Rochelle Burgess Hon. BSc (Psychology) MSc (Health Community and Development)

r.a.burgess@lse.ac.uk

Rochelle Burgess is a recent graduate from the Health, Community and Development program at the London School of Economics and Political Sciences (LSE). She is currently completing a research fellowship at the Health Economics and HIV/AIDS Research Division (HEARD) at University of KwaZulu-Natal, Durban, South Africa. Following the completion of her fellowship Rochelle will begin doctoral research on mental health and HIV/AIDS at the LSE.

Scholarly Abstract

Currently, more than half of the human population resides in cities. Over one-third of these cities are located in the global south, where many of the world’s slum and squatter settlements are located. The unique experience of the urban poor has helped initiate a reconfiguration of poverty definitions, led by Amartya Sen’s capabilities approach. Countless poverty alleviation programs have since incorporated his ideals, but with limited success. This paper attempts to address these issues by examining the role of psychosocial phenomena such as identity, social representations and stigma in the escape from poverty. Through unpacking the interactions between these phenomena against the background of poverty within Brazilian favelas, the author attempts to help inform a more concrete framework for the application of Sennian approaches to poverty alleviation in urban centers.

Keywords: urban poverty, capabilities approach, social identity, social representations, stigma, poverty alleviation, favelas.

Author’s Note

As a student of health and social psychology, I am interested in the interactions between individuals and their lived worlds, and in how the social contexts and structures within these worlds can impact our health. I have a broad range of interests outside of psychology, linked by a desire to mediate risks facing vulnerable populations all over the world. I envision true integration between disciplines and specialties for the betterment of society as a whole, both in rhetoric and practice. This paper was the result of many readings of Amartya Sen’s revolutionary work Development as Freedom, and a desire to see his theories prove more successful on the ground. My current research activities and interests include: addressing issues of mental health in communities affected by HIV/AIDS; AIDS as evidence for the value of comprehensive health care; the ability of broader social movements to influence health outcomes; and mental health supports in developing country contexts.

Supporting Capabilities: Using Psychosocial Concepts to Guide a Sennian Approach to Escaping Urban Poverty.

Introduction

For the fifty percent of the developing world that exists on less than one US dollar a day, no climb is more perilous than that which leads out of poverty. Many people living in poverty endure inadequate shelter, lack of access to health care, lack of clean water, and an inability to educate or provide for their children. While this description most readily aligns itself with images of rural communities in developing countries, globalization has transposed a similar reality upon urban landscapes. Thus those who go to cities to seek economic opportunity often find the cities poorly lacking. This influx to urban areas has lead to exponential increases in slum populations around the world, presenting a challenge to those attempting to address poverty in the world’s largest cities.

While the importance of a stable income in mitigating poverty is indisputable, we must suspect the notion that economic opportunity alone will translate to improved livelihoods. It is quite likely that this illusion has been propagated by the very manner in which states of poverty are defined. Neo-liberal doctrine has long placed the roots of poverty within the individual and his inability to capitalize on life circumstances to achieve economic success.
Urban poverty is a unique experience, however, which ties in a host of social factors such as high levels of crime, substandard housing conditions, and violence.

Unsurprisingly, this changing face of poverty has prompted a reconfiguration of poverty philosophies, led by Amartya Sen’s capabilities approach. Sen rejects preoccupations with economic indicators; instead, he explores the barriers that prevent individuals from engaging in five basic freedoms: social opportunity, political freedom, economic facilities, transparency guarantees, and protective security. He suggests that the only way to truly achieve happiness is through addressing the deprivation of capabilities that prevent the individual from engaging in these freedoms.
Sen’s definition of poverty incorporates social phenomena such as social inequity, cross cultural stigmatization, and power imbalances. This incorporation has opened the doorway to more encompassing strategies against poverty and has inspired countless program efforts in the field since 2000. However, results have been mixed,<
with scholars citing the inability of programs to appropriately consider the influences of these issues on the choices made by, and lived experiences of, the poor.

Such outcomes also highlight the absence of a framework capable of outlining how these freedoms can be actualized on the ground. The ability of psychosocial phenomena to describe the way that individuals interact with their world could potentially contribute to the establishment of a concrete pathway for actualizing Sen’s freedoms. By highlighting the intricacies of the interface between society and the individual through the application of psychosocial theory, poverty reduction strategies incorporating Sennian ideals could be better informed and stand a greater chance of success. This paper will examine mechanisms such as social identity, social representations, and stigma with respect to Sen’s capabilities approach, in order to illustrate the importance of psychosocial well being in Sennian approaches to poverty. Examples of these phenomena in the lives of the poor are presented in comparisons to one of the most famous sites of urban poverty: The Brazilian favela.

The Brazilian Favela

For decades, the favelas (Portuguese for ‘shanty town’) of Brazil have provided a window into the changing face of urban poverty. Their inhabitants reside in some of the most culturally rich environments in the world, albeit in one of the most unequal countries.
Although informal settlements have existed in Brazil for over 100 years,
the economic downturn of the 80s and 90s following the ‘golden era’ of the 60s is accredited for moulding once largely afro-Brazilian communities into the profile seen today: a mix of afro-Brazilian and poor white inhabitants.
Over eighty percent of Brazil’s population lives in cities, with more than 12 million households residing in informal settlements. Access to services vary, with 26 million individuals unable to access water, and over 80 million without access to formal sewage systems.

The conditions within Brazil’s informal settlements have not been static. Attempts to regenerate the favelas have ranged from removal policies in the 1970s, to upgrading programs in the 90s, such as the Favela Barrio regeneration program, launched in 1994.
Though living conditions in favelas have improved in recent years, favela life is still plagued by high levels of violence and crime. Drug trade is of particular concern in this respect; wars waged between drug lords and police officials often result in the deaths of innocent community members. Living in an environment with such complex social conditions has been proven to influence psychosocial wellbeing; as such, social conditions warrant consideration in attempts to improve living conditions in the favelas.

Considering the Psychosocial: Social Identity, Social Representations, Stigma, and the Brazilian Poverty Experience

Social identity theory describes identity formation as the process by which individuals come to define themselves in relation to others in their world.The process is thus heavily shaped by the nature of interactions with other people.In a similar vein, group identities are formed by comparisons of the self to a set of individuals who compose an ‘in’ group (and thus share similarities in values and behaviours) and against those who are in the ‘out’ group (and therefore representative of contradictory ideals and values).

