Newswise — The emigration of skilled professionals from lower-resource to higher-resource countries is commonly referred to as brain drain. The phenomenon affects many sectors, including neurology and epileptology.
The reasons for emigrating are generally divided into “push” factors (any influence that might drive someone out of a country) and “pull” factors (an influence drawing someone toward a country). “Push” factors vary by country and may be affected by policies and programs, while “pull” factors are more individual.
of 251 final-year medical students in Uganda found that 45% planned to leave the country seeking better pay, a safer work environment, or more advanced training. found that 43% of Indian medical students planned to leave the country after graduation; the most-cited reasons were better pay, better training, and more career opportunities abroad, as well as a limited number of residency opportunities in India.
Surveys from other countries, including and , illustrate similar “push” and “pull” factors:
Push: Low pay, low-quality training, expensive training, lack of training relevant to career goals, unsafe environment, poor working conditions, few opportunities for career advancement
Pull: Higher pay, high-quality training, more career opportunities, better quality of life, more resources/better equipment
Financial factors are paramount as both “push” and “pull” factors. People are pushed out by low salaries, but also in some cases by the high cost of training: in certain countries, residents must pay tuition and receive low or no salaries.
Lack of training and lack of opportunity are strong “push” factors in epileptology as well as general neurology. These factors go hand in hand; countries without training programs in neurology and epilepsy are unlikely to have job opportunities.
“These issues are significant,” said Jo Wilmshurst, head of pediatric neurology at the Red Cross Children’s Hospital at the University of Cape Town, South Africa. “In some cases the driving force is the desire to have a career path, and the perception that if they stayed where they were, they’d never have that future career,” she said.
Those who leave for career reasons are unlikely to return unless they have a job opportunity waiting for them that utilizes their specialized skills.
“If people return [from training elsewhere], institutions may not be ready for their specialized training,” said Melody Asukile, attending neurologist at the University Teaching Hospitals Adult Hospital in Lusaka, Zambia. “So you may be a trained neurologist but required to work as a general physician. Or if you trained in a high-resource setting and then come back and are faced with having to compromise all the time and finding other ways of doing things, that can lead to frustration and burnout.”
National priorities affect brain drain
Asukile grew up in Zambia and wanted to be a neurologist. “I knew there was a need for neurologists,” she said. “I myself had a neurologic condition and there was no one to diagnose and treat it. I went to the Ministry of Health and said, ‘I would really like to study neurology—can you support my studies?’ Because in those days, the Ministry would sponsor people to go out of the country and study if they thought a certain field was a priority.”
The Ministry declined to support her. Asukile found other funding and moved to South Africa, where she completed a neurology residency and specialization in clinical epileptology. She returned to Zambia as one of the country’s first native neurologists and is now involved in Zambia’s first neurology training program.
She understands why many people leave and do not return. “By the time you are specializing you may have a family, children, and you’re looking out for their future, too,” said Asukile. “You want them to have a good education, a good outlook for their lives.”
The impact of local training programs
Brain drain maintains status quo in countries through a vicious cycle: If neurology is not a government priority, then training programs, clinical opportunities, and research programs will not exist. This lack of infrastructure not only drives people away to train elsewhere, but also results in a lack of epidemiological data on the scope and impact of epilepsy on a country’s population. Without those data and the advocacy to address national health priorities, the cycle continues.
The lack of local training programs is a major factor pushing medical graduates to emigrate. Addressing the issue takes time and effort, but examples from Latin America and Africa show that change is possible.
Local neurology training programs are one solution to brain drain. Honduras, which established a training program in 1998, has the data to support that. “Building a local education facility can reduce brain drain,” said Marco Medina, neurologist at the National Autonomous University of Honduras. Medina directed the training program from 1998 until 2010, when he became dean of the School of Medicine.
Honduras’ program was established through a collaboration among the World Federation of Neurology, the Honduran Secretary of Health, the Honduran Neurological Association and the National Autonomous University of Honduras. By 2010, the ratio of neurologists to inhabitants in Honduras had increased by 50%. More than 40 neurologists have been trained through the program, with 99% staying in Honduras to practice.
The resources have resulted in a dramatic reduction in deaths from status epilepticus, as well as the establishment of prevention programs for neurocysticercosis and stroke. “The neurology department is recognized as one of the best in Central America,” said Medina. “The program attracts high-performing medical graduates, and neurologists are now available in smaller cities.”
Zambia’s neurology training program was established in 2018 and now has 12 graduates, some from other African countries. Asukile noted that the program provides training relevant to Zambia, with all the workarounds and cultural aspects baked in.
