274 RECURRENT HÆMATURIA
Letters
to
the Editor
PUSH-PULL FACTORS AND THE DOCTOR DRAIN
SIR,-Although I cannot agree with many of the contentions of Mr Dass (June 21, p. 1373) about the ill effects of foreign aid on developing countries, his concern at the substantial loss of medical manpower to the " economic lure of the West " cannot be overemphasised. An increasingly large number of physicians trained at great expense in the developing countries emigrate to the U.S., Canada, England, and, now, the oil-rich Arab states. The education costs alone of the 11 500 foreign medical graduates entering the U.S. each year has been estimated in excess of $500 million.1 Some 20 000 immigrant doctors represent a quarter of those employed in the British National Health Service.2 This massive transfer of medical expertise towards the affluent countries is an insidious drain on Third World resources that can only be described as professional/ intellectual imperialism. For those inclined to view this as a minor -problem of principles only, consider the UNCTAD study which valued the 1970-trained manpowerresource transfer into the U.S. at$3-7 billion, a figure in excess of the entire U.S. non-military foreign assistance for that year.22 Unlike most problems facing health systems in the developing world, this one could be solved overnight, merely with the stroke of a pen. Appropriate legislation would simply restrict the total number of foreign medical graduates allowed to emigrate to and practise in the respective affluent nations. Let those who would decry " unfair discrimination against doctors " explain the present heavy prejudice that favours physician immigration to the exclusion of vast numbers of unskilled or semiskilled who also wish to settle in the " lands of opportunity." It seems a cruel paradox that those who have received so much of their country’s limited resources in the form of their education should be given the highest incentive and greatest opportunity to emigrate. Dass strikes the concordant note in the solution, stating " the question of their going abroad would hardly arise if medical curricula were built around our own needs ". Medical education throughout much of the developing world prepares physicians to serve in a health system found mainly in the West. They are inappropriately trained to face the realities of practice in their own societies, so quite logically they seek opportunities to practise in the setting for which they were educated-the affluent hospital-based curative system of the West. A radical reorientation of medical curricula towards rural community needs and resource realities is required to eliminate this " push " factor. As a physician who was permitted to remain and work in the crowded refugee camps of India during the Bangladesh war, I can attest to the dedication and effectiveness of many Indian doctors serving there. Their response to that crisis and the pride and satisfaction they gleaned from their work suggests that a major solution to health in the developing world lies in abolishing the " lure of the West " and providing appropriate training and job incentives to enhance the " challenge of the developing world ". Faculty of Medicine,
Gadjah Mada University, Yogyakarta.
JON E. ROHDE, Visiting
1. 2.
Lecturer.
Weiss, R. J., Kleinman, J. C., Brandt, U. D., Felsenthal, D. C. New Engl. J. Med. 1974, 290, 1453. New Internationalist, Oxford, May, 1975, 27, 5.
SIR,-Red-cell casts are not present in normal urine. The red-cell cast has long been recognised as the hallmark of acute nephritis.1 Your leader of July 19 (p. 114) implies that red-cell casts are usually seen in the urine of children with mesangial proliferative nephritis. Arneil et awl. reported that granular casts and/or red-cell casts were found in the urine of 13 of 17 children with recurrent haematuria and various glomerular changes. Singer et awl. found red-cell casts in 4 of 11 children they biopsied for recurrent hsematuria—6 biopsies showed " segmental (mesangial) nephritis ", and 5 were normal. Rapoport et al. saw red-cell or " heme granularcasts in the urinary sediment of 31 of 33 patients with idiopathic focal proliferative nephritis. Ferris et al. implied (without giving full details) that red-cell casts were seen in cases of focal nephritis. None of these authors quantify numbers of red-cell casts. The urine of 80 children, three-quarters of whom have had renal biopsies, has been examined for the presence of red blood-cells (R.B.c.) and red-cell casts. A fresh midstream specimen of urine was collected, and intact red cells and red-cell casts were counted in a Fuchs-Rosenthal counting-chamber. 10 ml. of urine was centrifuged for five minutes at 3000 r.p.m., and 0-2 ml. of the shaken-up sediment was counted in a similar manner. The results in mesangial proliferative nephritis and in the " recurrent haematuria syndrome " are shown in tablesI and 11, respectively. Urinary protein is represented as the Albustix ’ (Ames Co.) reading. Red-cell casts were 1. 2.
