The brain drain of medical professionals from African countries to rich countries in Europe, North America, and the Middle East has been particularly pronounced since the 1980s. As Bibilola Oladeji and Oye Gureje have noted, as of 2011, there were more than 17,000 African physicians practicing in the US alone, over two-thirds of whom had been trained in African medical schools. Of this group, two-thirds were trained either in Nigeria or South Africa, the two countries with the most extensive medical training systems on the continent. Psychiatrists have also made up a significant piece of the larger medical migration, drawn by higher salaries, better facilities, opportunities for professional development, and prospects for long-term stability to seek jobs outside of the continent.
The brain drain has become a commonplace terminology to describe the emigration of highly skilled labor from developing countries to highly industrialized states in the post-colonial world. The concept has been particularly valuable for understanding persistent underdevelopment in sub-Saharan African countries as related not so much to deficiencies in African expertise as its redirection primarily for the benefit of wealthy countries. Similar to the “brawn drain” of the Atlantic slave trade or the natural resource depletion that characterized European colonialism in much of the continent, brain drain has had long-lasting impacts on African countries’ internal development and position in the global economy.
The impact of the brain drain on mental health care in Africa can be seen through the example of Nigeria, one of the few sub-Saharan African countries with university hospitals providing accredited medical training in psychiatry. Nigeria’s first trained psychiatrist of indigenous background was Thomas Adeoye Lambo, who studied at Birmingham and the Maudsley Hospital in the UK before returning to Nigeria to practice at the newly founded Aro Mental Hospital in 1954. Lambo and his acolyte, Tolani Asuni, developed much of the infrastructure of Nigerian psychiatry in the 1960s and 1970s, and several Nigerian universities began producing psychiatrists by the 1980s. The purpose of developing such programs was to produce a qualified mental health workforce for the country. Students from other countries in West Africa also trained in psychiatry at Nigerian institutions. Nigeria’s mental health care workforce grew slowly but surely from only three psychiatrists in 1955, to 25 by 1975, and 100 by 2001. But the brain drain has had a major impact on Nigerian psychiatry. Today, there are roughly 250 psychiatrists in Nigeria to serve a population of approximately 190 million. At the same time, a study from 2010 found that there were 384 Nigerian psychiatrists practicing in the US, UK, Australia, and New Zealand, a number 50% higher than the estimated total practicing in Nigeria.
The effects of this psychiatric brain drain have been significant. Beyond the worsening of the psychiatrist-to-population ratio, this phenomenon has the potential of severely weakening ongoing reproduction of this limited resource as more freshly qualified psychiatrists and senior residents are being enticed/encouraged to relocate on the guise of training opportunities abroad, from which they never return. In addition to psychiatrists, mental health nurses are also leaving the continent in droves, with packages designed to make emigration easy and more likely to be permanent. The rate of migration far outstrips the rate of production, leaving a huge deficit in human resources, one of the major pillars of a health system, according to the World Health Organization.
Several reasons have been proffered for the exodus of medical doctors from Africa to the economically developed world. Oberoi and Lin classified these reasons into endogenous and exogenous factors. Endogenous factors include poor working conditions, poor remuneration, and lack of job satisfaction and job security with little or no opportunities for career development. Exogenous factors include social pressures from relatives, preponderances of civil unrest, and armed conflicts with attendant high levels of insecurity. Ironically, the factors that push mental health care workers to relocate abroad are the same ones that likely contribute to rates of psychological distress in their communities of origin that, in turn, require more and better mental health care.
Since the late 2000s, the “global mental health” movement has sought to ameliorate this “treatment gap” in mental health services in developing countries, including Nigeria and others in sub-Saharan Africa. In most cases, reducing the treatment gap relies heavily on training lower-qualified workers to perform the duties of highly-skilled practitioners, a set of practices known as “task shifting.” Task shifting in international public health has existed for a long time, and has been employed extensively in the field of HIV/AIDS diagnosis and treatment in many environments. But it’s use in psychiatric care is somewhat more controversial. Most notably, global mental health has been critiqued as potentially socially and culturally insensitive, importing knowledge and practices from western industrialized countries that might not adequately reflect local cultural beliefs or social determinants of health, while simultaneously marginalizing indigenous health systems.
