Andrew Brooks examines the false comparisons that distort our understanding of developing countries and their healthcare
Hospitals are worse in Africa than in any other region in the world. In Sierra Leone, they are worse than in most of Africa. The infant mortality rate of 78 deaths per 1,000 births is shocking and among the highest anywhere. In stark comparison, it’s four in the UK.
For further context, life expectancy is 82 in the UK versus just 60 years in Sierra Leone. The sharp differences in healthcare outcomes are mainly a function of huge disparities in annual income, which is US$46,624 in Britain against US$1,613 per capita in the West African nation.
There is evidently a chasm in the basic conditions of life. So, is it not helpful to think about the two places as being at different historical steps on the same development ladder? Taking life expectancy as a historical comparison, Britons could expect to live to the age of 60 way back in 1935. So maybe we can think of Sierra Leone as being nearly a century behind the UK? Intuitively, it seems to make sense. However, there are serious problems with this type of historical comparison, especially as there is a connection between good healthcare in the UK and weak healthcare provisions in Sierra Leone.
I interviewed international doctors and nurses working in Sierra Leone. They made unfavourable comparisons between their experiences of Western hospitals and the local facilities. One described Connaught Hospital, the principal referral hospital in the capital, Freetown, as a ‘hellhole’. People were ‘dying all the time of stuff they shouldn’t die of’, as another doctor told me.
A tragic example, among many, was of an anaemic 13-year-old girl who died because she didn’t receive a blood transfusion. Resources were even ‘behind Haiti’, and in another historical comparison, one physician observed it was ‘a little bit like going back in time’. A published surgical report showed that hospitals in Sierra Leone were worse in 2010 than the facilities of the Union Army during the US Civil War more than 150 years earlier. The assessments about the level of care are disturbing and undoubtedly accurate, but what is not so helpful is when these comparisons are framed historically.
Moving around the hospital, talking with local and international staff, I saw the suffering of patients and the tough working conditions, but I wasn’t stepping into the past, but rather walking through a painful present. Wards with poor hygiene and a lack of drugs were part of a globalised world of smartphones and the internet. Patients were as keen to talk to me about last night’s Manchester United game as their medical care.
Most of the foreign doctors and nurses I talked with were experts in medicine, not human geography. Prior to travelling to Sierra Leone, they drew from a well of general knowledge that tries to explain the differences between rich and poor nations as being the result of local factors such as warfare, corruption, or disasters, rather than understanding how impoverishment is related to colonialism and is sustained by unequal world trade.
Dr Price Masuba was offered lucrative positions abroad, but he turned them down to work in a rural public hospital in Sierra Leone
The clearest way to pull apart the historical comparison is to think about the employment of Sierra Leonean doctors and nurses at home and internationally. Connaught Hospital was vastly understaffed, but the quality of local healthcare workers wasn’t the problem. As a Western doctor explained, the Sierra Leonean clinicians’ ‘anatomy knowledge and technical skills were fantastic; it’s just all the other supporting elements that need work’. As another described: ‘One of the surgical doctors is trained to an incredibly high standard, he knows what’s good.’
So, African doctors weren’t stuck in the past practising the medicine of 100 years ago. The same went for the nurses, who are in demand overseas. An estimated 60 per cent of Sierra Leonean-trained nurses emigrate. They seek a better life in the UK, Canada, the USA and nearby, but more affluent, Ghana. There are 520 Sierra Leonean health workers in the NHS and many more employed in other support jobs and private care homes, as well as thousands across other developed countries. The number in the NHS may seem small, but it’s equivalent to 16 per cent of Sierra Leone’s entire public health workforce.
Sierra Leone desperately needs more health workers to improve patient care, but the majority of those who are trained locally want to emigrate and make a better life for themselves. The nurses I talked with always asked about opportunities to come to London. This is logical. You can’t blame anyone for wanting to emigrate. Work at Connaught Hospital is hard and salaries too low to support even a basic standard of living.
