Short reportDoctors leaving 12 tertiary hospitals in Iraq, 2004–2007☆
Introduction
The migration of doctors to more developed countries has attracted considerable discussion (Hagopian et al., 2004, Mullan, 2005, Norcini and Mazmanian, 2005). Traditional migration theory suggests individuals change location in response to both push factors from the country of origin as well as pull factors from destination countries (Arah et al., 2008, Massey and Edward, 1993, Mathauer and Imhoff, 2006). Most attention has been given to economic drivers and the dissatisfaction with health systems management in countries of origin (Vujici et al., 2004). The role of conflict and human rights abuses serving as push factors has received little attention as a cause of displacement of doctors within a country or across borders.
Lebanon's 15 years of civil disturbances were a major push factor for the emigration for medical graduates from the American University of Beruit (Kronfol, Sibai, & Rafeh, 1992). The protracted civil war in Somalia resulted in mass migration or death of doctors and other health workers with serious health consequences for the population (Leather et al., 2006). Of the approximately 400 working in the public sector in Liberia at the outbreak of war in 1989, there were 87 remaining by 1997 and fewer than 20 by 2003, when conflict ended (Liberia Ministry of Planning, 2006). In Zimbabwe 840 doctors, of the estimated 1200 trained there during the 1990s, had left by 2002, as the economy deteriorated and violence increased (Huddart & Picazo, 2003). The 1959 Cuban revolution resulted in the departure of an estimated 3000 of Cuba's 6000 doctors and most of the faculty from the country's single medical school (De Vos, 2006). In Iran, the estimates of doctors emigrating after the double impact of the war with Iraq and the revolution range from 2500 to 8000 (Willis & Taghipour, 1992).
In Iraq, prior to the Hussein years, many Iraqi doctors completed specialty training in UK, and some remained there (Amin & Khoshnaw, 2003). During the Hussein government it was difficult to leave Iraq legally, but those who did manage to leave often went to English speaking countries, while it is thought that fewer went to neighbouring countries. In 2004 there were 2327 Iraqi doctors working in the UK, North America or Australia, of which 53.5% were in the UK (Mullan, 2005). Iraqi doctors were also living in Jordan and surrounding countries before 2003. In general, however, not many Iraqi doctors had migrated to other countries, partly because of a Hussein-era ban on doctors leaving. Following the U.S.-led invasion of Iraq in 2003, several researchers estimated 15% of Iraq's population fled their homes (Morton and Burnham, 2008, Mowafi and Spiegel, 2008). This flight included many academics, and medical doctors who had become targets of criminal or sectarian violence abroad (Salman, 2006). How many doctors may have left their posts because of violence is uncertain. A Lancet perspective (Pincock, 2006) suggested that 3000 doctors had left, and a MEDACT report (2008) suggested that 8000 of the perhaps 17,000 doctors estimated to be present in 2003 (WHO, 2008) had left.
To explore how migration of specialists has affected staffing of tertiary hospitals, we reviewed hospital personnel records in twelve tertiary hospitals from 2004 through late 2007. Tertiary hospitals were chosen because their personnel records were relatively complete, and because specialists working at these hospitals represented an important segment of Iraq's human capital.
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Methods
The study was conducted at 12 tertiary hospitals in Baghdad (6 hospitals), Basra (2), Erbil (2), and Mosul (2), the four principal cities of Iraq. The population of the Baghdad governorate was estimated at 5.8 million in 2004, and the three other governorates had a combined estimated population 6.5 million (Ministry of Planning and Development Cooperation, 2005). Each city has one medical school, except Baghdad which has four. We chose one teaching hospital and one general hospital for each of
Funding
This survey was funded by the Johns Hopkins Bloomberg School of Public Health Center for Refugee and Disaster Response.
Results
A total of 1243 specialists were recorded as employed in the twelve facilities on January 1, 2004. This number had declined to 1166 or 94% (95 CI: 92–95) of the original specialist population at the end of the study period in late 2007. The number of specialists, gains, losses, net change, and proportion of specialists in 2007 as compared to 2004 are summarized in Table 1. Trends by specialty area region are summarized in Fig. 1. The number of specialists in Baghdad decreased to 78% (95 CI:
Discussion
With relatively intact staffing records, the tertiary hospitals of Iraq offered an opportunity to quantify the effects of insecurity on migration of specialists, as well as the health system capacity to replace those leaving. Since 2004, there has been a substantial internal and external migration of specialist doctors from tertiary hospitals in Iraq's four principal cities. Most migration occurred from Baghdad which at the time of the 2003 US-led invasion was thought to have half of Iraq's
Conclusions
The migration of doctors from fragile states and in the face of conflict, though perhaps to be anticipated, is not at all well studied (Doull & Campbell, 2008; Interagency Health Evaluation Steering Committee, 2005). In the case of Iraq, the push and pull factors for the migration of doctors are complex. These include professional, religious and criminal factors which could likely differ among various strata in the health system. In addition to personal and family risks from violence, the
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Our gratitude goes to the senior medical personnel who collected these data at potential personal risks, and who wish to remain anonymous.