“When you are trained locally, you become a tailormade specialist for your setting, and the issues you need to deal with and how to resolve them is something you learn as part of your training,” she said. “And when you train a specialist locally, they train those behind them. You really see the difference because the trainees are part of helping us train the medical students, so we have seen a general increase in neurology education.”
Local training programs in many countries are supported by government. “That means the government is committed to this person, and there may be expectations of the person once they are trained,” said Asukile. “Whereas if you are training elsewhere without government support, you may not feel obligated to come back—there is no partnership.”
A public training program also can reflect governmental acknowledgment of neurology as a health priority, noted Asukile. But such acknowledgment is difficult to secure without local neurologists who can advocate and provide epidemiological evidence for the need.
“A lack of training makes epilepsy seem like it’s a low-prevalence issue, like it’s not an issue when it actually is a serious one,” she said. “I used to be kind of disgruntled because I thought that the government just didn’t care [about neurology]. But now I think they just didn’t know.”
Local-regional collaborations
Local-regional educational programs also can slow brain drain by offering training opportunities closer to home.
was founded in 2007, “with the idea of a south-to-south educational collaboration, allowing neurologists or neurosurgeons to become epileptologists or epilepsy surgeons,” said Medina. “More than 30 epileptologists have been trained through ALADE fellowships.”
Both pediatric and adult neurologists and neurosurgeons are eligible for the fellowships, spending 12 months at an established epilepsy center in Latin America. Before applications are opened, qualifying centers indicate their willingness to receive fellows and how many they can accommodate.
While most training programs choose qualified candidates from a pool of applicants, the African Pediatric Fellowship Program works differently. The Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, partners with more than 30 teaching hospitals in 13 other African countries, providing relevant training to trainees who are hand-selected by each hospital. After their time in Cape Town, trainees return to their place of employment.
“Trainees have been nurtured, they are passionate, they already have a foothold in their home setting and want to develop more professionally, and then they have the approval and support of their institution,” said Wilmshurst.
To customize their training, each trainee provides insight about the infrastructure and limitations at their home center. “They may be a long distance from other specialty care, or they may lack ICU facilities,” said Wilmshurst. “We can talk to them about adapting to manage something like status epilepticus, for example. What are your priorities and how do you cope?”
The program has been running for over 15 years and now accepts 50 to 60 trainees per year in all pediatric specialties.
In pediatric neurology, the program has taken a multidisciplinary approach, training not only neurologists but physiotherapists, speech therapists, and other professionals. “One of the biggest demands is the need for EEGs to be done better,” said Wilmshurst. “EEG is one of the most misused resources, if centers have access to it at all. So one of our requirements is that all the trainees that come through have to learn how to do an EEG from scratch, and they have to learn how to troubleshoot the machines.”
Researcher brain drain
Brain drain affects epilepsy research as well, and the issues are intertwined with clinical care.
Jaiver Macea Ortiz grew up in Colombia, where he completed his medical training and became a practicing neurologist. He earned a Master’s degree in epidemiology by studying part time while he practiced. Macea Ortiz enjoyed research and wanted to earn a PhD conducting epilepsy research. But he faced several challenges.
“It's possible to do a PhD in Colombia, but not in epilepsy,” he said. “There are not enough trained people to provide the supervision.”
Also, PhD students are not provided with stipends or tuition waivers. “So you have to work and then pay your tuition and fees, and that’s much more difficult,” said Macea Ortiz. “And I already did that during my neurology residency because until recently, residents in Colombia were considered students, so we had to pay to do our residency.”
And while opportunities to combine research and clinical practice are standard in high-resource countries, they are difficult if not impossible to find elsewhere. “There’s little time allocated for research,” said Macea Ortiz. “If your health care institution isn’t interested in research, it’s very difficult to do it because they won’t allocate the time. When you see a publication from someone from certain Latin American countries or from Africa, most of that work has been done in the evenings and during the weekends.”
In 2020, Macea Ortiz moved to Belgium to start his PhD, studying wearable devices for epilepsy detection. He earned his degree in 2024 and chose to stay in Belgium as a postdoctoral researcher while his wife earns her PhD.
They still plan to return to Colombia one day.
“That has been my idea from the beginning, to go back,” he said. “I think it is important to transfer some of this knowledge and skills. But of course, the future is uncertain.”
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Founded in 1909, the International League Against Epilepsy (ILAE) is a global organization with more than 125 national chapters.
Through promoting research, education and training to improve the diagnosis, treatment and prevention of the disease, ILAE is working toward a world where no person’s life is limited by epilepsy.
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