Nurses survive by selling medicines to patients and doctors subsidise their meagre government salaries by working in private clinics. The pull to emigrate is a problem of 21st-century globalisation, not something that Western nations had to face when they progressed up a development ladder. Doctors and nurses in 1930s Britain enjoyed relatively good salaries and weren’t compelled to seek new opportunities overseas. We can’t think of the Connaught as being a museum-like hospital of the past. It exists now in today’s interconnected world.
As well as disadvantaging countries such as Sierra Leone, the immigration of doctors and nurses improves healthcare in Britain and other affluent countries. There are 5,819 African nationals working as doctors in the NHS. In total, around 27 per cent of doctors in the UK were trained in developing countries.
If fewer doctors and nurses left the world’s poorest countries for the richest, what’s sometimes called the ‘medical brain drain’, then there wouldn’t be such a gap in healthcare. And yet there’s a very real need for more healthcare workers in Britain’s NHS, a problem shared by nearly every country in the world. That said, the scale of the shortfall in Africa is truly staggering. There are 280 physicians per 100,000 people in the UK. On average, across sub-Saharan Africa, there are 20 per 100,000, but in Sierra Leone, just two per 100,000.
How do development programmes, such as the one at Connaught Hospital that brought Western healthcare workers to work in impoverished settings, fit into this picture? Can aid work help push nations up the development ladder? Some inspiring people do amazing, lifesaving work every day in difficult circumstances, but the overall scale of international development assistance in the healthcare sector is tiny. It’s a cliché, but they are a sticking plaster on a gaping wound.
There are systemic problems that global development programmes can’t answer. Worldwide, there are far too few health workers, and they are in demand across a globalised job marketplace. Like any employment market, those with much-needed skills tend to move to where wages are highest. Few people head in the other direction for an overseas adventure. African healthcare workers migrate to work in British hospitals in numbers that dwarf the counter-movement of UK medical aid and volunteers.
National comparisons hide the globalisation of the health sector. The high standards of hospitals in rich countries and the long life expectancies aren’t just a result of the histories and conditions internal to these societies, but rather depend on global flows of migration and draw upon resources, medicines and scientific discoveries produced around the world. Equally, rather than being stuck in the past, Sierra Leone’s poor healthcare is a prisoner of the present, trapped not only by the outflows of skilled people, but by wider structural challenges.
Even if all the Sierra Leonean health workers trained locally were retained, there would still be a huge shortfall in the ratio of doctors to patients and multiple other elements of the national healthcare system that needed desperate attention. All of which would require money that Sierra Leone doesn’t have. Ultimately, poverty resulting from uneven international trading relationships and an absence of industrial development block improvements in medical provision.
Often, historical comparisons project visions of how people want the world to be rather than how it is. In international development, comparisons frequently support ideas that blame global inequalities on domestic conditions within poor countries: weak government, civil unrest, or an under-utilised natural environment. By casting the challenge of global development as an individual teleological problem of maturity – developing countries are still in an adolescent stage of growth in comparison to the established, fully developed adult economies of Europe and North America – is a profoundly misleading and patronising comparison. I would go as far as to call it a bullshit comparison. There is no inevitable pathway that will lead Africa to catch up with the West that depends on anything more than the march of time; rather, we need to transform economic and political structures instead of passively waiting for the decades to tick by.
A historical comparison dissolves the responsibility of the global north for inequality. To lift the poorest out of impoverishment, we need to continue to make comparisons – for example, in healthcare indicators (such as life expectancy and infant mortality) – but also to think about the wider relationships, those real-world political connections between rich and poor countries, such as debts, migration, uneven patterns of trade, environmental degradation, that have produced and sustain an unequal world.
Andrew Brooks is a reader in uneven development and deputy head of the geography department at King’s College London. His new book, Bullsh*t Comparisons: A Field Guide to Thinking Critically in a World of Difference, is published by Footnote Press
