Doctors Crossing Borders, and Other Perils of Professional Training

This fall I am teaching an Honors Seminar designed for students in my home university’s College of Health Sciences. The students are all eager to pursue their professional careers as medical doctors, nurses, and physical therapists. Sadly, only 10% of them have expressed any interest in practicing in those parts of the world where they are most needed. Should Christian universities and Christian professors advocate for medical missions, either short-term or career-long? One does not necessarily have to cross borders, political or cultural, to find suffering people in need of care. Surely there are needy people all over the world. However, while the universality of suffering is undeniable, the availability of care across the world is highly stratified, and, in contrast to the calling of Christ, we are all part of a system that creates that stratification in medicine and beyond.

Christianity has a long history of providing medical care for the neediest. The Knights Hospitaller, all the way back in the eleventh  century, were dedicated to providing healthcare for vulnerable pilgrims thousands of miles from their homeland. In 1812 Adoniram Judson Gordon, for whom my seminary alma mater is named, launched the foreign missionary movement from the United States and was followed in 1834 by an American medical missionary, Peter Parker. Parker opened a hospital in Canton (now Guangzhou), China and treated over 2000 patients in his first year.¹ There are certainly medical missions still active in the world. Samaritan’s Purse operates World Medical Missions, affiliated with mission hospitals all over the world, including 23 in Africa.² Medicine for All People³ and Blessings International⁴ both focus on supplying pharmaceutical and equipment resources to needy patients all over the world.

Sadly, these organizations have failed to relieve what some refer to as the maldistribution of healthcare professionals.⁵ The World Bank reports that the United States has 3.56 doctors per 1000 of the population. A very healthy ratio though not the highest. Those tend to be found in northern European countries like Sweden (7.06 doctors per 1000 people) and Norway (5.17).⁶ In other parts of the Occidental world, the UK has a ratio of 3.17, Canada 2.46, and Australia, 4.10. By contrast, Sub-Saharan Africa suffers from a dearth of physicians. Kenya has 0.23 doctors per 1000 of the population. Ghana has 0.16 doctors per 1000 people and Tanzania has only .05.

With this kind of distribution, one would hope that doctors entering practice would target those countries where they are most needed. Unfortunately, the opposite effect, referred to as the physician carousel, is more evident.⁷ Doctors from the UK tend to migrate to the United States. Doctors from South Africa fill the void left by those migrating British doctors by moving their practice from South Africa to the UK. Ghanaian, Kenyan, and Tanzanian doctors, in turn, migrate to South Africa to practice. In some cases, the carousel is more direct. Nurses emigrating from Ghana to the UK have approached an epidemic.⁸

The migration process of doctors and other healthcare professionals from low-concentration countries to higher-concentration countries often involves doctors or medical students crossing borders to receive more or better training. They then remain in their new country to practice, attracted by lifestyle and career benefits like a higher standard of living for their families and access to more sophisticated technology for their patients. The percentage of foreign-born or foreign-trained doctors has reached appreciable levels. In the US, over 25% of doctors are foreign-trained.⁹ In the UK, the percentage of foreign-trained doctors is 31% and growing. Other English-speaking countries are also among the most reliant on foreign-trained doctors – Australia 32%, Ireland 40%, and New Zealand 42%.¹⁰

The economic pull of opportunity for young practitioners has overwhelmed attempts to regulate the migration of medical professionals away from the areas where they are needed most. Ghana is on the World Health Organization’s “red list” of countries where the concentration of healthcare professionals is so sparse wealthier nations are discouraged from recruiting there. Nonetheless, with wages in the UK running seven times those available for nurses in Ghana, the migration doesn’t require active recruiting. One of the only forces running counter to the carousel effect is the work of medical missions, and those numbers are limited. It is difficult to calculate the number of missionaries in the field at any particular time but a 2021 study from faculty at Gordon-Conwell Theological Seminary put the total number of foreign Christian missionaries at 430,000, and one would expect medical missionaries to represent only a small fraction of that total.¹¹ In 2017, Samaritan’s Purse reports that it sent 878 medical professionals to 37 different countries for short-term medical missions.¹² Médecins Sans Frontières (Doctors Without Borders), one of the most famous secular organizations for cross-border medical assistance, employs approximately 68,000 people spread over 77 countries but less than 20% of its staff are sent from outside their country of practice.¹³ Compared to a global shortfall of 4.3 million doctors and nurses, much of it in developing nations, the numbers border on inconsequential.¹⁴

Is there a means by which the Christian community can counteract the effects of the carousel and correct the maldistribution of needed healthcare workers? Short of government-funded financial incentives or government-enforced career controls, that effort may have to begin with those of us training the next generation of healthcare professionals, including me. Faculty in Christian universities can actively seek to overturn the popular connection between healthcare professions and worldly riches. What if our approach to these professional domains was to present them as contexts for service rather than sources of wealth?

