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| Leaders in international health have begun to address the critical shortage of professionals in the poor regions of the world with the highest disease burden. The report Human Resources for Health: Overcoming the Crisis1 was issued by the Joint Learning Initiative in 2004. The 2006 World Health Report: Working Together for Health emphasised the need to expand the supply of health workers in poor countries.2 But many articles on the loss of health professionals in sub-Saharan Africa highlight migration to higher paying jobs in wealthier countries as a major cause of the shortage of health professionals.3,4 In fact, emigration is not the greatest drain on the supply of health professionals in some countries severely aff ected by AIDS. Death is depleting the ranks of health professionals more rapidly than recruitment abroad. We documented an annual death rate of 3·5% for nurses and 2·8% for clinical officers in Zambia’s Lusaka and Kasama districts. Over a decade, these death rates would account for the nurse vacancy rate of 37% in the institutions studied. Death claimed more nurses and clinical officers (68%) than resignation (23%) or normal retirement (9%). The median age at death was 38 years, suggesting that AIDS, rather than diseases of advancing age, is responsible for most of the deaths.5
If the same death rate applied to all 8500 nurses and midwives serving in the public-health service in 2000,6 the number of deaths (298) is nearly double the number of Zambian nurses (169) who applied for registration in the UK in 2003–04.1 Policymakers might be tempted to focus on stopping emigration as the best strategy to strengthen the African civil service. Undoubtedly, the pay of health professionals is low and the burden of disease in the population makes the job diffi cult. But the dead do not complain about conditions of service. It is time to put more eff ort into keeping HIV-positive professionals alive and serving in national institutions. The general expansion of access to antiretroviral therapy in countries with high levels of HIV-positive professionals is not an adequate response. In Zambia, the Government has so far directed civil servants to use public clinics. The need to queue for such AIDS care will increase absenteeism, already a major problem. Zambian nurses also tell us that stigma makes HIV-positive staff reluctant to report for treatment at their own institutions. If a nurse delays testing until her CD4 count is very low, the risk increases that treatment will fail. Some nations are taking steps to provide access to HIV/AIDS care for civil servants. US$30 a worker a year would cover the cost for an HIV/AIDS insurance plan for civil servants and their families in Uganda. The plan would give access to HIV/AIDS services at selected public and private providers.7 In Namibia, public servants already participate in a medical scheme that gives broad access to private providers. Governments can reduce premature deaths in the civil service by making antiretroviral therapy available and convenient. Governments should consider programmes with the components listed in the panel. Antiretroviral therapy extends the survival of HIV-positive patients,8 and there is increasing evidence that patients receiving antiretrovirals are active and productive.9 If the death rate of Zambian nurses could be cut by 60%, Zambian health institutions would benefi t more than they would from a total ban on recruitment to the UK. Stopping the brain drain requires an unprecedented level of cooperation. Keeping HIV-positive professionals alive and at work in their home countries is a simpler task, and one that we know how to do. Frank FeeleyCenter for International Health and Development, Boston University School of Public Health, Boston, MA 02118, USA I declare that I have no conflict of interest.
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