Task shifting has also been proposed as a strategy for alleviating the effects of the brain drain on the health care sector. In a review of policies to address brain drain in sub-Saharan African countries, Edward Zimbudzi has identified some areas of possible intervention. These include ethical recruitment, brain drain tax or compensation for source countries, increasing investment in training more professionals, improving remuneration of health workers and working conditions in general, importing more staff, ensuring political stability, and encouraging remittances. However, the review concluded “that there is considerable consensus on task shifting as the most appropriate and sustainable policy option for reducing the impact of health professional brain drain from Africa.” While some studies have concluded that task shifting has effectively filled the treatment gap, others have indicated that it is by no means a comparable substitute for professional mental health care due to lack of proper supervision and training of lower level workers, among other factors.
But we would like to offer a different critique of the task-shifting discourse: it’s tendency to normalize the brain drain of health care professionals. Global mental health has always emphasized practicality over ideology: anything that can be done to fill the “treatment gap” is presumably better than not doing it. The origins of the medical brain drain are not really global mental health’s concern, but its consequences are a large part of the foundation of the movement’s argument for “scaling up” the health care workforce to address the “treatment gap,” which is effectively the primary justification for the movement’s existence. However, in making the case for immediate action, the discourse on task-shifting in global mental health replicates the long history of ignoring the long-term exploitation of African resources in order to focus on short-term, externally funded, non-state interventions to provide what Africa supposedly “lacks.”
Promoting task shifting to lower cadre health care workers as the best way to scale up mental health services in low- and middle-income countries indirectly suggests that these countries cannot hope for better, even as billions of dollars are lost by African countries from investment in training highly qualified health workers who go on to treat patients in wealthy countries. Meanwhile wealthy countries acquiesce to helping train up less-qualified caregivers to fill the “treatment gap” created in part by this brain drain. It also implies that African countries can get by on less than wealthy countries. Indeed, severe mental illness continues to be neglected under the “task shifting” model that does little to increase specialist capacity to handle such cases. While this rather popular principle in global mental health appears practical, it inadvertently panders to the notion that some lives are more important than others, and calls to question the relative value placed on the health and lives of citizens of the developing countries of Africa compared to the developed world. It reinforces and normalizes global inequalities.
Mitigating the psychiatric brain drain must ultimately be about much more than filling “treatment gaps.” It must also be about addressing the geopolitical and macroeconomic conditions that have produced the gap in the first place. Developing equitable and sustainable mental health services for all Africans is a political, economic, moral, and ethical issue of contemporary urgency and historical significance.
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Educating the Native and the Ivy League Myth
Elite schools in the US continue to place a premium on institutions, not ideas. Where you went to school is what matters.
As a young student, I was always fascinated by the “top” universities and the erudite people that emerged from those august institutions. My first contact with Ivy League people was when I arrived at Mpala Research Centre in Laikipia in 1999 to start my MSc research. I met students and faculty from Princeton University (which is a trustee of the research centre) and was reassured that they looked “normal”, given all the academic challenges and foibles that a Kenyatta University student like me had. After I finished my MSc, the administration was impressed enough with my work to offer me a job as resident scientist, which I took up with the alacrity of someone catching a big break through hard work (I got a rude awakening later, but that’s a story for another day). As part of my job, I was to supervise a group of Princeton undergraduates undertaking a senior field project and, wanting impress, I sharpened my ecologist brain, especially because I thought I would be instructing some of the world’s sharpest young minds. Now I laugh at my consternation when, after mapping out clear and easy ecological transects for them, they strayed off into a neighbouring ranch and I got a call from the security personnel there that they were sunbathing topless on the research vehicle (they were ladies) and that the boss might be offended.
