"Holland Hires in South Africa, Which Looks to Ghana, In a New Global Market"

In this West African country's newest hospital, there is a pristine isolation unit, with eight private rooms for patients highly vulnerable to infection. All of them sit empty.

An intensive care unit - three beds, each with a state-of-the-art ventilator unit - gathers dust. So do two recovery wards, each with 29 beds. Six Swedish made dialysis machines, enough to handle the needs of half the country's emergency kidney patients, are idle.

There are patients for these beds, but no nurses to serve them. "We don't need equipment, just nurses," says Michael Morna, a physician in the hospital. One recent morning he checked on a patient with burns covering nearly three-quarters of his body. The burns were healing, but the patient was fighting a serious infection. "In an isolation room, he would have avoided an infection and been home three weeks ago," says Dr. Morna. "Now it's a miracle he's still alive."

'Some Will Die'

At least the burn victim got treatment. Dr. Morna recently sent away four people with kidney problems - patients who would receive dialysis if there were nurses to staff the machines. He doesn't know where these people went, but if left untreated, he says, "some will die."

Ghana once had enough nurses, but more than 500 left the country last year, most to take higher paying jobs in wealthy countries. Nurses in Ghana, a poor country, earn about $75 a month. Last year's departures were nearly tripple the 1999 total and more than double the number of nursing graduates produced in 2000.

Many other poor nations are losing nurses too, mainly to rich nations. Thousands of nurses left South Africa - one of the nations hardest hit by AIDS - for Britain, Australia and the U.S. Half of Trinidad and Tobago's nurses have left the country. So many nurses have left Jamaica that the government forced Britain to put a moratorium on hiring them. Many nurses leave Canada each year for the U.S., forcing Canada to raid Britain, which in turn poaches nurses from Ghana.

In the Netherlands, a shortage of nurses means surgeons stand idle, and patients wait. Hospitals then recruit nurses from South Africa, which hires replacements from Ghana. "So the shortage of nurses in Ghana is indirectly linked to cutting down the waiting list for care in Holland," says Jan van der Horst, a Dutch government official who advises Ghana on health-care issues.

The global flow of nurses, from poor to rich lands, reflects the way talent today goes to the highest bidder, regardless of national borders. This rewards talented people, of course, but adds to the problems of health-care systems in many poor nations, many of which are already cracking under the strain of overcrowding and the AIDS epidemic.

One recent afternoon in Ghana's biggest hospital, Korle Bu, in the capital city of Accra, 62 premature or ailing newborns were crammed into an intensive care unit for infants. The government-run hospital once assigned six or seven nurses per shift. Now it can muster only three.

At 3 p.m., about 40 mothers, seated on narrow benches that line a long corridor, breast-fed their babies. One nurse helped mothers whose babies were having trouble sucking. Another nurse addressed the whole group in a loud voice. "Show patience," Sara Owusu Boakye pleaded. "We are just one nurse for 20 babies. Show patience."

With a skeleton staff, cornres get cut. Nurses are trained to take the temperature of a premature baby every three hours. Instead, they do it just twice a day. Alberta Gomashie, another nurse at Korle Bu, realizes the risks. She may not notice if an infant's fever suddenly spikes. "You will make mistakes if you are stressed," she shrugs. "You will leave some of the job out. You can't do everything."

Especially not when you're distracted by flies. Some infants were covered with nets, to protect against bites. Near the end of her shift, Ms. Gomashie tracked an insect hovering near a crib, and smashed it between her palms. "I got one!" she exclaimed.

Ms. Gomashie, who earns the equivalent of just $75 a month for a six-day work-week, knows there are more lucrative alternatives elsewhere. One of her former colleagues, who has taken a nursing job in London, returned for a visit to her old ward in Korle Bu. Ms. Gomashie greeted the woman, gently complaining about her own rising workload but showing no rancor. "Why stay here when you're caring for two babies in a cot and you know that it's wrong?" Ms. Gomashie said. "If there is a way to make ends meet better than this, go ahead and get it."

No Avoiding Them

Ms. Gomashie has stuck with Ghana because her husband has a good job and she expects a second child early this year. Still, she can't avoid recruiters. Recently, she walked through the ward's swinging doors and ran into one prowling the halls.

Plenty of nurses are eager to go. One recent morning, a Ghanaian nurse named Rose rode a bus for four hours from her home in Takoradi, a seaport, to Accra, and then took a 20-minute taxi ride to a recruitment office. Rose, whose employer doesn't know she is looking for a job outside the country, applied a year ago to work in Britain, and was visiting on this day to learn about her application. She took her file and peered wearily through her wire-rimmed glasses, trying to make sense of the latest letter from the British government.

In bureaucratic English that she labored to grasp, the letter said she was qualified to serve as a trainee nurse in Britain but still needed to obtain a work permit. This could take months, the recruiter's secretary said. Rose shook her head, fighting back tears. She was determined to wait, though, because the recruiter (to whom she has paid $150, or two months salary) promised a free round trip to Britain and a salary 20 times her current earnings.

