{"id":546,"date":"2010-08-13T16:33:34","date_gmt":"2010-08-13T15:33:34","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=546"},"modified":"2010-08-13T16:33:34","modified_gmt":"2010-08-13T15:33:34","slug":"when-being-the-worst-off-isnt-the-worst","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/","title":{"rendered":"When being the Worst-Off isn’t the Worst"},"content":{"rendered":"

For a little over a year now I’ve been tinkering with a paper on the brain drain – that phenomenon by which expertise migrates from poorer to wealthier areas – and how we should think about it from a moral point of view. \u00a0Earlier drafts have been inflicted on attendees at the “New Directions in Bioethics” conference in London last summer, the conference of the Political Studies Association in Edinburgh at Easter, and an iSEI<\/a> seminar here in Manchester just before Christmas. \u00a0I’m glad to say that the paper’s approaching completion, but the demands of space have forced me to leave out a potentially interesting avenue of investigation.<\/p>\n

I’ve been working with a simplified model. \u00a0My hypothetical world is one in which there are only two economies – an deeply undeveloped economy called South and a developed economy called North – and the flow of expertise is a flow of medical expertise from South to the North. \u00a0For the sake of simplicity, I ignored (at least to begin with) considerations like the cost of education. \u00a0So the basic picture is this: as soon as anyone gains any kind of transferable skill in South, he has a good economic reason (and perhaps moral reason) to move to North, where the rewards for him and his family are much greater. \u00a0This means that South never gets the benefit of expertise, and so we can expect its development to be hindered, while the gap between it and North widens. \u00a0And, of course, the wider the developmental gap, the greater the incentive to migrate.<\/p>\n

But there was a midnight thought that went like this: maybe the exodus of expertise isn’t all that bad for South after all. \u00a0While more doctors is better than fewer, it doesn’t follow that few is a disaster.<\/p>\n

The thought takes its lead from a book I mentioned<\/a> on this blog a little while ago, Rose George’s The Big Necessity<\/a><\/em>. \u00a0George makes it very clear that a vast improvement to public health is there for the taking, if only half-decent sanitation could be made available. \u00a0Moreover, education would also improve (especially among girls); and, properly treated, human waste could be a decent fertiliser, which’d help grow more crops.\u00a0 Both of these points have economic benefits of their own, so there’s the prospect of a virtuous circle being created. \u00a0It’s also the case that the big killers associated with a lack of sanitation are, actually, often comparatively easy to treat: cholera, diarrhoea, and the like needn’t be all that challenging.<\/p>\n

So here’s the night thought: medical expertise may actually be wasted in parts of the world where there’s a basic lack of infrastructure. \u00a0At the same time, much of the work that doctors would do could be done by properly-trained local auxiliaries: clean water, and proper storage of what drugs there are, would make a huge difference to public health, but don’t require experts. \u00a0What experts there are could train local people to administer antibiotics and so on; with clean water, there’d be less need for them to begin with, though. \u00a0Of course, things like HIV and malaria would remain untreated – but they’re just about untreated now in the poorest parts of the world anyway, so the difference would be small.<\/p>\n

Bluntly: let the experts go. \u00a0They aren’t really necessary. \u00a0What’s really necessary in the poorest parts of the world is infrastructure.<\/p>\n

That’s counterintuitive enough – but things get even stranger when you make the model a bit more complex. \u00a0Imagine that there’re actually three economies in the world: the very poor South, the rich North, and a third that I’ll call Equator. \u00a0Equator is a middle-income economy, and stands poised to make the leap to wealth. \u00a0 What’s distinctive about Equator is that it has sorted out its infrastructural problems. \u00a0People may not be wealthy, but they all have access to clean water, food is not a problem, and basic illnesses that are big killers in South are not big killers in Equator.<\/p>\n

On the other hand, it is still not wealthy, and so experts still have an incentive to move to North in order to optimise their welfare. \u00a0So there’s still a brain drain.<\/p>\n