Later on, I asked a postgraduate student from the same institution how these ladies could be so casual about their studies and she couldn’t hide her amusement at my ignorance. “Grad school is competitive. Undergrads get in because of money and name recognition.” I was stunned, but I remembered this when I saw the poor work they submitted at the end of their study. Being an aspiring lecturer (and a student of the late brilliant Prof R.O. Okelo) I marked them without fear or favour, assuming that they would be used to such standards at Princeton. I was told that I couldn’t give them such low marks because they were supposed to qualify for med school after their biology degrees.
They strayed off into a neighbouring ranch and I got a call from the security personnel there that they were sunbathing topless on the research vehicle.
The next cohort included one serious student who I actually enjoyed instructing and who finished her course successfully. By that time though, I was getting restless and had started writing an academic and financial proposal for my PhD, and I finished it about six months after my student had returned to the US to graduate. The then Director of Mpala, Dr Georgiadis, refused to let me do my PhD on the job, so I submitted my proposal to several conservation organizations, including the New York-based Wildlife Conservation Society. I received a positive response from them (offering me a grant) which hit me with a strange mixture of feelings. First of all, I was elated at the prospect of starting my PhD, but I was completely baffled by the signature on the award letter. It was signed by the undergraduate student that I had supervised about eight months earlier. An American undergraduate who had spent two months in Africa was somehow qualified to assess a PhD proposal on the ecology of African wildlife written by an African MSc holder. It was my rude awakening to the racial prejudice that is de rigueur in African conservation practice. But I had to get my academic career moving, and indulge my first taste of the ultimate luxury that my competence and my work could afford me, which was the ability to say “NO”. It was with extreme pleasure that I wrote and signed my letter of resignation from my job at Mpala, leaving it on the Director’s desk.
Years later, after I finished my PhD and had a useful amount of conservation practice under my belt, I attended the Society for Conservation Biology conference in Sacramento, California, where there was a side event featuring publishers from several Ivy League universities. I excitedly engaged them because at the time Gatu Mbaria and I were in the middle of writing “The Big Conservation Lie”. I pointed out to all of them that there were no books about conservation in Africa written by indigenous Africans, but they were uniform in their refusal to even read the synopsis of what we had written. I later understood why when I learned that in US academia, African names — as authors or references — are generally viewed as devaluing to any literature.
An American undergraduate who had spent two months in Africa was somehow qualified to assess a PhD proposal on the ecology of African wildlife written by an African MSc holder.
From Sacramento, I made the short trip to Stanford University in Palo Alto, to give a seminar to an African Studies group. I felt honoured to be making an academic contribution at an Ivy League university and I prepared well. My assertions about the inherent prejudices in African conservation practice were met with stunned silence by the faculty, many of whom are involved with conservation research in Africa. One bright spot in that dour experience was the brilliant PhD student who echoed my views and pointed out that these prejudices existed within academia as well. I later found out that he was Kenyan — his name is Ken Opalo and he now teaches at Georgetown University.
Fast forward to today. The Big Conservation Lie was published, and after the initial wailing, breaking of wind, gnashing of teeth and accusations of racism, Mbaria and I are actually being acknowledged as significant thinkers in the conservation policy field and our literary input is being solicited by various publications around the world. Now, the cultural differences between how European and American institutions treat African knowledge are becoming clear (certainly in my experience). I have been approached by several European institutions to give talks (lectures), and have contributed articles and op-eds (to journals and magazines) and one book foreword. Generally, the approach is like this:
“Dear Dr Ogada, I am_______ and I am writing to you on behalf of________. We are impressed with what you wrote in _____ and would appreciate it if you would consider writing for us an article of (length) on (topic) in our publication. We will offer you an honorarium of (X Euros) for this work, and we would need to receive a draft from you by (date). . .” Looking forward to your positive response. . .”
When inviting me to speak, the letters are similarly respectful and appreciative of my time. The key thing is the focus on and respect for one’s intellectual contribution. Publications from American Ivy league schools typically say:
“Dear Dr Ogada, I am __________, the editor of __________. We find your thoughts on _______ very interesting and we are pleased to invite you to write an essay of________ (length) in our publication. Previous authors we have invited include (dropping about 6-8 names of prominent American scholars).
