Through this Sunday, April 17, the World Health Organization (WHO) is seeking comments on its plans to monitor compliance with a global code of practice on the international migration of doctors and nurses.

We think there are better, cost-effective ways to improve health workforces in developing countries than compliance with this code that is self-contradictory, unlikely to help the poor, and ethically problematic.

First, the code contradicts itself. It establishes that all health workers—like all people—have the right to leave their countries to seek a better life (section 3.4) and that the international movement of health workers between two countries benefits both of them (section 3.8), through skill formation and technology transfer… and then it says that such movement must be stopped. It urges all countries to seek zero international movement of health workers—both by filling all their health sector positions with locals (section 5.4) and by stopping the recruitment of health workers from countries facing shortages (5.1), that is, the poorest countries where conditions for health workers are the worst. This contradiction is as baffling as saying: “You may drive anywhere you wish, now that my friends have taken away your car.”

Second, the self-sufficiency and anti-recruitment strategies endorsed by the code—certain to harm poor-country health workers—are unlikely to improve basic health outcomes for others in the most vulnerable poor countries. Blocking a Mozambican surgeon from stepping across the border into South Africa does little to remedy a long list of problems that primarily determine poor health outcomes in Mozambique: poor sanitation, tainted water supplies, lack of malaria prevention, little incentive for health workers to serve rural areas, a disconnect between health workers’ advanced skills and the basic needs of the poorest, risky sexual practices among the public, absenteeism at ostensibly staffed clinics, constraints on income and education that limit the public’s demand for formal health care, lack of pharmaceuticals, needless legal barriers to private practice for underserved communities, and so on.

Finally, while the benefits of forcibly blocking that Mozambican doctor from entering South Africa are unclear, the harm is perfectly clear. It certainly limits her freedom in a way that no one at the WHO would want their own freedoms restricted. Whether her movement is blocked by denying her entry at the border, by eliminating all the jobs she could have taken (self-sufficiency for South Africa), or by concealing from her any information about those jobs (banning anyone from recruiting her), the effect is equally ethically troubling. Her movement is stopped by others, against her will, without consulting her. Worse, it is usually done by people enjoying vastly higher living standards than she can enjoy in Mozambique, living standards that most of them enjoy by birthright.

Fortunately, there are good alternatives to coercive barriers on health worker movement. A team of World Bank health experts recently studied the human resource policies of Kenya, Zambia, Rwanda, and the Dominican Republic, and found several other ways that all four countries could improve the effectiveness of their health workforces:

[S]ignificant weaknesses were found in policies and practices related to recruitment, deployment, transfer, promotion, sanctioning, and payment methods of public sector health workers. Recruitment processes are plagued by delays and not targeted to areas with staff shortages. Salaries and allowances are not being used to provide strong incentives for increasing rural practice and lowering absenteeism. Available wage bill resources are often not fully spent, and even when they are, considerable scope is available to use these resources more strategically. Thus, improving recruitment, deployment, transfer, promotion, and remuneration practices is just as important—and maybe more important—than expanding the health wage bill in addressing health workforce challenges.

In other words, there is much that countries can do to make their health workforces more effective—with the side effect of decreasing health workers’ incentive to emigrate—even without spending much more money.

Likewise, Dr. Churnrurtai Kanchanachitra and co-authors have just offered a long list of ways that developing countries can strengthen health workforces without coercing health workers’ movement. These include creating incentives for health workers to work in rural areas; dealing with other constraints like financial barriers and poor-quality health services that might be even more important in affecting health outcomes; and creating partnerships between hospitals from sending and receiving countries.

The WHO has chosen instead to focus on blunt instruments of coercion in its code of practice. But governments are not bound to the code, and may make better choices. As the WHO considers its guidelines for monitoring compliance with that code, it should reconsider the sections relating to self-sufficiency and anti-recruitment and strike them from the final version. We urge governments and the WHO to work constructively with the many alternative tools available to improve developing-country health outcomes and health systems without the troubling methods of coercion.

What if we had a law that everybody had to stay in their home state? What if North Dakotans had to stay in North Dakota despite the collapsing economy there? Then wages would collapse and we would have very poor North Dakotans. Happily no one would dream of such a stupid law.  Instead we have middle class North Dakotans moving to other places voluntarily, where employers want to hire them voluntarily. And so (former) North Dakotans stay middle class.

For states…but not for countries. We treat migration usually as a non-option if Zambia has an economic decline, so Zambians stay there and get even poorer as the economy declines.

This is the great point made by Lant Pritchett in a classic article and in a CGD book. Why can’t we start treating Zambians like North Dakotans?   If their home economy is declining, let them move to other places voluntarily, where employers want to hire them voluntarily. Why do we recognize the right to live wherever you want for North Dakotans and not for Zambians?

