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Abstract

Care drains around the world emerged due to a combination of rising rates of female labor force participation, declining birth rates, and rapidly aging societies in developed countries. These trends led to a lack of workers for care of children, elders, the disabled, and the chronically ill in more developed countries. The presence of political and economic challenges as well as high prevalence of infectious diseases such as HIV/AIDS and tuberculosis are also strong motivating factors that contributed to the rise in care drains worldwide. Care drains can pose major ethical, economic, and human rights issues in a global scale.

Introduction

The phenomenon known as “care drain” originated from the more widely understood and utilized term “brain drain.” The term “brain drain” was crafted in the 1960s to emphasize the impact of a loss of skilled laborers on the sending country.

During this time, immigration policies in western countries such as the USA, Canada, and Britain focused on facilitating the migration of highly trained health professionals from poorer, less developed countries. Hundreds of thousands of migrant health care workers were licensed in an effort to offset huge shortages in doctors and nurses in these developed countries. Migration of health care workers peaked in the 1970s and then reduced greatly in the 1980s and early 1990s due to concerns over having too many foreign doctors (Wright et al. 2008). However, later in the 1990s, the worldwide supply of women care workers became strained with a shift from women staying home to care for their families to women working outside of their families for paid wages (Michel et al. 2011). This shortage of women care workers caused another huge demand worldwide for migrant health care workers but speciﬁcally women care workers. In 2001, Arlie Hochschild crafted the term “care drain” to emphasize the impact of a loss of woman laborers in the sending country (Dumitru 2014). This care deﬁcit has become increasingly visible over the past decade and has made it pertinent to analyze the issue on a deeper level (Michel et al. 2011).

Care drain can be deﬁned as the migration of women from developing countries to developed countries to perform care work (Michel 2010). Signiﬁcant sending regions include the Caribbean, Asia, Sub-Saharan Africa, and Eastern Europe with the highest rate of migration of care workers. Major receiving regions include the UK and Western Europe, Australia, and North America. Among the numerous care professions, nurses are the highest in number of health care professionals who are migrating to other countries for care opportunities although doctors are also migrating in great numbers as well (Hamilton and Yau 2004). Social, ﬁnancial, political struggles and unstable sociopolitical structure in the global south provides necessary environment for care drain. Aging populations and a need for more care providers, better pay, and promised better life in the developed world also exacerbate care drain (Bettio et al. 2006).

Background

In general, care drain around the world emerged due to a combination of rising rates of female labor force participation, declining birth rates, and rapidly aging societies in developed countries. These trends led to a lack of workers for care of children, elders, the disabled, and the chronically ill in more developed countries (Michel 2010). The USA in particular is facing a huge shortage of care workers for the aging and elderly population (“Care Gap” 2012). With little assistance from the US government in terms of public care, US families are increasingly seeking out services from migrant woman care workers (Michel et al. 2011). In addition, developed countries of the global north offer promises of pay up to four times the amount offered in developing countries of the global south, promises of better work conditions and health care services. The presence of political and economic struggles as well as high prevalence of infectious diseases such as HIV/AIDS and tuberculosis are also strong motivating factors that contributed to the rise in care drain worldwide (Hamilton and Yau 2004). However, care drain can pose major ethical, economic, and human rights issues on a global scale.

Ethical Considerations

Scope Of The Conceptual Definition

Ethically, the term “care drain” in itself is highly controversial. By attributing care drain mainly to woman workers, this term may promote gender injustice and gender bias. For one, women may be regarded only for their natural roles as caregivers and not for their knowledge or skill set (Dumitru 2014). Many women have formal education and should be considered among the highly skilled migrants but are only studied as unskilled care workers which can distort the results of many studies (Hochschild 2002). In addition, the exemption of male workers in analyzing care drains around the world may further exasperate misconceptions regarding gender and domesticity and only give a one-sided perspective of the care drain issue around the world (Manalasan 2006).

One point to consider regarding the deﬁnition is the need to handle the issue on a broader point of view beyond healthcare. The phenomenon of care drain affects not only the provision of healthcare but also involves removing mothers from their families and teachers from schools, which can obviously have devastating effects. Another key point to consider about the deﬁnition of care drain is that the deﬁnition should not be limited to drains between countries but also take into account drains within countries. Overlooking the movement inside the countries and the dynamics behind internal migration hampers an adequate understanding of care drains and their impacts on a country.

Problems Emerging In Native Countries

Besides the obvious problem of losing trained labor force, an ethical issue that arises with care drain is whether woman care workers who go abroad for job opportunities are performing a great injustice to their own families. The traditional role of women in low-income countries is more family oriented. Women do not work outside the house, and caring responsibilities for the family are not shared with men, therefore it could be anticipated that removing mother and/or wife from this nonwestern family structure could be more overwhelming for children. Some research has shown that there is a huge negative impact on children’s school performance when one of their parents migrates out of the country. In addition, the family left behind may face psychological stress with having an absence of a strong female presence (Bettio et al. 2006). However, this area of study is still relatively new, and the severity of the impact of the absence of the care worker and the extent to which the father’s role in the family changes is still questionable.

