Design, setting and participants: South African-trained doctors living in Australia and the spouses or adult children of deceased practitioners who had emigrated from South Africa were contacted by email between August 2008 and February 2009. The sample of doctors was gathered and expanded by an email “snowball” technique and through advertising in alumni and professional journals and newsletters. A questionnaire was emailed to 653 contacts.
Results: Responses were received from 469 of the 653 email contacts (72%), from a population of about 2200 South African doctors in Australia. Of the 469 respondents, 434 (93%) had been motivated to emigrate by a wish to leave South Africa, rather than by Australian inducements. The primary reason for emigration before 1990 was opposition to apartheid (142/205 [69%]); the primary reason for emigration after 1990 was the level of violent crime (including “safety” issues) (116/264 [44%]).
The migration of doctors from developing to developed countries is a global concern.1 It is most noticeable from the former colonies of the British Empire2 and from areas of the Middle East where English is the language of medical education.
Health care in the United Kingdom,3 the United States,4 Canada5 and Australia6 is heavily dependent on doctors from developing countries. It has been argued that the “doctor drain” is another form of colonialism.7 A sense of social injustice, and even of guilt, has triggered the suggestion that countries like Australia should desist from employing these doctors8 or, at the least, should financially compensate the donor countries.6 In 2001, South Africa officially asked Canada to cease “poaching” doctors,9 and in 2008, the UK agreed to slow the migration of South African doctors to the UK.10
Has Australia deliberately attracted South African doctors who would otherwise not have migrated, or has it been a country of choice for many who had already decided to emigrate? Should Australia, knowing of South Africa’s desperate shortage of doctors, feel guilty about its reliance on doctors educated at South Africa’s expense?11
Between April and October 2008, we sent emails to a few South African-trained doctors known to us personally. The Medical Journal of Australia and the newsletters of some Australian medical organisations carried a notice inviting South African medical graduates living in Australia to make email contact with us, as did the alumni magazines of some South African universities. All contacts were asked to distribute the invitation to participate in our study to further contacts, so that the network expanded in a “snowball” manner. In this way, we recruited a total of 653 doctors (including two who had completed their final medical examinations in Australia) or widows or adult children of deceased graduates whose experi-ence was considered relevant.
A questionnaire was emailed to all contacts. Included were open questions about reasons for migration. Responses were grouped according to the categorisation described by Tatz and colleagues,12 and entered into a spreadsheet for analysis.
The primary reasons given for migration before 1990 are shown in Box 1. Of the 205 respondents who emigrated before 1990, 142 (69%) said they had left because they objected to apartheid. If “concern for the future” (including the fear of a violent backlash or even of civil war) is added to this number, apartheid drove out 161 respondents (79%).
The primary reasons given for migration from 1990 onwards are shown in Box 2. Of the 264 respondents who migrated after 1989, 116 (44%) gave the primary reason as the level of violent crime or “safety” issues. If “concern for the future” (including “children’s future”) is added, this figure rises to 157 (59%).
Thirty respondents (11%) said that they were primarily attracted to Australia: eight because of job opportunities for themselves or their spouse, one because of the lifestyle, 17 as travellers, and four who were married to Australians. To these 30 must be added 16 older doctors (6%) who joined émigré children (of these older doctors, seven did not practise).
The pattern of all reasons (primary or secondary) for emigrating shows a shift similar to that of the primary reasons. Apartheid and concern for the future were cited by 176 of the pre-1990 emigrants (86%). The political situation, the level of crime, safety issues and concern for the future were cited by 171 of the 264 post-1989 emigrants (65%).
For 38 (8%) of the 469 respondents, the primary reason for emigration was an attraction towards Australia. It is clear that, during both periods of migration, “push” rather than “pull” factors were the predominant driving force. In the words of one respondent, “With all respect to Australia, it was not so much the positives of the country that pulled us towards it, but rather a push from the negatives of South Africa”.
The respondents, having decided to emigrate, wished to choose the most appropriate new homeland. With few exceptions, they preferred an English-speaking country where their qualifications were likely to be recognised. (Between 1995 and 2002, 101 South African doctors [presumably Afrikaans-speaking] registered in The Netherlands.)13 Their other preferred host countries are shown in Box 3. Belgium, Hong Kong and Sweden were mentioned twice as possible destinations. Bahrain, Botswana, Germany, Gibraltar, Italy, Namibia, Saudi Arabia, the West Indies and Zimbabwe were each mentioned once. Had Australia not accepted the respondent doctors, they would probably have migrated elsewhere, most preferring Canada, the UK, New Zealand or the US. One hundred and eighty-three respondents had not considered another country.
Most of the respondents gave more than one reason for choosing Australia above other host countries. The primary reasons given are listed in Box 4.
The Medical directory of Australia (MDA), published by the Australasian Medical Publishing Company, lists almost every registered doctor in Australia. The 1957 MDA listed 10 South African graduates, whereas the 2009 edition lists 2209 (3.2% of Australian doctors). What accounts for this 200-fold increase over the past half-century?