Bird, C. Urinary Deposits. London, 1846. Arneil, G. C., Lam, C. N., McDonald, A. M., McDonald, M. Br. med. J. 1969, ii, 233. 3. Singer, D. B., Hill, L. L., Rosenberg, H. S., Marshall, J., Swenson, R. New Engl. J. Med. 1968, 279, 7. 4. Rapoport, A., Davidson, D. A., Deveber, G. A., Ranking, G. N. McLean, C. R. Ann. intern. Med. 1970, 73, 921. 5. Ferris, T. F., Gorden, P., Kashgarin, M., Epstein, F. A. New Engl. J. Med. 1967, 276, 770. TABLE I-MESANGIAL
PROLIFERATION (9 CASES,
TABLE II-RECURRENT HaeMATURIA
(13
CASES,
ALL
BIOPSIED)
NONE
BIOPSIED)
Letters
to
the Editor
PUSH-PULL FACTORS AND THE DOCTOR DRAIN
SIR,-Although I cannot agree with many of the contentions of Mr Dass (June 21, p. 1373) about the ill effects of foreign aid on developing countries, his concern at the substantial loss of medical manpower to the " economic lure of the West " cannot be overemphasised. An increasingly large number of physicians trained at great expense in the developing countries emigrate to the U.S., Canada, England, and, now, the oil-rich Arab states. The education costs alone of the 11 500 foreign medical graduates entering the U.S. each year has been estimated in excess of $500 million.1 Some 20 000 immigrant doctors represent a quarter of those employed in the British National Health Service.2 This massive transfer of medical expertise towards the affluent countries is an insidious drain on Third World resources that can only be described as professional/ intellectual imperialism. For those inclined to view this as a minor -problem of principles only, consider the UNCTAD study which valued the 1970-trained manpowerresource transfer into the U.S. at$3-7 billion, a figure in excess of the entire U.S. non-military foreign assistance for that year.22 Unlike most problems facing health systems in the developing world, this one could be solved overnight, merely with the stroke of a pen. Appropriate legislation would simply restrict the total number of foreign medical graduates allowed to emigrate to and practise in the respective affluent nations. Let those who would decry " unfair discrimination against doctors " explain the present heavy prejudice that favours physician immigration to the exclusion of vast numbers of unskilled or semiskilled who also wish to settle in the " lands of opportunity." It seems a cruel paradox that those who have received so much of their country’s limited resources in the form of their education should be given the highest incentive and greatest opportunity to emigrate. Dass strikes the concordant note in the solution, stating " the question of their going abroad would hardly arise if medical curricula were built around our own needs ". Medical education throughout much of the developing world prepares physicians to serve in a health system found mainly in the West. They are inappropriately trained to face the realities of practice in their own societies, so quite logically they seek opportunities to practise in the setting for which they were educated-the affluent hospital-based curative system of the West. A radical reorientation of medical curricula towards rural community needs and resource realities is required to eliminate this " push " factor. As a physician who was permitted to remain and work in the crowded refugee camps of India during the Bangladesh war, I can attest to the dedication and effectiveness of many Indian doctors serving there. Their response to that crisis and the pride and satisfaction they gleaned from their work suggests that a major solution to health in the developing world lies in abolishing the " lure of the West " and providing appropriate training and job incentives to enhance the " challenge of the developing world ". Faculty of Medicine,
Gadjah Mada University, Yogyakarta.
JON E. ROHDE, Visiting
1. 2.
Lecturer.
Weiss, R. J., Kleinman, J. C., Brandt, U. D., Felsenthal, D. C. New Engl. J. Med. 1974, 290, 1453. New Internationalist, Oxford, May, 1975, 27, 5.
SIR,-Red-cell casts are not present in normal urine. The red-cell cast has long been recognised as the hallmark of acute nephritis.1 Your leader of July 19 (p. 114) implies that red-cell casts are usually seen in the urine of children with mesangial proliferative nephritis. Arneil et awl. reported that granular casts and/or red-cell casts were found in the urine of 13 of 17 children with recurrent haematuria and various glomerular changes. Singer et awl. found red-cell casts in 4 of 11 children they biopsied for recurrent hsematuria—6 biopsies showed " segmental (mesangial) nephritis ", and 5 were normal. Rapoport et al. saw red-cell or " heme granularcasts in the urinary sediment of 31 of 33 patients with idiopathic focal proliferative nephritis. Ferris et al. implied (without giving full details) that red-cell casts were seen in cases of focal nephritis. None of these authors quantify numbers of red-cell casts. The urine of 80 children, three-quarters of whom have had renal biopsies, has been examined for the presence of red blood-cells (R.B.c.) and red-cell casts. A fresh midstream specimen of urine was collected, and intact red cells and red-cell casts were counted in a Fuchs-Rosenthal counting-chamber. 10 ml. of urine was centrifuged for five minutes at 3000 r.p.m., and 0-2 ml. of the shaken-up sediment was counted in a similar manner. The results in mesangial proliferative nephritis and in the " recurrent haematuria syndrome " are shown in tablesI and 11, respectively. Urinary protein is represented as the Albustix ’ (Ames Co.) reading. Red-cell casts were 1. 2.
Bird, C. Urinary Deposits. London, 1846. Arneil, G. C., Lam, C. N., McDonald, A. M., McDonald, M. Br. med. J. 1969, ii, 233. 3. Singer, D. B., Hill, L. L., Rosenberg, H. S., Marshall, J., Swenson, R. New Engl. J. Med. 1968, 279, 7. 4. Rapoport, A., Davidson, D. A., Deveber, G. A., Ranking, G. N. McLean, C. R. Ann. intern. Med. 1970, 73, 921. 5. Ferris, T. F., Gorden, P., Kashgarin, M., Epstein, F. A. New Engl. J. Med. 1967, 276, 770. TABLE I-MESANGIAL
PROLIFERATION (9 CASES,
TABLE II-RECURRENT HaeMATURIA
(13
CASES,
ALL
BIOPSIED)
NONE
BIOPSIED)