Economically, care drain can have a signiﬁcant impact on the native country as well as the new country. With regard to the native country, women from developing countries leave their native countries for the job opportunity. Subsequently, native countries lose tens of thousands of care workers. This results in a transnational labor market that drains resources from poorer countries and concentrates them in wealthier countries which creates a worldwide misdistribution of woman care workers (Michel 2010). In addition, many developing countries such as the Philippines pay for the training of health workers. When health workers migrate, developing countries lose a large amount in training investments ($500 million per year) (Hamilton and Yau 2004). Care drain also has a high cost for care drain workers. Care drain workers must use already low wages or scarce family resources (no wages) to hire other workers to take care of their own families. This creates a “global care chain.” In addition, care drain workers who are not compensated for their work at all still have to pay for costs of emigration and suffer huge losses from loss of wages and time (Michel 2010). However, there are situations where the migration of skilled care workers can beneﬁt the sending countries. For instance, highly skilled care drain workers who are in excess in their country and are able to ﬁnd a decent opportunity abroad can make a suitable income and contribute back to their country through sending remittances (Hamilton and Yau 2004). Nevertheless, these situations are extremely rare and usually in the cases of highly skilled care workers such as physicians. However, the cost-beneﬁt ratio in such cases is still subject to further investigation.

Problems Emerging In Host Countries

The issue of care drain around the world is problematic not only for low-income/sending countries but for high-income/receiving countries as well. Although there are some positive beneﬁts of having care drain workers, there are major negative consequences that must be considered. With regard to human rights, labor market analysts refer to care drain workers as the “3D”: dirty, difﬁcult, and dangerous (Michel 2010). Care drain workers often have to endure a range of abuses, are denied promised wages, exploited heavily, and barred from any civil rights. In addition, there are countless accounts of rape, starvation, verbal and psychological abuse, and violent punishments such as having boiling water poured on workers. Care drain workers are a prime example of what is referred to as “modern slavery” by many news outlets. This new form of slavery exists in prominent countries all around the world including the UK, Canada, and the USA. In the UK, many lobbying groups for rights of domestic workers have spoken loudly regarding the presence of domestic slaves in UK households and call for major changes to unfair government policies on domestic workers in the country. Current immigration policies in the UK do not allow domestic workers to change employer, renew their work visa, return home, or apply for permanent citizenship after 5 years of work (Ropeta and Bureau 2014). A lack of adequate immigration policies facilitates severe mistreatment of informal caregivers and health-care professionals by their employers (Kaelin 2011). However, the British government states that the immigration policies are in place to prevent abuse of the immigration system and that migrant domestic workers are protected under UK employment laws. Whether this form of protection is enough is still to be seen.

Another problem experienced both by the “drained” care workers and also by the local workers is lower wages and unemployment due to misdistribution and reckless migration policies. An uncontrolled and unbalanced increase of workers causes hostility against drained care workers and creates racist reactions and discrimination in the host society, which further increases exploitation and vulnerability. With all of these potential problems, why is the demand for care workers increasing? One possible answer is an aging society that requires more qualiﬁed care workers. Another factor might be the gravitational attraction of power that high-income countries or regions have and the desire to live in better living conditions. Understanding the dynamics of market-driven economies should also be considered to understand the increasing need for care drain workers. For one, the need to decrease the cost of labor is paramount for the market. An increase in the demand for care workers helps to lower the cost of labor in competitive environments where healthcare services, including care based, are provided by for-proﬁt entities. Therefore, although it does not necessarily mean that the demand corresponds to the actual need in the society, high-income countries shape national policies offering citizenships, security, better wages, and promotion opportunities in order to deliberately create an extra vacuum for care workers.

Analysis Of Care Drain From A Population Health Perspective

The number of migrant care workers who move from less developed countries of the global south to developed countries of the global north is increasing signiﬁcantly (Kaelin 2011). The impact of care drain on social structure, public health needs for the countries of origin, as well as occupational health and safety risks for workers raise concerns that can be listed as

Disturbing the social and family structure
Developing a care gap in the source community
Creating an additional risk for occupational health and safety

Disturbing The Social And Family Structure

Care drain workers, mostly women, originate from societies where traditional family structure carries a signiﬁcant importance for the social fabric. Care drain workers leave their families, elderly parents, and their small children behind to take care of their own needs. These workers mainly come from low-income communities with limited educational opportunities. It is known that poorer, less educated families rely on women in the family for elderly and child care. Care drain, therefore, has a major impact on the families from the low socioeconomic stratum of the society. Viewed from the ecological model perspective, an intact family structure is critical for a healthy social life and for social determinants of public health.