In the favela, social identities are created in an environment where it is often difficult to find sources for positive self-validation. Brazilian culture is famous for its dominant masculinities. In such a culture, the ability to provide for one’s family becomes a top priority and is cited by residents as the impetus for a move to urban centres.The ability to act as a provider is also cited multiple times by Sen as a capability for individuals. In Pearlman’s examination of poverty in the favelas, 70% of respondents said that finding a good job is the only real opportunity to escape chronic poverty. However, a lack of job opportunities in the urban marketplace makes unemployment a reality for many. In cases like these, when it is impossible to provide for the family, a huge blow can be inflicted upon the maintenance of a positive sense of self. As men attempt to maintain positive identities through other means, alcoholism and domestic violence are often infused into the home. As one favela community leader put it, “If a man is out of work, he doesn’t help around the house, but he does get in the way more than ever. He’s drinking and squabbling, blaming things on his wife.”Such statements also describe typical defensive behaviour in social psychology, through which individuals attempt to maintain a positive sense of identity through projection of fears and negative feelings and through placing blame on others. Subsequently, many families are plagued by domestic violence, which is known to entrench individuals in the poverty cycle.What’s more, in many families, economic opportunities that become available in the way of informal work for women or children may be rejected based on the dominant male’s decision, fuelled by his need to remain acting head of household.Closely connected to this concept of identity formation is the idea of social representations, which have been described as the mechanisms through which individuals see and construct their worlds.The nature of this process involves interactions with peers in public spaces that allow the opportunity to formulate ideals and definitions that are used to help navigate one’s social environment. Once formed, these representations can be understood as images, categories, and phenomena that organize meanings and allow individuals to classify circumstances and other individuals.The theory of social representations has great value in unpacking the motivations behind responses to poverty alleviation programs in poor communities. Howarth, Foster, and Dorrer describe some key aspects of social representations theory, which can be applied to the favela experience.First, social representation theory provides perspectives on the competing systems of knowledge across lay and professional spheres. For many poverty alleviation programs, which are characterized by the introduction of new knowledge and skills, the ability or inability of individuals to incorporate new information will heavily influence levels of success. Second, social representations have the ability to entrench and sustain stigmatizing activities and practices within a group.Urban dwellings are often permeated by social, economic, and political variables that influence the opinions formed about actors and groups within a community. For example, in a community that has experienced failed program attempts from outside agents, existing representations may leave residents prejudiced and dubious of future initiatives.

Sen places a high importance on the ability of individuals to engage in political freedoms in the process of escaping poverty. Favela residents have developed representations to explain experiences of high crime and violence committed against them by government and public officials, and these representations deter them from involving themselves politically. There is instead a belief that government workers and officials serve the interests of the wealthy.Even in communities that have reached the level of participation necessary to improve situations of poverty, political experiences have not been positive, leading to a sense of defeat among favela residents. As one favela resident describes:

We built a police station with our own hands and money to curb the violence. The police agreed to come here after lots of pressure. They abandoned the station… after criminals destroyed it in a shoot out… finally we got fed up and tore it down with sledgehammers.Negative social representations like these also carry the potential to interfere with the few economic opportunities that may present themselves. For example, in the wealthy communities that typically border Brazilian favelas, there is a representation of favela residents that dubs them as violent, active participants in the drug trade and other illegal activities, uneducated, and, of course, impoverished.Though only a small proportion of favela residents actually fit this precise image today, the power that such false representations have on the daily choices and lifestyles of millions of the urban poor is unmistakeable. As one favela resident reported, “If I say I am from [the favela] they’ll retract the job offer because they think we are all criminals here.” Another said, “One day a company called me for a job, but when they realized I lived in [the favela] they changed their minds, thinking that I was one of those… they couldn’t trust.This externally imposed representation of favela residents can damage their emotional well being, which reduces their self esteem and subsequently reduces the likelihood of engaging in job seeking behaviours after repeated interactions of this nature. These negative social representations often create widespread stigmatization from one group to another. In discussions of favela life, stigma is best defined as any negative thoughts, feelings, or actions directed towards a particular group of individuals.In this context, the urban poor are impacted by the negative thoughts, feelings, and actions directed at them by the stigmatizers: Affluent members of society.

External representations and stigma towards favela residents are beyond their immediate control. This, however, does little to alleviate the negative impact and the ability of these factors to dictate their lived experiences. Repetition of the types of experiences explained above can substantially erode feelings of self worth. More importantly, they can damage the belief that one’s efforts can result in a significant change in one’s situation; this belief is a driving factor behind the uptake of poverty alleviation programming. In order to distance themselves from outwardly imposed negative representations, individuals respond with a range of behaviours. Pearlman describes a typical example witnessed during her fieldwork in the favelas:

Young women… spend virtually their entire earnings on clothing and accessories that to them symbolize ‘south zone chic’. I spoke with one young man who had a cell phone, a pager, and a palm pilot hanging off the waistband of his baggy shorts… he confessed that none of them worked. They were merely fashion accessories.It can be safely assumed that this hyper consumption of material items is done with the intent to combat the stigma and negative representations associated with a life of poverty by projecting the image of affluence. From an economic standpoint, such testimonials point to a shift in priorities: incomes traditionally dedicated to helping a family escape from poverty are now being invested in maintaining a positive sense of self worth among the youth in the favela. Debt levels may increase within a home, and the effectiveness of economic opportunity is once again lessened. The need to maintain positive self-identities and self representations can also explain the high volume of gang related activities among youths in favela communities. Creating a positive sense of self is an important aspect of psychological development. As Howarth describes, in absence of other opportunities to assert positive identities and challenge stigmatizing sentiments, it is not uncommon for youths to join gangs. Gangs provide an opportunity for validation from a member’s peers, though this often occurs through engaging in negative activities. If poverty alleviation programming seeks to tackle such issues, it would follow that alternative means must be put into place for youth to find similar self-validation.

Discussion

The cities of the world house considerable potential. The work of international development agencies and grassroots organizations has led to the expansion of social opportunity, access to health care and education, and improvements in basic infrastructure in centres of urban poverty like Brazil’s favelas. Such efforts clearly encapsulate the freedoms that Sen deems pertinent in the escape from poverty on a theoretical basis. On the ground, however, these efforts have not been adequate in reducing the number of people who live in dehumanizing conditions within urban centres, indicating the existence of a missing link. Once the interlaced relationships between these three phenomena—social identity, social representations and stigma—are examined in light of Sennian ideology, the role of the psychosocial in escaping urban poverty begins to take shape. A strong sense of self, fostered in part by positive individual and group identities, self efficacy (defined as the belief in one’s ability to succeed in various tasks and often influenced by stigma and negative representations), and positive social representations of one’s group in a broader cultural context, are as important as any program initiative. Ultimately, we have seen that psychosocial wellbeing can impact an individual’s likelihood to engage in the facilities made available to him or her via public programming. The likelihood that an individual will take advantage of opportunities created by training programs, a social opportunity for Sen, engage in job seeking behaviour (economic opportunities), or participate in civic programming and political processes (political freedoms) are influenced heavily by the psychosocial wellbeing.