The entire tone of the letter implies that you are being offered a singular privilege to “appear” in the particular journal. It is even worse when being asked to give a lecture. No official communication, just a casual message from a young student saying that they would like you to come and talk to their class on__________ (time and date on the timetable). No official communication from faculty or the institution. After doing that a couple of times, I realized that the reason these kids are so keen to have an African scholar speak to them and answer all their questions is because they need his knowledge, but do not want to read his publications, or (God forbid) have an African name in the “references” section of their work.
The reason these kids are so keen to have an African scholar speak to them and answer all their questions is because they need his knowledge, but do not want to read his publications.
European intellectuals seem to be catching on to the fact that knowledge and intellect reside in people, not institutions. That is why they solicit intellectual contributions based on the source of an idea they find applicable in that space and time. Name recognition doesn’t matter to them, which is why they seek people like Ogada, who doesn’t even have that recognition in Kenya. The elite schools in US still place this premium on institutions, which is why whenever an African displays intellectual aptitude, those who are impressed don’t ask about him and his ideas, but where he went to school. They want to know which institution bestowed this gift upon him.
For the record, I usually wait about a week before saying “no” to the Ivy League schools. Hopefully, they read my blog and will improve the manner in which they approach me, or stop it altogether.
Cuba Can Help Vaccinate the World
On 25 January, the Progressive International will host a special briefing live from Havana with Cuba’s leading scientists, government ministers and public health officials as part of its Union for Vaccine Internationalism.
2022 began with a “tsunami” of new Covid-19 cases crashing over the world, according to the World Health Organization. Over 18 million cases have been recorded in the past week alone, a record number since the pandemic began two years ago. In the first 10 days of January, nearly 60,000 Covid-19 deaths have been recorded worldwide — though the total death count is far higher than the official statistics describe.
The Omicron variant is reported to have less “severe” implications among vaccinated patients. But the world remains perilously under-vaccinated: 92 of the WHO’s member countries missed the 2021 target of 40 percent vaccination; at the current pace of rollout, 109 of them will miss their 2022 targets by July.
These statistics tell a story of a persistent vaccine apartheid. Across the EU, 80 percent of all adults have been fully vaccinated against Covid-19. Meanwhile, only 9.5 percent of people in low-income countries have received a single dose. Omicron is a death sentence for thousands in these countries — and as the virus travels across the Global South, new variants will emerge that may be less “mild” for the vaccinated populations of the North.
But the governments of these Northern countries refuse to plan for global vaccination — or even meet their own pledges. By late last year, they had delivered only 14% of the vaccine doses that they had promised to poorer countries through COVAX, the UN vaccine-sharing initiative. Big pharmaceutical corporations are focused almost exclusively on production of boosters for the world’s rich countries, creating a shortfall of three billion doses in the first quarter of this year.
President Joe Biden could easily help fill this shortfall by compelling US pharmaceutical corporations to share their vaccine technology with poorer nations. But he has so far refused to do so. A new production hub in Africa — where only 3 percent of people are vaccinated — is now trying to replicate the Moderna vaccine. But without Moderna’s help, or Joe Biden’s executive action, production could take more than a year to begin.
Amidst this crisis of global solidarity, Cuba has emerged as a powerful engine of vaccine internationalism. Not only has the island nation successfully developed two Covid-19 vaccines with 90 percent effectiveness, and vaccinated more than 90 percent of its population with at least one dose of its homegrown vaccine, Cuba has also offered its vaccine technology to the world. “We are not a multinational where returns are the number one reason for existing,” said Vicente Vérez Bencomo of the Finlay Vaccines Institute in Cuba. “For us, it’s about achieving health.”
But the US and its allies continue to oppress and exclude Cuba from the global health system. The US blockade forced a shortage of syringes on the island that endangered its vaccine development and hindered mass production. US medical journals “marginalize scientific results that come from poor countries,” according to Vérez Bencomo. Meanwhile, the WHO refuses to accredit the Cuban vaccines, despite approval from regulators in countries like Argentina and Mexico.