In today’s globalized environment, developed and developing countries have integrated more than ever. On one side, this integration brings new opportunities for people but on the other side increases opportunities for disparities and social and public health problems. Countries with social and public health problems are not as isolated as they were in the early twentieth century. Therefore, on the short run, immigrant care workers seem like a relevant solution for the huge care gap in the global north. On the long term, however, the impact of care drain on the social determinants of health in the global south might signiﬁcantly mark the social structure of the countries of the global north. For instance, the Arab Spring, a regional and international conﬂict which started in 2010, has already had a signiﬁcant impact in Italy, Turkey, Greece, Cyprus, Malta, Spain, and France. The Mediterranean Sea became a “one-way migration highway.” Immigrants from the conﬂict regions ﬂed their country, changing the social structure of these countries forever. This example might seem as a farfetched extreme at ﬁrst; however, the Arab Spring might as well serve an ampliﬁed model to demonstrate how the social structure interruption in the global south can bring long-term effects to the social structure in the global north. The nineteenth century imperialism, which extracted gold, ivory, and rubber from the third world, has not disappeared; it has just transformed into a new form of imperialism. As observed by Hochschild, today love and care have become the new gold, ivory, and rubber; care drain is extracting potential from the global south in an increasing pace. However, contrary to Hochschild’s claim that “migration creates not a white man’s burden but, through a series of invisible links, a dark child’s burden” (Hochschild 2003), we argue that care drain will create a long-lasting burden for the global community for the south as well as for the north. Social welfare reforms and human rights regulations on a global scale seem like the only sustainable solution, yet it is extremely hard to reach.

Developing A Care Gap In The Source Community

Many of the origin countries already suffer from a severe shortage of caregivers. High mortality and morbidity (due to HIV/AIDS, TB, malaria, etc.), long devastating civil wars (Liberia, Sierra Leone, Mozambique, etc.), social and ﬁnancial inequality (India, Philippines, etc.), and poor and unstable educational, ﬁnancial, and social structures have already limited the availability of caregivers for less developed countries. The World Health Organization (WHO) notes that there are seven times more nurses for the same population in Europe than in either Southeast Asia or in Africa (WHO 2007). Countries such as Botswana and Mali suffered from interruption of health services due to loss of care providers caused by the AIDS epidemic; yet, many trained care providers leave for developed countries such as the UK and USA. The Philippines is the world’s main exporter of health care providers experiencing shortage of care providers due to care drain (Kaelin and Ball 2004).

The public health care structures in many countries of the global south, who provide workforce to the global north, are already too fragile and do not have a necessary safety net for compensating these losses. A recent Ebola epidemic in West Africa had a devastating effect on basic public health care services. Besides lives lost from Ebola, mortality from prevalent infectious diseases such as TB, malaria, and diarrheal diseases soared due to an interruption in basic health care services, and water and sanitation services have long-lasting impact on these countries.

It is important to note that in addition to all these problems, the social structure in the global south is signiﬁcantly different from the global north. Care structure in the global south is more community and family oriented and depends on women in the family. Pulling young women away from these responsibilities creates a signiﬁcant gap in the care structure. Children of a woman who works for a family in the global north are usually dependent on the care of their grandmother or other women in the family. This gap creates a domino effect, ﬁrst for the family and then for the community. For example, children in a Caribbean community are more prone to educational, social, legal, and health problems during their life. Therefore in the long run, care drain affects the social structure of the global south community; ripple effects would go beyond the borders of the source community.

Creating An Additional Risk For Occupational Health And Safety

Migrant care workers face a special burden of difﬁcult working conditions. They usually work without protection of legal regulations, worker compensations, or job safety and security provided for other workers. Many of them even surrender their passports and work without beneﬁting from basic human rights such as travel, vacation, privacy, and free communication. Many countries’ immigration laws and job regulations may unintentionally promote and deepen these problems and create an additional burden. From the occupational health and safety perspective, many care workers’ working conditions could be easily summarized as modern-day slavery. Care workers are at constant risk of abuse and exploitation as “servants of globalization.” Care work often needs long hours of service, in some cases 24-h a day. Already vulnerable, such work demand creates an additional risk for care workers. Since many migrant care providers are not legally employed, they work without legal protection (Kaelin and Parreñas 2003). Under these circumstances private care services in the global north with usually less legal regulations increase the risk for migrant care workers.

Conclusion

Care drain represents a dramatic reﬂection of inequities in a global scale. Its impact is on families, community, and social texture of both providing and receiving countries. The long-term adverse effects of care drain impacts the global community, and the burden stretches from generation to generation. It would be impossible to establish a successful intervention without taking this fact into consideration. Connecting the phenomenon of care drain directly to the failure of sending countries on providing opportunities within their own countries and training to healthcare professionals to be sent overseas is a wrong model of explanation for the very same reason (Hamilton and Yau 2004). Care drain must be critically analyzed on the global scale and must be understood in social, political, historical, and economic contexts. Colonial-era arguments of nineteenth and early twentieth centuries are not sufﬁcient enough to explain the global impact of this problem or to arrive at long-term sustainable solutions.

Comprehensive immigration policies must be established on a global scale to protect domestic workers from abuse and unethical treatment and ensure that employers will continue to have an ample supply of migrant care workers to offset critical shortages in care within their country. Another option, although highly controversial, is to force receiving countries to compensate sending countries for monetary loss associated with the care drain or to implement a care tax for receiving countries. However, neither of these proposals provides a clear solution for the social and public health impact of care drain in the long run. More research on the impact of care migration on the global health and socioeconomic structure of the global community is needed to determine the best course of action on short and long term to protect the welfare of the care workers, families, communities, and countries around the world.

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