Response to David in comment below: yes things could be good for the North Dakotans left behind BECAUSE OF all the North Dakotans that have left. Just think of supply and demand for labor — if the spur to migration was a downward shift in demand for labor, then having a lot leave shifts back the supply of labor and wages can remain the same. WITHOUT migration, North Dakota wages would have collapsed, which is what actually does happen in the migration-not-allowed Zambias of the world.

The good news doesn’t stop there. The usual fears for or about migrants—that they would be vulnerable to poor treatment, or that they would take advantage of the program to over stay their visas—don’t seem have materialized:

In addition to estimating per-capita income gains of 30-40%, we find that participating in the RSE leads to greater subjective well-being, more durable asset purchases, housing improvements, and in Tonga, a large increase in secondary schooling. Moreover, as a recent evaluation by New Zealand’s labor department found, these gains came with minimal displacement of native workers, and overstay rates of less than 1%.

Previously on this blog, Michael Clemens wrote that the development program known as leaving Haiti has pulled far more Haitians out of poverty than anything else that has ever been tried.

So why is nobody worried about brain drain of the gigantic numbers of Asian students studying in the US?

Source: Institute of International Education

One intriguing answer comes from political scientist Devesh Kapur, who studies the political effects of skilled migration (the so-called brain drain) on migrants’ home countries (we’ve blogged before about the positive economic effects of the brain drain). In a new book presented yesterday at the Center for Global Development, Kapur finds:

[T]he positive selection of Indian migrants through education has strengthened India’s democracy by creating a political space for previously excluded social groups. Because older Indian elites have an exit option, they are less likely to resist the loss of political power at home.

Governments have historically used emigration as a pressure valve, to rid themselves of political dissidents and other undesirables, and preserve stability at home. After the Paris-wide workers riots of 1848, the French government tried shaking their “subversive elements” by offering them land grants in Algeria. Kapur also cites the examples of Cuba and Zimbabwe, where leaders allowed the periodic exodus of discontented citizens as a deliberate strategy to keep their hold on political power while migrants’ remittances helped keep things going economically.

In the decades following independence in India, Kapur argues, the migration of India’s high caste, highly-educated elite allowed more middle and lower caste Indians empowered by new voting rights to seek more political power and a bigger share of economic pie. In the 1990s, as affirmative action threatened elite privileges, the rich let them go with less of a struggle because emigration to Europe or the US gave them other, attractive options. At the same time, though, Kapur says that members of the upper class that chose exit have still retained their voice: their continuing influence in Indian politics perpetuates social inequalities.

Tobias Pfutze (formerly one of our own at DRI) has also worked on this relatively neglected aspect of the brain drain, studying Mexican immigrants to the US and their influence on politics back home. In local elections in 2000 to 2002, Pfutze found that places in Mexico that sent more immigrants to the US were more likely to vote to boot out the authoritarian Institutional Revolutionary Party (PRI), which had dominated Mexican politics since 1929. His work suggests that the influence of Mexican immigrants to the US actually helped facilitate the Mexican transition from a one-party system to democracy.

–

photo credit

Many do not realize that New York’s thriving Chinatown is a suprisingly recent phenomenon.  Even during America’s open immigration years in the late 19th and early 20th centuries, Chinese were not welcome.  The Chinese Exclusion Act of 1882 formalized ugly prejudice.

New York’s Chinatown stayed very small, surrounded in the early 20th century by Italian and Jewish immigrants.

Lower East Side in 1920 (Chinese yellow, Italian blue, East European Jews purple)

Even as late as 1950, Chinatown was small.

1950: Highest concentrations of Chinese shaded dark red, lower percentages orange to tan

Chinese Exclusion stayed in effect de facto until 1965, when the racist provisions of US immigration law were removed, liberalizing immigration by all non-European groups.

Only 5 years later in 1970, Chinatown had already expanded greatly. Italians and Jews had already left for middle-class and upper-class neighborhoods elsewhere

Chinatown in 1970 (higher percentage Chinese shown as darker red-brown)

Today Chinatown is one of Manhattan’s most thriving neighborhoods. Other East Asian immigrants also congregate there.

The ladder out of poverty continues for today’s immigrants, following the Italians and Eastern Europeans, who in turn had followed the Germans and Irish.

The next time I have dim sum at Jing Fong on Elizabeth Street, I’ll raise a glass of green tea to immigration freedom.

You can see why anti-immigration sentiment is a big deal in the European countries shown and in the US. (This is a descriptive statement, I myself hate xenophobia.)

But what about the countries at the top of the graph? Let’s exclude the special and controversial case of Israel from all the following statements.