But what does this mean in a practical sense? How can this improved understanding of the poverty experience inform future poverty initiatives of the Sennian variety? The importance of psychosocial wellbeing is no secret. Research has long identified the role of social phenomena and psychological wellbeing in the lives of the poor, yet the integration of these ideas into a single concerted approach was not attempted until quite recently. Despite advances in rhetoric surrounding poverty alleviation practices, interventions continue to operate in a vertical manner. Programming aimed at reducing poverty works within a vacuum, often separate from attempts to address social issues such as violence against women and gang related violence among youth. There are many examples of NGO-operated initiatives that seek to rectify this gap, and could help to inform large scale programming which has yet to incorporate such practices, if given the real opportunity to do so.

This discussion has highlighted the ability of psychosocial barriers such as negative social identity, negative social representations, and high levels of stigmatization to inhibit the degree to which individuals can experience and interact with Sennian freedoms in their daily lives. It appears that for Sen’s freedoms to be capitalized on, development programs must create opportunities for the urban poor to foster positive self-identities, formulate new representations of their place in society, combat the negative representations held by those outside favela communities. If these concepts were incorporated into the planning of poverty alleviation strategies, sustainable success could be far more attainable. The time for truly a multi-disciplinary approach is long overdue. Once the field of Sustainable Development takes into account the role of the psychosocial, the opportunities that cities provide for escaping poverty can be developed to their full potential.

Works Cited

Amato, Paul, and Jiping Zuo. “Rural Poverty, Urban Poverty and Psychological Well-Being.” The Sociological Quarterly 33.2 (1992): 229-240.

Amis, Philip. “Making Sense of Urban Poverty.” Environment and Urbanization 7.1 (1995): 145-58.

Arias, Desomond E. “Faith in our Neighbours: Networks and Social Order in Three Brazilian Favelas.” Latin American Politics and Society 46.1 (2004): 1-38.

Brewer, Marilynn B. “The Many Faces of Social Identity: Implications for Political Psychology.” Political Psychology 22.1 (2001): 115-25.

Campbell, Catherine et al. “‘Dying Twice: A multi level model of the roots of AIDS stigma in two South African communities.” Journal of Health Psychology 12.3 (2007): 403-16.

Chant, Sylvia, and Cathy McIlwaine. Geographies of Development in the 21^st century: An Introduction to the Global South. Cheltenham: Edward Elgar, 2008.

Frediani, Alexandre. “Amartya Sen, the World Bank, and the Redress of Urban Poverty: A Brazilian Case Study.” Journal of Human Development 8.1 (2007): 133-52.

Howarth, Caroline. “Race as Stigma: Positioning the Stigmatized as Agents, not Objects.” Journal of Community & Applied Social Psychology 16 (2006): 442-51.

—. “A Social Representation is not a quiet thing: exploring the critical potential of social representations theory.” British Journal of Social Psychology 45 (2006): 65-86.

Howarth, Caroline et al. “Exploring the potential of the theory of social representations in community-based health research and vice versa?” Journal of Health Psychology 9 (2004): 229-43.

Huddy, Leonie. “From Social to Political Identity: A Critical Examination of Social Identity Theory.” Political Psychology 22.1 (2001): 127-56.

Patel, Vikram. “Poverty, inequality, and mental health in developing countries.” Poverty, Inequality and Health: An International Perspective. Eds. David A. Leon and Gill Walt. Oxford: Oxford University Press, 2001. 247-262.

Pearlman, Janice. “The Metamorphosis of Marginality: Four Generations in the Favelas of Rio de Janeiro.” The Annals of the American Academy of Political and Social Sciences 606 (2006): 154-77.

Riley, Elizabeth, Jorge Fiori, and Ronaldo Ramirez. “Favela Barrio and a new generation of housing programs for the poor.” Geoforum 32 (2001): 521-31.

Sen, Amartya. Development as Freedom. New York: Random House, 1999.

The World Bank. Cities Alliance: Cities Without Slums 2007 Report. Washington, D.C.: 2007.

—. Voices of the Poor: From Many Lands. New York: World Bank Publications, 2002.

^, Urban poverty is a unique experience however, which ties in a host of social factors such as high levels of crime and substandard housing conditions and attendant violence.

Unsurprisingly, this changing face of poverty has prompted a reconfiguration of poverty philosophies, led by Amartya Sen’s capabilities approach. For Sen, preoccupations with economic indicators are absconded in favour of an exploration of the barriers which prevent individuals from engaging in five basic freedoms: social opportunity, political freedom, economic facilities, transparency guarantees and protective security. He suggests that only through addressing the deprivation of capabilities that prevent the poor from engaging in these freedoms, will individuals truly achieve happiness. Sen’s incorporation of social phenomena such as social inequity, cross cultural stigmatization and power imbalances into poverty definitions has opened the doorway to more encompassing strategies against poverty, and inspired countless program efforts in the field since 2000. However, results have been mixed, with scholars citing the inability of programs to appropriately consider the influences of these issues on the choices made by, and lived experiences of, the poor.

Such outcomes also highlight the absence of a framework capable of outlining how these freedoms can be actualized on the ground. The ability of psychosocial phenomena to describe the manner in which individuals interact with their world could potentially contribute to the establishment of a concrete pathway for actualizing Sen’s freedoms. By highlighting the intricacies of the interface between society and the individual through the application of psychosocial theory, poverty reduction strategies incorporating Sennian ideals could be better informed and stand a greater chance of success. The remainder of this paper will examine mechanisms such as social identity, social representations and stigma with respect to Sen’s capabilities approach, in order to illustrate the importance of psychosocial well-being in Sennian approaches to poverty. Examples of these phenomena at work in the lives of the poor are presented throughout the discussion, via comparisons to one of the most famous sites of urban poverty: The Brazilian favela.

The Brazilian favela

The favelas (Portuguese for ‘shanty town’) of Brazil have provided a window into the changing face of urban poverty for decades. Its inhabitants reside in one of the most culturally rich environments in the world, albeit in one of the most unequal countries in the world. Although informal settlements have existed in Brazil for over 100 years, the economic downturn of the 80’s and 90’s following the ‘golden era’ of the 60’s is accredited for moulding once largely afro-Brazilian communities into the profile seen today: characterized by a mix of afro-Brazilian and poor white inhabitants.

Over eighty percent of Brazil’s population lives in cities, with more than 12 million households residing in informal settlements. Access to services are variable, with 26 million individuals unable to access water, and over 80 million who lack access to formal sewage systems. The conditions within Brazil’s informal settlements have not been static; attempts at regeneration of favelas have ranged from removal policies in the 1970’s, to upgrading programs, such Favela Barrio regeneration program, launched in 1994.

Though living conditions within favelas have witnessed improvements in recent years, life in favelas is still marred by high levels of violence and crime. Drug trade is of particular concern in this respect; wars between drug lords and police officials waged within favelas often result in the death of innocent community members. Living in an environment with such complex social conditions has been proven to influence psychosocial well-being, and as such, warrants consideration in all attempts to improve living conditions in these environments.