Some parts of the world have long seen nurses and doctors leave home for better pay and experience abroad. Ireland once sent nurses all over the world, though it now imports them. For decades, the Philippines has exported thousands of nurses, treating them like a cash crop. The Asian country educates far more nurses than it needs, and benefits from money sent home by expatriates.

But most poor countries can't spare nurses. Until recently, rich countries mainly hired nurses from other rich countries. That's changing as the market for nurses become global. "Recruiters now target nurses even in poor countries, and even where nurses are in short supply," says James Buchan, an adviser to the World Health Organization who teaches at Queen Margaret University in Edinburgh.

Poor countries will find it even harder to retain nurses if the current moderate nursing shortage in the U.S. turns into a severe crisis over the next few years, as some experts expect. "I'm always telling people in developing countries, 'You don't want the U.S. situation to worsen because we'll grab up all of the world's poor nurses,' says Cheryl Peterson, director of international nursing at the American Nursing Association.

Prodded by big nursing employers, notably hospitals and nursing-home chains, Congress is expected this year to consider a new visa program making it easier to import nurses. Some offiicials in poor countries are considering demanding compensation from rich countries for the loss of nurses.

Poor countries find there is little they can do to stop the outflow. But some governments try to profit from the flow by forming specific exchange programs with rich countries. Britain, for instance, is considering the importation of nurses from China with the Chinese government's approval. Ghana has shipped nurses to Jamaica and imports some from Cuba under government-to-government deals. In some of these cases, government gets a cut of the money paid to the nurses. Poor countries can also benefit if the nurses return home more experienced.

It's a Business

But increasingly, nurses - and hospital recruiters - drive the global flow.

Recruiters typically enter a country with little warning and snap up scores of nurses, sometimes from a single hospital. "It's a business for them. There's no morality in it," says Tim Martineau, a researcher at the Liverpool School of Tropical Diseases in Britain who is studying recruiting patterns.

Governments are trying to intervene. South Africa, for instance, complained to the British government about raids on its nurses, and Britain's National Health Service responded by advising its hospitals to stop hiring South Africans. But this has only served to redirect the flow of nurses from South Africa, not reduce it. Nurses now look to the U.S. for jobs, and the recruiters are ready. "Nurses! Think of it as your seat in America," one recruiter, O'Grady-Peyton International of Savannah, Ga., declared in a South African advertisement last November. "Gain invaluable experience, learn the latest medical techniques and live a fuller life in a relaxed environment," the ad said.

More than 100 nurses met with O'Grady-Peyton recruiters in six South African cities. Joseph O'Grady, the company's founder, personally met with all of them, promising jobs and green cards to the roughly 20 nurses who survive the company's screening process.

In Ghana, recruiters don't need to do much wooing. Poor working conditions, awful pay and a lack of training opportunities drive nurses to look elsewhere for work. In the early 1990s, the government - supplier of almost all of the country's health services - cut nursing pay in an austerity move. Those cuts have been only partially restored, so that even a job a in Nigeria can look attractive to a Ghanaian nurse.

"We know there's a lot of things driving nurses out of here," says Ken Sagoe, a medical doctor who oversees health-care staffing in Ghana. Mr. Sagoe wants to make nursing more attractive, perhaps by giving bonuses to those who work in remote areas. He also wants to increase enrollment in nursing schools but worries that "we may end up educating more, only to have more leave." Indeed, his wife, a nurse, is studying for her master's degree in Scotland and working occasionally as a nurse there.

Nurses, to be sure, can benefit from working outside of their home countries, so some argue, it is best to let them go. "Don't try to stop people from leaving," says Victor Sackey, a recruiter in Ghana. "There's free movement of labor. If there are limits, people will find a way to evade them."

Mr. Sackey, who keeps a home in London, is a self-styled minister and brings a religious fevor to nurse recruitment. He extols the virtues of working in Europe and the U.S. and insists that Ghana could emerge as "another Philippines, exporting nurses to the world."

When Mr. Sackey first set up shop in Accra two years ago, nurses were so excited that hundreds lined the street in front of his office. The government arrested Mr. Sackey but quickly released him. He later persuaded the government to let him send 35 nurses abroad each year.

Even without the help of recruiters, nurses from Ghana look elsewhere for jobs. In October, hundreds of nurses from the country's depressed northern region signed a petition threatening "to quit their nursing work in Ghana and go to other countries where they are better dealt with." One of the country's senior nurse administrators, Wilberforce Adade, recently applied for a job at a London hospital, where his sister works. Mr. Adade who oversees scores of nurses in a distrct of northern Ghana, recently took yellow fever and other vaccines to satisfy his British visa requirement. If offered a job, he says, "definitely I'm going."