Correct me if I’m wrong, but I have not heard of prominent anti-immigration movements  in any of these countries.

Is that because these are non-democracies in which immigrants can be treated as second-class citizens with little or no rights?

Again, this is just descriptive speculation — I would certainly NOT recommend that approach to the democracies.  But it does show the complicated political economy you get when you mix xenophobia, democracy, equality before the law, and immigration.

My German and Scots-Irish ancestors, some of whom probably arrived as indentured servants (i.e. temporary slaves),  were called “guano” (birdsh*t) by Ralph Waldo Emerson in 1851. Emerson of course placed Anglo-Saxon English at the top of the racial hierarchy.

But my ancestors later made it into the top in solidarity against new waves of “black” Irish Catholic immigrants in the mid-19th century, considered to belong to the inferior Celtic race.

Irish Catholics in turn were moved up into whiteness when the “swarthy” southern Europeans and eastern European Jews arrived in the late 19th century and early 20th century. These latter would become “white” in the 20th century, but not before racist hysteria slammed the American immigration door shut just before Jews and others desperately needed to escape from fascism in Europe.

Painter ranges far and wide, detailing efforts to define the poor as a separate race, and poverty a hereditable condition. Not to mention nonsense about skull measurements, and mythical histories of mythical peoples like Saxons, Nordics, and Aryans, all in a desperate attempt to have a bright line between White and non-White.

Now we know that no such line exists, but not before “race experts” spent a couple generations in power in the academic establishment. Good cautionary tale for being careful and modest when we attempt to talk about ethnicity and development today.

UPDATE (3/26, 12:34EDT) Great NYT mag article explaining the details of the Gujarati hotel story (see end of post)

I’ve long been fascinated by the Vietnamese nail salon phenomenon. My female friends report a remarkably high concentration of Vietnamese women in nail salons in US cities. I even heard there was a nail trade magazine for the US market that is in Vietnamese. Alas I was never able to do more to document this systematically. Today I happened to stumble over a University of Chicago Ph.D. dissertation by Martin Mandorff that finally nailed it (bad pun was unavoidable).

Mandorff shows that ethnic specialization is remarkably widespread among US immigrants. The following table from 2000 census data shows the leading specializations (the OVER is how much males from that group are over-represented in the industry,* is for self-employed and ** is for employees).

Gujaratis (already famous worldwide as entrepreneurs and traders) are even more specialized as hotel owners. And then there is a group that I had only vaguely heard of: Chaldeans – they are Aramaic-speaking Roman Catholics from northern Iraq. They’ve got the liquor franchise.

It’s amazing how something so unexpected appears from the spontaneous efforts and social interactions of ethnic entrepreneurs. Mandorff of course has much more detailed and analytical explanations, which you should check out.

The phenomenon of ethnic business networks is of course not new, but it’s far more widespread than most people realize (almost every African nation has an indigenous group known as the entrepreneurs and traders –the Hausa in Nigeria, Gurage in Ethiopia, Serahule in the Gambia, etc.) And it’s too well known to even bother mentioning the famous merchant diasporas like the Jews, the Lebanese, East African Indians, overseas Chinese in SE Asia, and so on. Thomas Sowell has written at least TWO insightful books on the phenomenon: Race and Culture, and  Migrations and Cultures.  Avner Greif’s now standard explanation  (at least partial explanation) for ethnic networks was that small ethnic clusters could use the the threat of explusion from the group to enforce contracts and other trustworthy behavior (a more precise version was worked out in his  famous article on the experience of Mediterranean traders called Maghribis –11th century Jews in Cairo).

It’s all a very big hint that social and family relationships, culture, and self-organizing networks are an important part of economic development that has been much neglected by previous generations of development economists. Now the tide is turning – I gave a whole two-hour Ph.D. class on Wednesday that only scratched the surface of recent research by economists on culture, social norms, and development.

UPDATE: just received link to an NYT article by the always amazing Tunku Varadarajan (formerly at Wall Street Journal, now colleague of mine at NYU) explaining where the Gujarati dominance of hotels came from:

70 percent of all Indian motel owners — or a third of all motel owners in America — are called Patel, a surname that indicates they are members of a Gujarati Hindu subcaste. … ”In some American small towns they think ‘Patel’ is an Indian word for ‘motel.’”

{Patels are members of a caste called} vaishyas, or traders, who were once employed to calculate the tithes that were owed to medieval kings by farmers in Gujarat, an Indian state on the Arabian Sea.

More great details follow in Tunku’s article on how the “Patel Motel Cartel” came about in America.

UDPATE 2: An academic paper that traces the origins of Hasidic Jews dominating the 47th Street Diamond District in Manhattan all the way back to the 11th century, with some suggested explanations.