Considering the Psychosocial: Social identity, social representations, stigma and the Brazilian poverty experience

Social identity theory describes identity formation as the process by which individuals come to define themselves in relation to others in their social world. The process is thus heavily shaped by the nature of interactions with others. In a similar vein, group identities are formed by comparisons of the self to a set of individuals who compose an ‘in’ group (and thus share similarities in values and behaviours) and against those who are in the ‘out’ group (and therefore representative of contradictory ideals and values).

In the favela, social identities are navigated within an environment where it is often difficult to find sources for positive validation. Brazilian culture is famous for its dominant masculinities. In such a culture, the ability to provide for one’s family becomes a top priority, and is cited by residents as the impetus for a move to urban centres. The ability to act as provider is also cited multiple times by Sen as a capability for individuals. When this is impossible, it can inflict a huge blow to the maintenance of a positive sense of self. In Pearlman’s examination of poverty in the favelas, 70% of respondents said what they needed was a good job, and believed it to be the only real opportunity to escape chronic poverty. However, lack of job opportunities in the urban marketplace makes unemployment a reality for many. As men attempt to maintain positive identities through other means, alcoholism and domestic violence are often infused into the home. ‘… If a man is out of work, he doesn’t help around the house, but he does get in the way more than ever. He’s drinking and squabbling, blaming things on his wife” Such statements also describe typical defensive behaviour, where individuals attempt to maintain a positive sense of identity through projection of fears and negative feelings through placing blame. Subsequently, many families are characterized by domestic violence, which is known to entrenching individuals within the poverty cycle. In many families, economic opportunities that may become available to them in the way of informal work for women or children may be rejected based on the dominant male’s decision, fuelled by his need to remain acting head of household.

Closely connected to this concept of identity formation is that of social representations, which have been described as the mechanisms through which individuals see and construct their worlds. The nature of this process involves interactions with peers in public spaces that allow for the opportunity to formulate ideals and definitions which are used to help navigate one’s social environment. Once formed, they can be understood as images, categories, phenomena which organize meanings and allow individuals to classify circumstances, and individuals in our lived worlds.

The theory of social representations is of great value in unpacking the motivations behind responses to poverty alleviation programs within poor communities. Howarth, Foster and Dorrer describe some key aspects of social representations theory which can be applied within the favela experience. First, social representation theory provides perspectives on the competing systems of knowledge across lay and professional spheres. For many poverty alleviation programs, which are highlighted by the introduction of new knowledge and skills, the ability or inability of individuals to incorporate new information will heavily influence levels of success within communities.

Secondly, social representations have the ability to entrench and sustain stigmatizing activities and practices within a group. Urban dwellings are often permeated by social, economic and political variables which influence the opinions formed about actors and groups within a community. For example, in a community that has experienced failed program attempts from outside agents, existing representations may leave them prejudiced and untrusting of future initiatives.

Sen places a high importance on the ability of individuals to engage in political freedoms in the process of escaping poverty. But for citizens in favelas, representations they have developed to explain experiences of high crime and violence committed against them by government and public officials deter against the involvement necessary to fully utilize this freedom. There is instead a belief that “elected officials, civil servants, employers and vendors… largely [serve] the interests of the rich” . Even in communities where the level of participation and involvement necessary to improve situations of extreme poverty has occurred, experiences have not been positive, leading to a sense of defeat among favela residents.

… we built a police station with our own hands and money to curb the violence. The police agreed to come here after lots of pressure. They abandoned the station… after criminals destroyed it in a shoot out… finally we got fed up and tore it down with sledgehammers

Negative Social representations such as these also carry the potential to interfere with the few economic opportunities which may present themselves in cities. For example, in the wealthy communities that typically border the Brazilian favelas, there is a representation of favela residents that dubs them as violent, active participants in the drug trade and other illegal activities, uneducated, and of course, impoverished. Though only a small proportion of favela residents actually fit this precise image today, the power that such false representations have on the daily choices and lifestyles of millions of the urban poor is unmistakeable.

“If I say I am from [the favelas] they’ll retract the job offer because they think we are all criminals here’… ‘one day a company called me for a job, but when they realized I lived in [the favelas] they changed their minds, thinking that I was one of those… they couldn’t trust”

This externally imposed representation carries the potential of reducing the emotional well-being of favela residents, reducing their self esteem and subsequently reducing the likelihood of engaging in job seeking behaviours after repeated interactions of this nature. These negative social representations often create wide spread stigmatization from one group to another. In discussions of favela life, stigma is best defined as any negative thoughts, feelings or actions directed towards a particular group of individuals. In this context, the urban poor are thus impacted by the negative thoughts, feelings and actions directed at them by the stigmatizers: the affluent members of society.

External representations and stigma towards favela residents are factors beyond their immediate control. This, however, does little to alleviate the negative impact and the ability of these factors to dictate their lived experiences. Repetition of these types of experiences can substantially erode feelings of self worth, and more importantly, the belief that one’s efforts can result in a significant change in their situation, a driving factor behind the uptake of poverty alleviation programming.

In order to distance themselves from outwardly imposed negative representations, individuals respond with a range of behaviours. Pearlman describes a typical example witnessed during her fieldwork in the favelas:

Young women… spend virtually their entire earnings on clothing and accessories that to them symbolize ‘south zone chic’. I spoke with one young man who had a cell phone, a pager, and a palm pilot hanging off the waistband of his baggy shorts… he confessed that none of them worked. They were merely fashion accessories

It can be safely assumed that this over consumption of material items is done with the intent to combat the stigma and negative representations associated with a life of poverty by projecting the image of affluence. From an economic standpoint, such testimonials point to a shift in priorities: incomes traditionally dedicated to helping a family escape from poverty are now being invested in maintaining a positive sense of self worth among the youth in the favela. Debt levels may increase within a home, and the effectiveness of economic opportunity is once again lessened.

The high volume of gang related activities among youths in favela communities can also be attributed to the need to maintain positive self identities and representations of self. Creating a positive sense of self is an important aspect of psychological development. As Howarth describes, in absence of other opportunities to assert positive identities and challenge stigmatizing sentiments, it is not uncommon for youths to join gangs. These groups provide an opportunity for validation from their peers, though this often occurs through engaging in negative activities. If poverty alleviation programming seeks to tackle such issues, it would follow that alternative means must be put into place for youth to find similar self validation.

Discussion

The cities of the world house unattested amounts of potential. Work at the hands of international development agencies and grassroots organizations have led to the expansion of social opportunity, access to resources such as health care and education, and improvements in basic infrastructure in centres of urban poverty like Brazil’s favelas. Such efforts clearly encapsulate the freedoms that Sen deems pertinent in the escape from poverty on a theoretical basis. On the ground, however, they have not been adequate in reducing the number of people who live in dehumanizing conditions within urban centres, indicating a missing link.