But here’s the problem: Equator has, ex hypothesi<\/em>, developed to a point at which its experts could be of some significant use. \u00a0The population of Equator is beginning to live long enough and well enough to have to start worrying about the illnesses of wealth; those with HIV or cancer have at least a glimmer of hope that they’ll get treatment. \u00a0So Equator has much more to lose from the migration of expertise than does South; and this makes it look, potentially, as though it’ll be hit harder by the phenomenon.<\/p>\n

(Granted, some Southern experts may settle in Equator rather than North – but even this doesn’t solve the problem. \u00a0For one thing, the rewards of working in Equator are likely to be smaller than those of working in North; and this might mean that it actually isn’t worth the effort for Southern experts to go there. \u00a0For another, only those that can’t get work in North are likely to settle in Equator, and so it may end up with a higher-than-desirable portion of second-raters, quacks, and out-and-out shysters.)<\/p>\n

So this is the paradox. \u00a0While the poorest may turn out not to suffer too much from the brain drain because they couldn’t make the best possible use of experts to begin with, this is not the case in Equator. \u00a0So the brain drain may actually, from a certain point of view, be worse for slightly wealthier countries. \u00a0At best, the welfare effect of the brain drain would seem to follow a U-shaped curve, whereby\u00a0things get worse and worse as wealth increases until, eventually, the economy is strong enough to be able to offer a real incentive for people to migrate in, or not to leave to begin with.\u00a0 The problem here is that, for each increase in wealth while an economy is on the downward part of the curve, the next increase becomes harder as the experts leave.<\/p>\n

I feel I must have missed something; but as it stands, it looks like, from a certain point of view, being the world’s worst-off isn’t always as bad as it gets.<\/p>\n","protected":false},"excerpt":{"rendered":"