Migration has long been recognised as a consequence of factors pushing people away from their homeland and other factors pulling them towards another country.14 The reasons for the migration of South African doctors cannot be understood without appreciating the two differing periods of recent South African history. The apartheid era of 1948 to 1994 was followed by the parliamentary democracy established after Nelson Mandela’s release from gaol in 1990. The emigration must therefore be studied in two eras: before and after 1990, when the change to a democracy was seen as inevitable. Factors which pushed some to migrate during the apartheid era deterred others. After 1990, many who had never considered emigrating started to do just that.
Before 1990, much emigration was in response to the repressive violence of apartheid. A 2007 study by Tatz and colleagues12 of the migration to Australia and New Zealand of 608 South African Jews (almost three-quarters of whom were professionals) demonstrated four waves of migration before 1990:
After the election of the Nationalist government in 1948;
After the shootings at Sharpeville in 1960;
After the shootings in Soweto in 1976; and
After South Africa’s invasion of the Portuguese colonies of Mozambique and Angola in pursuit of guerrilla fighters in 1985, with the accompanying states of emergency in response to intense opposition from an increasingly politicised and restless population.
As the repression of opposition to apartheid intensified through the 1980s, pressures were being applied progressively from without. Economic disinvestment and academic15 and sporting boycotts took their toll. Many South Africans thought that the country was on the brink of civil war. Responses to the 2007 survey revealed that most Jews who emigrated before 1990 had been reacting against apartheid, or because of fear of an imminent civil war.
Most survey respondents who emigrated from 1990 onwards were concerned by the increase in violent, often homicidal, crime affecting the white community, which had been better protected under the effectively policed apartheid regime. They feared for their future, and for that of their children, under an African National Congress government, with the threat of civil war reaching its peak in 1993.
Such “push” factors may not have been confined to South African doctors. While chairing the Registration Committee of the New South Wales Medical Board between 1987 and 2000, one of us (P C A) noted that many immigrant doctors belonged to minority groups discriminated against in their home country — for example, Coptic Christians from Egypt, Muslim doctors from India, Chinese doctors from Malaysia and followers of minority religions, such as Zoroastrianism, from Iran. As data on religion and ethnic origins are not sought by Australian immigration or medical registration authorities, this impression remains anecdotal. “Push” factors might, however, relate equally importantly to immigrant groups other than South Africans.
The use of email, allowing respondents to write as much as they wished in response to open-ended questions about their motivation for migration;
The high proportion of all Australian-resident South African doctors who participated in our study (about 21%); and
The high survey response rate (72%).
The initiation of the “snowball” recruitment process among known colleagues (moderated, however, by most responses being elicited through notices in Australian medical publications and South African alumni magazines);
Self-selection by respondents (five questionnaire recipients replied declining to participate, but no reasons were given); and
Interpretation bias by spouses or children of deceased doctors. (In relation to the 28 deceased doctors, 13 responses came from spouses and 15 from adult children. All but three of the 28 families had migrated before 1990. Of the three post-1990 migrants, two had not practised in Australia.)
No comparable studies of emigrant South African doctors were elicited in a Google Scholar search using the terms migration, emigration, South Africa, doctors, physicians, medical practitioners and medical graduates. Gilchrist, studying the contribution to the field of paediatrics in the US by 65 paediatricians trained at the University of the Witwatersrand between 1940 and 1979,16 concluded that “their departure . . . was in no small part influenced by the apartheid policies”.
A German study surveyed a few chief executive officers and human resource managers of South African hospitals and other health care institutions for their opinions on why doctors had emigrated. Although the information was second- or third-hand and the authors concede the unreliability of their findings, they concluded that emigration after 1990 was largely due to the high crime rate in South Africa.17
In 1998, Weiner and colleagues, using addresses maintained by the University of the Witwatersrand alumni office and a survey of 200 doctors, estimated the rate of emigration of 5294 doctors who had graduated from that university between 1925 and 1993. The estimated emigration rate was 44%– 47%.18 Although they did not look into reasons, they comment, “It is likely . . . that the reasons generally lie outside of the control of the health and education sectors”. They conclude, “It would be appropriate to investigate people’s reasons for emigration, since this could better inform policy”.
We considered our survey results in the light of the ethical question of whether Australia has “poached” doctors who would otherwise have remained in South Africa, a country seriously short of doctors. The answer was unequivocal. Few were attracted to better positions. As they had already decided to leave, Australia did not induce them to migrate. Had Australia not accepted them, they would have gone elsewhere. English language, relative ease of recognition of qualifications, southern hemisphere climate and lifestyle and family reunion were the main reasons for preferring Australia to other host countries.
1 Primary reason given for leaving South Africa before 1990 (n = 205)
2 Primary reason given for leaving South Africa from 1990 onwards (n = 264)
3 Other potential host countries considered by respondents
4 Primary reason for choosing Australia above other host countries (all respondents) (n = 469)
* Includes “medical standards”, “for children’s sake”, availability of a visa, training opportunity, salary, “others doing it”, Jewish community, “good idea”, “by chance”, “travelling and remained”, “only option”, and no reason given.