That is why the Progressive International is sending a delegation to Havana: to combat misinformation, to defend Cuban sovereignty, and to help vaccinate the world.
Bringing delegates from the Union for Vaccine Internationalism, founded in June 2021 to fight the emerging apartheid, the Progressive International will convene Cuban scientists and government representatives to address international press and members of the scientific community in a showcase of the Cuban vaccine on 25 January.
The goals of the showcase are both local and global. Drawing attention to the promise of the Cuban vaccine and the perils of the US embargo against it, the showcase aims to forge connections between Cuba’s public biotech sector and manufacturers who might produce the vaccine and help the Cuban government recuperate the costs of its development.
In the process, the showcase aims to set an example of international solidarity in the face of the present global health crisis, advancing the cause of vaccine internationalism around the world.
This article was first published by Progressive International.
DRC: Bring Patrice Lumumba Home
The return of Patrice Lumumba’s remains must not be an occasion for Belgium to congratulate itself, but for a full accounting of the colonial violence that led to the assassination and coverup.
For much of the past year, there have been plans for the sacred human remains of the Democratic Republic of the Congo’s first post-independence prime minister, Patrice Émery Lumumba, to finally be returned to his children in Belgium, and then repatriated to the Congo. Originally scheduled for a ceremony on June 30, 2021, the 61st anniversary of the country’s independence passed with Lumumba’s remains still in the custody of Belgian authorities. The ceremony with Belgian King Philippe, current Prime Minister Alexander de Croo of Belgium, and Congo President Felix Tshisekedi, was then planned for January 17, 2022, the anniversary of the assassination. Last week, Tshisekedi announced another delay—this time until June 2022. The official reason for the delay was the rising number of COVID-19 cases in the Congo, but the pandemic crisis is deeply entangled with a series of other political maneuvers and other crises that are undoubtedly factors in the decision.
At the center of this story, Lumumba’s family continues to be victimized. As Nadeen Shaker recently reported, his children were forced to escape to Cairo during their father’s house arrest, never to see him again. The disturbing fact that the remains of Lumumba spent another Independence Day in Belgium may provide opportunities for metaphor and analogy, but, amid the widespread complicity in this ongoing desecration, the most important outcome must be to respect the ethical and legal claims of his children, which daughter Juliana Lumumba described in an open letter to the Belgian king last year.
The story of the execution and its aftermath is well told by Ludo de Witte in The Assassination of Patrice Lumumba. On January 17, 1961, Lumumba was killed along with comrades Maurice Mpolo and Joseph Okito by Belgian authorities, with the support of neocolonial Kantangan separatists and the US. Two days later, Gerard Soete, Belgian police commissioner of Katanga, and his brother exhumed the body to chemically eradicate all physical evidence of their crime in order to prevent the kind of mobilization which its identification would inspire. Though the execution was kept secret for nearly a month, its announcement inspired exactly what his executioners feared, as African people throughout the world engaged in protest and other revolutionary acts of remembrance—from the well-known demonstration at the United Nations, and other cities throughout the world to a legacy in a visual, musical, and literary culture that continues to this day.
In February 1961, while the Cultural Association of Women of African Heritage organized a major protest at UN headquarters in New York, Lumumba’s widow Pauline Opango Lumumba led a march of family and supporters to the UN offices of Rajeshawar Dayal in Kinshasa. There, she requested that the UN help her receive the remains of her husband for a proper burial. After Ralph Bunche offered “apologies” for the New York protest, Lorraine Hansberry “hasten[ed] publicly to apologize to Mme. Pauline Lumumba and the Congolese people for our Dr. Bunche.” Meanwhile, James M. Lawson of the United African Nationalist Movement and other Black activists organized a wake for Lumumba at Lewis Michaux’s Harlem bookstore. When Pauline died in Kinshasa in 2014, she was still waiting to bury her husband. She, and her iconic demonstration, are memorialized in Brenda Marie Osbey’s poem “On Contemplating the Breasts of Pauline Lumumba,” which is part of a long line of African American efforts to uplift the Lumumba family. The immediacy of Pauline’s demands remains after 6 years.
