sense to get a few years’ experience in England before I do that.’
She admits the prospect of working within the Kenyan public health system is not very appealing, given its current state. But she does not rule it out.
Race and immigration
It’s 9.30am and Nancy is back at work in the nursing home. Several residents are sitting at tables dotted informally around the pleasantly decorated common room.
It’s impossible not to notice the race dimension at the home. While the overwhelming majority of the 60 or so residents are white, nearly all the care and nursing staff are black or Asian. Most are international recruits coming from sub-Saharan Africa, Asia and the Caribbean.
In an earlier conversation I had asked Nancy if she had ever encountered racism at work. She replied that in a nursing home where she used to work, a resident refused to have her sores dressed by Nancy because ‘she could not believe that a nurse from Africa would be able to do it properly’. Given time, however, the resident adjusted her prejudices and when her regular carer left the home, she not only let Nancy do the dressing – but insisted that she continue doing so. ‘You just have to be patient and try not to take it to heart when people say things that can hurt you,’ says Nancy.
A few weeks after her return to Britain, British Conservative Party leader Michael Howard initiates a campaign against ‘immigration’ which he says is ‘out of control’. Australia is held up as a shining example of a country that has ‘the problem’ of migrants and asylum seekers ‘under control’.
As some commentators note, this is ‘dog-whistle politics’. What the Conservatives are really talking about is race, but they do not use the word and furiously deny any trace of racism when this is pointed out to them. But the ‘dog whistle’ has been transmitted and is heard and understood by those who are most attuned to hear it – those who want to hear it.
The politics of fear and xenophobia is taking its classic form, and very soon the Labour Party, not wishing to be outmanoeuvred in the run-up to a general election, starts making similar noises. Instead of coming clean about the extent to which the British economy – and others like it – depend on migrant workers prepared to do the jobs locals are not, the Labour Party insists that it has got immigration ‘under control’.
I am ashamed of what is going on and ask Nancy how it makes her feel.
‘I don’t think they can be talking about me. Are they going to send all foreign nurses back? I don’t think so,’ she says phlegmatically.
I wonder how the trip back to Kenya has affected Nancy and how she feels about the nurses she has left behind.
‘I want to bring them with me to England,’ she replies.
‘But what about the health situation in your own country?’
She pauses: ‘Listen, the nurses I saw in Kenya are so demoralized they are not working properly. So much is needed. When everything is in such a mess, where do you start?’ She recalls the scene in the hospital in Tigoni, where it seemed to her that nurses had just stopped nursing. ‘Not one of those patients was being cared for. You could tell. It’s not just a question of money. It’s morale too. If the Government cared for nurses and gave them some incentives then they would be willing to work.’
Nancy intends to return to Kenya in a few years’ time, once Ruth has settled into her studies. Would she consider going back into the Kenyan public health system, I ask?
‘They would not have me back. I’m over 50; they would consider me too old. If I go back into health work it will be on a voluntary basis.’
She is still planning to set up a clinic and has managed to buy a small plot in the poor Nairobi neighbourhood of Githurai, near to where her son Ayub lives. She is now in the process of obtaining the title deeds. ‘The clinic would be very low-cost and we would not charge the people who have nothing. I would just try to make enough to feed myself.’
If Nancy can make the clinic in Githurai a reality, keep costs low and use her skills as a nurse where they are so badly needed, it will undoubtedly benefit the local people.
But the crisis in medical staffing needs to be tackled on a macro, international scale too. Trying to put a block on international recruitment is a non-starter. Nor is it necessarily desirable. Why should health staff, specifically, be denied freedom of movement just because the work they do is important? And why should those coming from the poorest countries be especially discriminated against?
Nurses and doctors have always travelled and worked abroad. For many, one of the attractions of the job is that it is international and portable. Often health professionals do not work abroad merely for financial gain, but for the training opportunities it offers and the chance to work with new medical technologies.
So what are the possible solutions?
• Ethical codes to stop rich countries actively poaching medical personnel from developing countries appear to be a step in the right direction. But, generally, ethical codes – such as the Commonwealth Code – are weak and voluntary, and even those developing them realize that they are limited in effect. They also fail to answer the basic question: what right have we to discriminate against nurses and doctors from poor countries?
• Regulating and co-ordinating international recruitment through a central body could help set standards and protect migrant workers from some of the current super-exploitation. At the moment, unaccountable private agents recruit not only for the private sector, but also indirectly for public health services which poach international staff from private hospitals and nursing homes.
• Reparation or reimbursement is increasingly called for by health bodies in poorer countries to compensate for their loss of skilled staff. However, setting up a mechanism for this is complex. Would compensation be tied to individual migrants? If so, what would happen when the migrant returned to their country? Would money have to be paid back?
• Educational initiatives might prove more workable. The rich, recruiting counties could fund the training of medical staff in the poorer countries, for example. Those workers would be free to move, or stay, but at least their training would not drain Majority World health budgets or the individuals and families who have to support trainees. Planned exchanges, whereby medical professionals – from rich or poor countries – can work abroad for a few years, would also make migration less random and unpredictable.
• International links between the national health services of rich countries and those of poorer countries could be made and strengthened to support the development of health systems in poorer circumstances.
• IMF structural adjustment policies always carry a high social cost and should be resisted on that basis alone. But at least the IMF could make it clear that public sector cuts should not include medical staff in countries currently going through health crises. The message needs to be clear so that governments cannot use the IMF or World Bank as an excuse for slashing health jobs or failing to recruit health workers
• Valuing medical staff is the fundamental means of keeping them. One of the most common reasons for nurses emigrating is the feeling that they are undervalued in their own countries. If pay is low, prospects are obstructed and demoralization is rife, they will search for ‘greener pastures’ – wherever their starting point.
• Valuing health is imperative. But the quest for healthcare ‘on the cheap’ is a universal affliction. Healthcare does not come cheap – but rich-world governments are reluctant even to ask their electorates to pay the real cost of it through taxation. Instead they pass on the real cost to the poorest people in the poorest countries. The patients in those desolate wards in Tigoni Community Hospital, for example. The nurses who have lost all hope and faith in what they are doing. The women who are dying in childbirth to save on medical fees. The people sick with HIV/AIDS who have no chance of getting hold of anti-retrovirals. Next time a politician tells you that she or he can improve healthcare in your country without putting up taxes – think on this.