Once the interlaced relationships between these three phenomena – social identity, social representations, and stigma – were examined in light of Sennian ideology, the role of the psychosocial in escaping urban poverty begins to take shape. A strong sense of self, fostered in part by positive individual and group identities, self efficacy (defined as the belief in one’s ability to succeed in various tasks and often influenced by stigma and negative representations), and positive social representations of one’s group in a broader cultural context, are as important as any program initiative. Ultimately, we have seen the ability of psychosocial well being to impact the likelihood of individuals to engage in the facilities made available to them via public programming. The likelihood that an individual will take advantage of opportunities created by training programs, (a social opportunity for Sen), engage in job seeking behaviour (economic opportunities), or participate in civic programming and political processes (political freedom) are influenced heavily by the psychosocial wellbeing.

But what does this mean in a practical sense? How can this improved understanding of the poverty experience inform future poverty initiatives of the Sennian variety? The importance of psychosocial well being is no secret. Research has long identified the role of social phenomena and psychological well being in the lives of the poor, yet the integration of these ideas into a single concerted approach was not attempted till quite recently. Despite advances in rhetoric surrounding poverty alleviation practices, interventions continue to operate in a vertical manner. Programming aimed at reducing poverty works within a vacuum, often separate from attempts to address social issues such as violence against women and gang related violence among youth. There are many examples of NGO-operated initiatives which seek to rectify this gap, and could help to inform large scale programming which has yet to incorporate such practices if given the real opportunity to do so.

This discussion has highlighted the ability of psychosocial barriers such as negative social identity, social representations and high levels of stigmatization to inhibit the degree to which individuals can experience and interact with Sennian freedoms in their daily lives. It would appear that for Sen’s freedoms to be capitalized on, development programs must also focus on creating opportunities for the urban poor to foster positive self identities, formulate new representations of their place in society, and spaces to combat the negative representations held by those outside of favela communities. If these concepts were incorporated into the planning of poverty alleviation strategies, it stands to reason that sustainable success could be far more attainable. The time for truly multi-disciplinary approaches is long over due, and it seems that once the role of the psychosocial is taken into account by those in the development field, the opportunities that cities provide for escaping poverty can be utilized to their full potential.

Works Cited

Frediani, Alexandre. “Amartya Sen, the World Bank, and the Redress of Urban Poverty: A Brazilian case study”. Journal of Human Development. 8 ,1 (2007): 133-52

Amato, Paul, Zuo, Jiping. “Rural Poverty, Urban Poverty and Psychological well- being”. The Sociological Quarterly,33,2 (1992): .229-240

Sen, Amartya. Development as Freedom. New York: Random House,1999.

Pearlman, Janice. “The Metamorphosis of Marginality: Four Generations in the Favelas of Rio de Janeiro.” The Annals of the American Academy of Political and Social Sciences 606 (2006):154-77.

Riley, Elizabeth, Fiori, Jorge, and Ramirez, Ronaldo. “Favela Barrio and a new generation of housing programs for the poor” Geoforum. 32 (2001): 521-31

Chant, Sylvia, McIlwaine, Cathy. Geographies of Development in the 21^st century An introduction to the global south. Cheltenham: Edward Elgar publishing, 2008.

The World Bank. Cities Alliance: Cities without slums 2007 report. Washington: 2007

Huddy, Leonie. “From social to political Identity: A Critical examination of social identity theory.” Political Psychology. 22.1 (2001):127-56.

Brewer, Marilynn B. “The many faces of Social Identity: Implications for Political Psychology”. Political Psychology. 22 .1 (2001): 115-25.

Amis, Philip. “Making sense of Urban Poverty”. Environment and Urbanization. 7 .1 (1995): 145-58

Campbell, Catherine et al. “‘Dying twice’ a multi level model of the roots of AIDS stigma in two South African communities” Journal of Health psychology. 12.3 (2007): 403-16.

Howarth, Caroline. “Race as Stigma: Positioning the Stigmatized as Agents, not Objects.” Journal of Community & Applied Social Psychology 16. (2006): 442-51.

Howarth, Caroline. “A Social Representation is not a quiet thing: exploring the critical potential of social representations theory” British Journal of Social Psychology. 45(2006): 65-86

Howarth, Caroline et al. “Exploring the potential of the theory of social representations in community-based health research and vice versa?” Journal of Health Psychology. 9 (2004): 229-43.

The World Bank. Voices of the Poor: from many Lands. New York: World Bank Publications, 2002

Patel, Vikram. (2001). Poverty, inequality, and mental health in developing countries. In D.A.Leon & G.Walt (Eds.), Poverty, inequality and health: An international perspective (pp. 247-262). Oxford: Oxford University Press.

Arias, Desomond E. “Faith in our Neighbours: Networks and Social Order in three Brazilian favelas” Latin American Politics and Society. 46.1 (2004): 1-38

Daniel Yeow

[Download PDF]

Abstract
The world has changed a great deal in recent times and the challenges which present themselves are unlike any that we have faced before. Foremost among these are climate change, world poverty, and the many forces which are inextricably linked to these such as population growth, economic development, and the spread of technology. In this article, the convergence of these pressures is examined in light of the challenges and opportunities offered by globalization. The role of information will be examined with the view to shedding new perspective on some of the more pervasive problems that accompany globalization and economic growth.

The gun fires. Your muscles tighten; you jump off the start line. “Calm down,” you tell yourself. There is chaos. An elbow here, a palm there, you struggle to find your space. The field spreads, the pace quickens. Or maybe the pace quickened first, causing the field to spread. You forget. Your heart plays pinball inside your chest, you can feel it hammering away. Your legs feel heavy as the unmistakable sensation of lactic acid overwhelms you. Pins and needles pierce your skin and sink into muscles you never knew existed. It is too late. You hit the wall three quarters into your mile. Runners pass you left and right, you slow to a jog then stagger to a halt. Your head is spinning. Your race is over; your pace was unsustainable.

The question of sustainable development is one of the most intractable questions of the modern age and one which is increasing rapidly in urgency. Sadly this urgency has less to do with the fact that millions of innocent people are dying from easily-preventable causes and more to do with reasons of pure economic self-interest. Although widely recognized that, in the long run, economic prosperity and environmental sustainability for all benefits everybody, the causation of this sudden urgency is the other way around. It has arisen because the realization has hit us that, if we don’t act with the utmost expediency, then we will all soon feel the direct effects of our failures. The scarcity brought on by climate change has finally tightened the time scale of the feedback loop enough for us to feel it. So much for altruism.

Forgetting for the moment about sustainability, there are many problems with development, and these are only exacerbated when sustainability is thrown into the mix. Different countries have developed via very different paths and in very different environments. Some, such as South Korea and China, have started with a focus on health then followed with a focus on wealth, while others as diverse as Brazil and the United Arab Emirates, for very different reasons, have done it the other way around. There have also been significant shocks to development for which economists generally don’t plan, such as long droughts and world wars. Information technology has also changed the landscape of development introducing variables which development practitioners would not have even imagined as recently as ten years ago. The issue of population growth further complicates matters: current developed countries simply did not have to consider the astronomically higher numbers of people which current developing behemoths such as China and India must.