Why should Christian universities take on this challenge? Because medical missions is not a dark-ages invention. It has biblical roots. In Matthew 10, Jesus sent out his disciples with instructions to heal the sick. In Acts 5, people from all over Judea brought their sick friends and relatives to be healed by the Apostles. In taking on that mission, the disciples, and those of us who participate in medical missions today, follow Jesus’s own example (Matthew 15:21-28).

Of course, this phenomenon is not exclusive to healthcare workers. Well-trained professionals in every area are needed in less developed countries. Educators, scientists, business professionals, pastors, writers, lawyers, and almost every other profession is in short supply in diverse parts of the world. Christian educators of every discipline could encourage our students to consider missional activity, putting their professional skills to work for the good of the needy and the advancement of the Kingdom.

The hard truth is that this challenge will ultimately require us to change our common understanding of the instrumentality of professional work and professional training. Far from the common secular mindset that sees professional preparation as a means of financial security and social status, we may be required to reinstate the biblical model of professions as a context for Christian service. The New Testament holds many examples of Christian disciples with professional training. Paul was a tentmaker. Luke was a physician and Matthew a tax collector. Jesus himself is identified as a carpenter (Mark 6:3). Yet almost none of the biblical narrative is devoted to extolling their professional skills and they are never even significant to the metanarrative of God’s redemption of the world. For biblical Christians, their professional training only provides a context in which those disciples served God and participated in His redemption.

In his book, “Brothers We Are Not Professionals¹⁵ , John Piper pleaded with pastors to consider their calling as one of slavery to Christ, not one of professionalism. That same strain of Christian self-surrender is applicable in greater or lesser degree to every profession. To the extent a Christian practitioner can remain true to the Gospel while remaining in good standing in the profession, professionals of every stripe can dedicate themselves to missional service in and through their professional activity. Let’s communicate the value of professional education and professional careers the way they would be understood scripturally, as providing a means for valuable service to the Lord (1 Corinthians 12:6-8).

1. Louis Fu, “Healing bodies or saving souls? Reverend Dr Peter Parker (1804–1888) as medical missionary,” Journal of Medical Biography. 2016;24(2):266-275. doi:10.1177/0967772014532895
2. Samaritan’s Purse, “World Medical Missions,” 2024, Mission Hospitals (samaritanspurse.org).
3. Medicine for All People, “About Us”, 2024, About Us – MAP International – Medicine for All People
4. Blessings International, “Medical Missions,” n.d., Home – MedicalMissions.com.
5. Giles Dussault & Maria Franceschini, “Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce,” 2006, Human Resource Health 4, 12. https://doi.org/10.1186/1478-4491-4-12.
6. World Bank Group, “Physicians (per 1000 people),” Physicians (per 1,000 people) | Data (worldbank.org).
7. Karinne Lantz, “Turning the Health Professional Carousel: Is Canada Undermining Human Rights in Developing Countries?” 2007, 8 Paterson Rev Int’l Affairs 34.
8. Naomi Grimley & Camilla Horrox, “Ghana patients in danger as nurses head for NHS in UK – medics,” 2023, BBC, https://www.bbc.com/news/world-africa-65808660
9. American Immigration Council, “Foreign-Trained Doctors are Critical to Serving Many U.S. Communities, 2018,https://www.americanimmigrationcouncil.org/research/foreign-trained-doctors-are-critical-serving-many-us-communities.
10. Anna Fleck, “The Countries With The Most Foreign-Trained Doctors,” Statista, 2023, https://www.statista.com/chart/3849/the-countries-with-the-most-foreign-trained-doctors/.
11. Gina A. Zurlo, Todd M. Johnson, & Peter F. Crossing, “World Christianity and Mission 2021: Questions about the Future,” International Bulletin of Mission Research, 45(1), 2020. https://journals.sagepub.com/doi/full/10.1177/2396939320966220.
12. Samaritan’s Purse, “World Medical Mission Fact Sheet,” 2024, https://www.samaritanspurse.org/our-ministry/world-medical-mission-fact-sheet/.
13. Médecins Sans Frontières, ”About MSF,” n.d.,  https://www.doctorswithoutborders.ca/about-msf/#:~:text=Around%2068%2C000%20people%20work%20for%20MSF%20in%20over,hired%20in%20the%20countries%20in%20which%20we%20work.
14. Nigel Crisp & Lincoln Chen, “Global Supply of Health Professionals,” The New England Journal of Medicine, 370(10) 2014,  Global Supply of Health Professionals | New England Journal of Medicine (nejm.org)
15. Broadman & Holman Publishers, Nashville, TN, 2002.