While Lumumba’s body was dissolved in sulphuric acid, Soete, like the US lynchers of Sam Hose and so many others, kept trophies of his victims as he traveled from the Congo to Belgium, often displaying them for friends and journalists. After Soete died, his daughter Godelieve continued her father’s tradition, culminating in a bizarre 2016 interview, during which a reporter found the remains in her possession. (In her efforts to defend her father, Godelieve further revealed that his brutality was visited upon his children.) The Belgian police intervened and, for the past five years, Lumumba’s remains have been held by the Belgian government responsible for his death. In September 2020, a court finally ruled they should be returned to the family.
These most recent delays are occurring at a time when the ongoing mistreatment of human remains is receiving public attention. The case of the Morton Collection at the University of Pennsylvania led activist Abdul-Aliy Muhammad to uncover the ongoing desecration of the remains of Tree and Delisha Africa, who were killed when the city of Philadelphia bombed their family’s home on May 13, 1985, leading to the discovery that the city held additional remains of the victims of its violence against the MOVE organization.
Since 2005, in South Africa, the Truth and Reconciliation Commission (TRC) created the Missing Persons Task Team to identify the remains of the Black victims of the country’s apartheid era. Drawing on the expertise of researchers with experience in similar initiatives in Argentina and elsewhere, this government project has been deliberate in its efforts to include the families of the missing at all stages, while seeing their work as integral to the larger mission of the TRC, and further representative of a larger model of repatriation of human remains and possessions. As different as these cases of violence may be, government sanction—at multiple levels and taking different forms—remains constant.
In an October 2021 program hosted by Friends of the Congo, Juliana Lumumba explained that for her, as the daughter of a martyr, repatriation and memorialization of her father’s remains were not finite events to be completed like items checked off of a to-do list. Rather, the return must be part of a wider and ongoing process: “I told Belgium, that if we want a reconciliation we need reconciliation of memories because we can not make a reconciliation when our memories [are] so different and so contradictory.” Juliana’s words carry a particular weight at a time when the Special Parliamentary Commission on Belgian Colonial History has received a sharply critical historical report that may or may not lead to meaningful action of the sort that the family has demanded.
Lumumba’s son Guy-Patrice Lumumba opposes Tshisekedi’s efforts to exploit the repatriation for political gain. Tshisekedi himself is familiar with some of the political challenges of memorialization after the remains of his own father, longtime popular opposition leader Etienne Tshisekdi, spent more than two years in Europe before their return in 2019 after Felix’s election. Felix is quickly losing whatever claim he had on his own father’s mantle (see Bob Elvis’s song “Lettre à Ya Tshitshi” for a recent indictment of the president’s abandonment of his father’s mantle). He may find value in an association with a revered nationalist icon amid political protests from opponents concerned about his overreaching efforts to control the country’s powerful electoral commission as the 2023 election cycle approaches.
Meanwhile, the younger Tshisekedi’s international standing has been consolidated through his position as head of the African Union, where his responsibilities include negotiating for the provision of COVID-19 vaccines for member states. He recently met with President Biden and made an official visit to Israel, the latter of particular concern given its historical involvement in mercenary efforts against pro-Lumumba rebels and its ongoing role in the plunder of the Congo’s resources (to say nothing of Tshisekedi’s support for Israel’s occupation of Jerusalem and its status as an observer at the African Union). Such actions highlight the extraordinary distance between Lumumba’s legacy and Tshisekedi’s leadership.
For decades, the Lumumba family has made a series of unanswered demands through formal inquiries and legal appeals. A group of scholars and activists have also asserted the return of Lumumba’s remains must not be an occasion for Belgium to congratulate itself, but rather an opportunity for a full accounting of the colonial violence that led to the assassination and its subsequent coverup.
Hopefully soon, Lumumba’s family can mourn on their own terms and have all of their demands for justice met immediately and without equivocation.
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