Perhaps we, the citizens of this planet, are fortunate. No, I know we are fortunate. The size of this planet, the composition of its atmosphere, and its distance from the sun (among many other critical factors) are just about exactly fine-tuned for humanity to have flourished in the way that it has. Or perhaps it is the other way around: we have evolved to be perfectly well-suited to developing the way we have on this particular planet. It is also fortuitous that the issues of wealth disparity, environmental sustainability and growth of the global economy have come to the forefront within such a short time of each other, allowing us to more easily see their interconnectivity and the necessity of an integrated solution. In any case, neither the parameters of the planet nor the biological makeup of humankind are easily or quickly alterable so it would be prudent for us to be careful in all matters which may disturb the delicate balance that governs the relationship between us and our environment. It is an important relationship, and we can’t just ‘break up’ when things get too hot.

Globalization is our best hope. The monotonic increase in connectivity in the global community has been a given for a long time. The progress of this connectivity in the economic realm has far outstripped that of any other, except perhaps information technology. The result of this laissez-faire global expansion is that, without any other significant power than the market to hold back the invisible hand, a great many things were exploited including people and, of course, the environment. As a result of this, globalization has been politicized as the devil that increases disparity. But if I give a hammer to a person who then kills someone with it, does that make the hammer evil? While the exploitation is obviously deplorable, I believe that this perspective could easily be the other way around. Hammers can be fabulously creative tools as well. What would Rodin have said if we had accused him of using evil tools?

Globalization is the infrastructure through which global problems will be addressed with global solutions. The problems brought on by climate change especially, are necessarily global in nature, and any effective solution will necessarily require an operational framework that only a global tool like globalization can provide. In addition, the kind of increases in productivity needed to raise the poorest of the poor out of poverty will require a division of labor on a scale which can only be realized within the framework of globalization. Many cite the increased complexity of these new frameworks as unnatural and therefore ultimately doomed to failure. Still others argue that humans are naturally exploitative and that larger networks will only lead to greater exploitation. However, I believe that it is the other way around, that the current climate of exploitation is only temporary and increased connectivity is perfectly natural. After all, we evolved in an environment of an iterative game, where cooperation is the norm and exploitation the exception (à la tit-for-tat, in the iterated prisoner’s dilemma).

We have not so much outgrown our planet as we have outgrown ourselves. The world in which Adam Smith wrote The Wealth of Nations is vastly different from ours, and the theory of free markets seems as out of place as classical physics in a relativistic world. The sheer size and complexity of networks in the world we live in requires that we can no longer apply theories which assumed negligible transaction and information costs. These assumptions predict a world in which the market is able to efficiently and fairly allocate resources. Instead, lack of good information leads to an inefficient and, importantly, inequitable distribution of resources. We have grown past the realm where transactions are simply impersonal and where institutions keep transaction costs reasonable, and into a world where effective information transmission is the dominating force in our decisions concerning the division of these scarce resources. There are enough resources in the world to go around but, owing to the quirks of the geopolitical climate brought on by self-reinforcing path-dependencies (like that darned QWERTY keyboard), we continue to fight wars over them, both on the ground and in the boardrooms of diplomatic institutions and multinational corporations.¹

Information is now the world’s most valuable commodity. The distribution and dissemination of information will rise exponentially in importance as we continue to struggle with these problems. The institutions and infrastructure that globalization will provide will facilitate a global division of labor on a massive scale which will, in turn, require cooperation between world leaders on a scale which has hitherto never been seen. As human networks increase exponentially in size and complexity, the infrastructure of information will need to keep up; in fact, it will need to catch up. The disadvantages caused by the disparity in information, the information asymmetry between the haves and have-nots, are at the heart of the causes of wealth disparity around the world. It is somewhat remarkable that in this modern age, an information advantage can still lead to unfair bargaining which then leads to an inequitable equilibrium. But Black Swans like the internet are turning this the other way around: access to information is flattening the world². Our challenge is to proceed both cautiously and with the utmost urgency and expediency.

The role of the state is now more important than ever. Due to its unique comparative advantage in the collection of information, it will always have an unusual advantage when it comes to information asymmetry. In the tradition of mechanism design theory, through the rule of law, the state’s responsibilities will now encompass the nurturing of global institutions in order to mitigate the effects of negative externalities of globalization and ensure that everyone gets a slice of the bigger economic pie. It must ensure that the cogs of this intricately balanced machine continue to spin because even if this machine makes things worse, it may also make things better.  However, if it becomes trapped in its current state, our world will surely spiral towards disaster. The damaging costs of war are no longer linked to the question of direct economic and human loss. Rather, the unsettling of these cogs by conflict will adversely threaten the goal of keeping the world sustainable. Some say that this kind of international cooperation will only be realized once world peace has been established, but I believe that unless we can establish this kind of cooperation, world peace will never be established.

Things do not look good. The population continues to grow alongside its ecological footprint. The benefits of globalization are struggling desperately in a losing race with its own unfortunate ill-effects. Over a billion people continue to ‘live’ on less than a dollar a day. Our information technology struggles to keep up with the mammoth demands that are made of it. Global warming continues to wreak havoc on the world’s climate in ways which we are only beginning to understand. Climate shocks have a long and well-documented history of precipitating social upheaval and have already been found to be an important factor in several current world conflicts. Unless we learn to bring these diverse disciplines together and recognize the inescapable connections which exist between them, we will be faced with an unpleasant climate – meteorologically, economically, and politically – from which there will be no escape. There is certainly no other way around and if this does not change, the world will certainly not end, but it will become a world which is far more difficult to inhabit, a world which will not be able to sustain even a fraction of our current population, and a world in which our current level of productivity will be utterly unfeasible.

It is somewhat sad that it has come to this. I had hoped that we would address these problems sooner and for no other reason than for equity’s own sake. Unfortunately, this is often not good enough, so now economics compels us to act. We are forced not by our conscience but by the threat that the very equations which govern the allocation of scarce resources, both natural and human, will consume civilization as we know it and replace it with something far less palatable. Without global cooperation, we cannot hope to solve any of these problems in the long run and, with a fifth of this globe living in abject poverty, we can only be a fraction as effective as we should be in trying to break out of this cycle. Unfortunately, as climate-caused complications worsen, the economies most vulnerable to the changes are negatively affected, making it even more difficult to find their way onto that bottom rung. We need to harness the power of positive feedback and exponential growth to everyone’s advantage and travel upwards on this unfortunate spiral before it is too late to turn this cycle the other way around.