For a little over a year now I’ve been tinkering with a paper on the brain drain – that phenomenon by which expertise migrates from poorer to wealthier areas – and how we should think about it from a moral point of view. \u00a0Earlier drafts have been inflicted on attendees at the “New Directions in […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[328,475,472],"tags":[317],"class_list":["post-546","post","type-post","status-publish","format-standard","hentry","category-philosophy","category-politics","category-thinking-aloud","tag-research"],"yoast_head":"\nWhen being the Worst-Off isn't the Worst - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"When being the Worst-Off isn't the Worst - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"For a little over a year now I’ve been tinkering with a paper on the brain drain – that phenomenon by which expertise migrates from poorer to wealthier areas – and how we should think about it from a moral point of view. \u00a0Earlier drafts have been inflicted on attendees at the “New Directions in [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/\" \/>\n<meta property=\"og:site_name\" content=\"Journal of Medical Ethics blog\" \/>\n<meta property=\"article:published_time\" content=\"2010-08-13T15:33:34+00:00\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"When being the Worst-Off isn’t the Worst\",\"datePublished\":\"2010-08-13T15:33:34+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/\"},\"wordCount\":1085,\"commentCount\":11,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"keywords\":[\"Research\"],\"articleSection\":[\"Philosophy\",\"Politics\",\"Thinking Aloud\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/\",\"name\":\"When being the Worst-Off isn't the Worst - Journal of Medical Ethics blog\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#website\"},\"datePublished\":\"2010-08-13T15:33:34+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/2010\\\/08\\\/13\\\/when-being-the-worst-off-isnt-the-worst\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"When being the Worst-Off isn’t the Worst\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#website\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/\",\"name\":\"Journal of Medical Ethics blog\",\"description\":\"A blog to discuss the ethics of medicine in its many guises and formats.\",\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#organization\",\"name\":\"Journal of Medical Ethics blog\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/logo\\\/image\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/files\\\/2026\\\/04\\\/jme-logo.png\",\"contentUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/files\\\/2026\\\/04\\\/jme-logo.png\",\"width\":200,\"height\":50,\"caption\":\"Journal of Medical Ethics blog\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/logo\\\/image\\\/\"}},{\"@type\":\"Person\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\",\"name\":\"BMJ\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g\",\"url\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g\",\"contentUrl\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g\",\"caption\":\"BMJ\"},\"sameAs\":[\"https:\\\/\\\/blogs.bmj.com\\\/\"],\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/medical-ethics\\\/author\\\/admin\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"When being the Worst-Off isn't the Worst - Journal of Medical Ethics blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/","og_locale":"en_US","og_type":"article","og_title":"When being the Worst-Off isn't the Worst - Journal of Medical Ethics blog","og_description":"For a little over a year now I’ve been tinkering with a paper on the brain drain – that phenomenon by which expertise migrates from poorer to wealthier areas – and how we should think about it from a moral point of view. \u00a0Earlier drafts have been inflicted on attendees at the “New Directions in [...]Read More...","og_url":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/","og_site_name":"Journal of Medical Ethics blog","article_published_time":"2010-08-13T15:33:34+00:00","author":"BMJ","twitter_card":"summary_large_image","twitter_misc":{"Written by":"BMJ","Est. reading time":"5 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/#article","isPartOf":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/"},"author":{"name":"BMJ","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#\/schema\/person\/ba3da426ed20e8f1d933ca367d8216fe"},"headline":"When being the Worst-Off isn’t the Worst","datePublished":"2010-08-13T15:33:34+00:00","mainEntityOfPage":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/"},"wordCount":1085,"commentCount":11,"publisher":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#organization"},"keywords":["Research"],"articleSection":["Philosophy","Politics","Thinking Aloud"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/","url":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/","name":"When being the Worst-Off isn't the Worst - Journal of Medical Ethics blog","isPartOf":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#website"},"datePublished":"2010-08-13T15:33:34+00:00","breadcrumb":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/08\/13\/when-being-the-worst-off-isnt-the-worst\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/blogs.bmj.com\/medical-ethics\/"},{"@type":"ListItem","position":2,"name":"When being the Worst-Off isn’t the Worst"}]},{"@type":"WebSite","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#website","url":"https:\/\/blogs.bmj.com\/medical-ethics\/","name":"Journal of Medical Ethics blog","description":"A blog to discuss the ethics of medicine in its many guises and formats.","publisher":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/blogs.bmj.com\/medical-ethics\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#organization","name":"Journal of Medical Ethics blog","url":"https:\/\/blogs.bmj.com\/medical-ethics\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#\/schema\/logo\/image\/","url":"https:\/\/blogs.bmj.com\/medical-ethics\/files\/2026\/04\/jme-logo.png","contentUrl":"https:\/\/blogs.bmj.com\/medical-ethics\/files\/2026\/04\/jme-logo.png","width":200,"height":50,"caption":"Journal of Medical Ethics blog"},"image":{"@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#\/schema\/logo\/image\/"}},{"@type":"Person","@id":"https:\/\/blogs.bmj.com\/medical-ethics\/#\/schema\/person\/ba3da426ed20e8f1d933ca367d8216fe","name":"BMJ","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/secure.gravatar.com\/avatar\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g","url":"https:\/\/secure.gravatar.com\/avatar\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/b4d8f39281bcae118348a1c027347b8e53b82d42520e774a8b50dd9a6ac6c01d?s=96&d=mm&r=g","caption":"BMJ"},"sameAs":["https:\/\/blogs.bmj.com\/"],"url":"https:\/\/blogs.bmj.com\/medical-ethics\/author\/admin\/"}]}},"_links":{"self":[{"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/posts\/546","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/comments?post=546"}],"version-history":[{"count":0,"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/posts\/546\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/media?parent=546"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/categories?post=546"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.bmj.com\/medical-ethics\/wp-json\/wp\/v2\/tags?post=546"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}