By putting the word ‘sustainable’ alongside ‘development,’ we thrust the issue into the realm of economists, who generally sit higher on the policy pecking order than environmentalists. But, this is not just a problem for economists; this problem affects us all. We need to educate ourselves and recognize this unique historic opportunity and seize it. We must be creative in our approach, and if we get stuck, we must find another way around because the stakes are too high for anyone to ignore. Economic prosperity is useless if the environment cannot sustain it, and we would simply be betraying the trust of our descendants. We haven’t hit the wall just yet, and nobody is going to pass us on this race, but if we don’t want to run ourselves into the ground we need to keep our wits about us and realize that the real urgency isn’t in reaching the finish line quickly, but in staying on our feet to ensure that we reach it at all.

Read the rest of this entry »

Daniel Bohl

[Download PDF]

Abstract
Currently, the United States trains only three quarters of the physicians it requires to fill its entry-level residency positions. The other quarter of residents employed by its hospitals is composed of immigrants who have been trained in other countries. This reliance of our healthcare system on foreign physicians puts a tremendous strain on the healthcare systems of developing nations. At the same time, by replacing American medical school graduates with graduates of foreign schools, the policy prevents a significant number of Americans who desire to practice medicine from doing so. An alarming shortage of physicians by the year 2020 has been forecasted. Discussion of how this shortage will be addressed is long overdue. The options are clear: either the United States can increase its dependence on foreign medical training programs or it can expand its own. It should choose the latter.

Introduction

Professional migration has been an on-and-off topic for several decades. Recently, a new debate with respect to physicians has brought the topic once again into the spotlight.

There is no question that professional migration is harmful to developing nations. Their governments make investments in the education of their people, only to have those people (and the investments in them) leave to pay off somewhere else. For the most part, however, there is a consensus among scholars that none of the actions on the parts of any of the parties involved are unethical; these arguments are justified by invoking the rights to the freedom of movement and the freedom of trade.

However, this paper argues that with respect to physician migration, one action taken by developed nations is unethical: developed nations intentionally generating a demand for physicians from developing nations. Developed nations, it will argue, should expand their physician training programs to generate enough physicians so that the luring of human capital from developing nations is no longer necessary. While physician migration is obviously a very complex issue with work required from many different parties for a total solution, this paper decidedly limits its scope to the development of a policy prescription to the United States.

The paper will begin with a summary of the current international situation, its causes, its consequences, and its projected future. This summary will serve as background for a discussion on the ethics surrounding the issue. Finally, the conclusions of this discussion will be applied to the policies of the United States government.

Background

Physician Migration and Imbalance: Causes, Consequences, and Future

When, in a classroom of Ghanaian medical students in Accra, students were asked how many of them would like to go abroad for further study after graduation, virtually every hand went up. When they were asked how many thought they would later return home, half of the students’ hands went back down.¹ A great number of the student-physicians in which Ghana invests do not intend ever to practice in Ghana; instead, they envision their futures in New York, London, and Chicago.

A total of one half of Ghanaian physicians practice abroad, with 20% in the United States and another 10% in the United Kingdom.^2,3 Ghana is not unlike other developing nations: 70% of physicians trained by Zimbabwe in the 1990s have since left.⁴ 60% of Liberia’s physicians practice in the United States or the United Kingdom.⁵ 120,000 doctors currently address the needs of the 900 million people on continent of Africa, a physician to population ratio of 13 to 100,000.⁶ The number of physicians in the United States, the United Kingdom, Canada, and Australia per 100,000 population are 293, 231, 220, and 271, respectively, approximately 20 times higher than the African physician population ratio.

The Causes of Physician Migration

The push. Conditions in which doctors working in developing nations live and practice contribute to their desires to leave. Some of the conditions regularly cited include financial insecurity, political instability, and inadequate educational institutions for their children. Physicians practicing in low-income countries also receive relatively low compensation and must deal with shortages of supplies and extremely high workloads. Opportunities for continued education within those countries are sparse.

The pull. A great attractive force draws physicians towards developed nations. The contrasts abound: physicians who migrate to developed nations share in the higher standard of living of those nations and benefit from greater financial and political stability; their children receive a better education and have greater professional opportunities; the relative abundance of high-tech equipment, medical supplies, and support staff; a much better physician to patient ratio make for far more satisfactory work conditions; and opportunities for continued education are widely available.

A second factor is a necessary contributor to the pull: high physician demand in the physician-receiving country. This demand exists in developed nations including the United States, the United Kingdom, Canada, and Australia because these countries consistently train fewer physicians each year than their healthcare systems require. They do so because allowing already trained physicians to cross their borders is less expensive than training physicians domestically. The influx of already-trained physicians represents an influx of human capital with no monetary exchange. This induced shortage draws in physicians from less developed nations all over the world.

The Consequences of Physician Migration and Imbalance

For developing nations. As stated, 50% of Ghana’s physicians currently work abroad. While these doctors make up only small percentages of the workforces of the developed countries in which they practice, they comprise a tremendous loss to Ghana’s increasingly strained healthcare system.

The major consequence of this loss is a dramatic decrease in the availability and quality of healthcare. Fewer doctors means fewer patient visits, less time with patients, more expensive care, and higher rates of disease.

The second consequence is the loss of considerable investment on the part of developing nations. While not always a tremendous loss in income for a developing nation due to the significant amount of money that finds its way back in the form of remittances, an individual migration always represents a tremendous loss in human capital. The United Nations Commission for Trade and Development estimates that each professional leaving Africa costs the continent US$ 184,000.⁷ This is money lost by healthcare systems that could be better spent on desperately needed medical supplies and support staff, and it is money that could be better spent on training physicians to practice at home.

For developed nations. Ironically, the countries with the strongest healthcare systems benefit from physician migration. Developed nations save millions of dollars by relying on foreign-trained physicians to fill the gap between the number they need and the number they train.

The future of physician migration

Studies forecast shortages of as many as 20% of physicians in the developed world by 2020 or 2025⁸. This represents 40 times the current yearly immigration rate. While decisions on how to manage these shortages have not yet been made, the choices presented to developed nations are clear and defined: developed nations must either expand their physician training programs or increase their reliance on the workforces of developing nations.

The Ethics of Physician Migration

Physicians as Human Capital on the Free Market

To talk about physicians on the free market may not be entirely appropriate, but it does provide a useful framework for a discussion of their demand, as well as for the investments made in their training and practice.

No country wants to train doctors. For wealthy nations, it is cheaper to allow them in from poorer ones; for poorer nations, it is extremely costly to have them leave for wealthier ones. With demand for physicians high in both groups, the wealthier nations with the thicker pocketbooks receive a major influx. In contrast, developing nations are left to train a higher number each year in order to retain a suitable workforce.

This is a win-lose situation for the nations involved, not an equal exchange, because, unlike in free trade involving goods, developed nations do not pay developing nations upon acquiring their “product.” These investments pay out only if the resultant capital remains in the investing country. When developed nations acquire the workers of developing ones, they essentially deprive developing countries of these investments.

However, specific rights of developed nations justify this seeming robbery in the instance that it is not pre-meditated. In other words, developed nations have a right to be self-serving when they find themselves in need, and they have a right to see unanticipated shortages in their workforce corrected. In times of shortage, developed nations are justified in allowing foreign physicians to fill their gaps, even if it means drawing from more needy developing ones.

The direct harm principle. While it may be ethical for developed nations to fill unanticipated physician shortages because of their right to self-service in a time of need, it is not ethical for them to use physician immigration as a long-term, cost-cutting solution.

The direct harm principle makes this dependence unethical. In other words, the free market is allowed to run ÒfreeÓ except when it causes direct harm to individuals. For example, the drug trade (both legal and illegal) is regulated everywhere, and the sale of organs is prohibited in nations around the world. These regulations of the free market protect one or more of the parties involved in the would-be transaction.

The emigration of physicians, unlike that of other professionals, causes a direct and immediate harm to individuals. Physicians are direct caregivers. When a physician leaves, individuals who desperately need treatment go without the very services they need. The people of developing nations are directly and immediately harmed by the action of the free market. Regulation of the free market in this situation is consistent with regulation in other instances.

Physicians as immigrants

Immigration is tolerated when the economy is strong, jobs are in surplus, and human labor is in need. Employed by the businesses of developed nations, immigrants provide the economies of those nations with the means by which to grow.

On the other hand, when the economy is weaker and unemployment is high, immigration takes on a different light. Many nationals accurately perceive it as an influx of foreign workers who will compete for jobs. During these times, immigration law takes a more conservative stance: policies are tightened and immigration is restricted.

In this sense, the “economy” is “strong” right now from the perspective of physicians in the developed world. There is a high demand/supply ratio for their service. In response, developed nations have opened their doors to immigrant doctors in order to fill their shortages and satisfy the needs of their publics. This is entirely consistent with immigration policy in other spheres and with that which is generally accepted.

However, while the demand/supply ratio for trained physicians is high, that ratio for another group of nationals, domestic premedical students, is, in contrast, low. In the United States, for example, medical school admissions rates are as low as 3%, with less than half of applicants accepted annually to the schools to which they apply.⁹These 21- to 30-year-olds desire nothing greater than to help fill their nations’ physician shortages. Yet, there are not enough spaces in medical school classes to allow them to do so. Medical school admission is the bottleneck that prevents these nationals from getting work.

By replacing would-be domestic medical school graduates in the workforce, immigrant doctors essentially impede potential medical students from obtaining employment. As discussed, situations that result in competition between immigrants and domestic workers generally result in a tightening of immigration policy designed to protect the jobs of nationals.

The requirements of current physician workforce demand and medical student workforce demand directly conflict. High demand for physicians requires immigration law to relax to increase the number of physicians. Yet, low demand for medical students requires the opposite to happen to ensure that young nationals are not put out of work. How can these two requirements be reconciled?

Governments must first ensure that more domestic premedical students are admitted into the physician workforce through the expansion of medical schools. In other words, it is the responsibility of a government to first find jobs for its own citizens. Nonetheless, medical school expansion and physician training are slow, so the increase in physicians will not be felt in the workforce for a number of years. During these years, the immigration of foreign doctors is acceptable because it does not compete with domestic medical school admissions. Once the result of training expansion is felt, immigration policy should be tightened so that medical school admissions can be kept at a maximum.

The government can and should use physician immigration to satisfy short-term need, but over the long run, the government should protect the jobs of nationals by expanding medical school classes and replacing the immigration of foreign-trained physicians with the resulting increase in domestic graduates.

Discussion

The two ethical analyses conclude that, while it is ethically acceptable for developed nations to draw on the supply of physicians from developing nations to fill unanticipated, short-term shortages, it is not acceptable for them to do so as part of a premeditated, cost-saving strategy that puts would-be physician-nationals out of work. Rather, developed nations should expand their physician training programs so that the luring of human capital and replacement of nationals in the workforce is no-longer necessary.

Impending Physician Shortage

The last major debate over physician shortages took place in the 1950s and 1960s. This debate, instigated through the Education Assistance Act of 1963, led to the opening of forty-three new medical schools between 1956 and 1980. During this time, the number of first-year enrolled students more than doubled from approximately 8,000 to 16,590.¹⁰,¹¹

In the early 1980s, the academic pendulum swung in the other direction. A major physician surplus was forecasted to present itself with the new millennium.¹²,¹³ The federal government responded by drastically cutting funding for medical education. Medical schools stopped growing their class sizes and the number of enrolled students entered a period of zero growth that would last for the next twenty years¹⁴.

However, the forecasted surplus did not materialize with the onset of the new millennium. In fact, demand for physicians remained high. This startling result prompted the undertaking of new modeling projects that have forecasted not a surplus but an alarming shortage over the next twenty years. One of these new studies published in 2002 predicts a shortage of as many as 200,000 doctors, or 20% of the physician workforce by 2020 or 2025.¹⁵ The authors expect that this shortage will be felt both in specialties and in primary care.

Since the release of this compelling evidence, the major interested advisory groups have all reversed their opinions. Both the American Medical Association (AMA) and the Association of American Medical Colleges have stated their belief that the previously feared surpluses are not likely to materialize¹⁶,¹⁷ and the Council on Graduate Medical Education (COGME) has reversed its stance entirely, declaring instead that physician shortages are imminent.¹⁸

The Response of Other Developed Nations

Predictions of shortages are not unique to the situation in the United States. Similar shortages are predicted in the United Kingdom, Canada and Australia. But these countries, unlike the United States, are actively addressing the issue. The United Kingdom plans to expand its physician training¹⁹. In addition, Canada has announced plans to open two new medical schools;²⁰ Australia is expanding its medical school capacity by thirty percent.²¹

Why the United States Must Act Now

Unless the United States plans to fill this yearly physician shortage with a significantly higher proportion of foreign-educated physicians over the long-term, policymakers must act now to expand the nation’s training programs. If they do not act, two decades from now an additional twenty percent of the new physicians each year will need to come from foreign programs, making the total figure fifty percent.

The issue is particularly pressing because of the delay between the action taken to expand training and the resulting increase in the supply of physicians available to the public. The Education Assistance Act of 1963 led to the last major increase in physician training and to a nearly doubling in medical school seats. Yet, it was fifteen years after that legislation was passed before an appreciable increase in the amount of physicians were available to the public. Experts doubt that this process could occur any more quickly today.²² With major shortages predicted fifteen years out, now is the time to act.

Conclusion

Both because it causes a direct harm to individuals in great need and because immigrant physicians replace Americans in their own job market, United States policymakers must take action to reduce the country’s dependence on physicians trained in other countries. The only ethical solution is to expand domestic physician training. In order for the effects of this policy to be felt before the physician shortage gets too severe, action must be taken immediately.

The inaction of United States policymakers with respect to this issue represents a failure on their part, but the United States remains in a position to act. Policymakers should immediately pass legislation similar to that passed in 1963 that would facilitate the training of more United States medical students and reduce its dependence on physicians trained in the developing world.

Read the rest of this entry »