Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 2, 2003

More and more, nurses in the Caribbean have been packing their bags and heading for countries with less-than-perfect climates to get better pay and more respect. Now the region is looking for ways to keep them from leaving—and even to lure those abroad back home.

Back in the 1980s, Glenda Caesar worked as a staff nurse in a hospital on the island of Trinidad. She earned the equivalent of about $250 per month. Given the cost of living, it left her with virtually no disposable income. To make matters worse, she says her working conditions were "deplorable," with extreme patient overcrowding and serious shortages of medicines and equipment.

So in 1990, along with three other nurses from Trinidad, Caesar accepted a job offer in Saudi Arabia that paid her more than four times her Trinidad salary. Leaving behind her tropical island home, she traveled to the harsh desert climate of Riyadh, where she enjoyed perks such as a "rest and recreation" allowance, had much better working conditions and earned enough to live comfortably and still send money back to her family in Trinidad.

Eventually homesickness compelled Caesar to give it all up and return home. But her fellow Trinidadians and other nurses from the Caribbean are still there. Moreover, others are following in their footsteps, emigrating to the Middle East, Europe, Canada and the United States. As fast as you can sing "Working for the Yankee Dollar," nurses from throughout the Caribbean have been packing their bags and saying, "Farewell, paradise!"

As early as the 1970s, the World Future Society was predicting that the global demand for nurses would be virtually infinite. Today, the shortage of trained nurses has become one of the most serious crises facing the health care industry worldwide. The World Health Organization (WHO) reports a shortage of nursing personnel in each of the six regions of the world it represents. If the trend is not reversed, "the ability of many health systems to function will be seriously jeopardized," says a 2000 WHO report.

Gloria Noel, a health systems management consultant and former nurse advisor to the Pan American Health Organization (PAHO), says three labor trends are feeding the problem: "Nurses are not entering the profession, those who are there are not staying, and those remaining are not happy. This crisis preoccupies health services policymakers, planners, educators, employers, managers and employees. Experts are studying the impact of the global nursing shortage on world health status and the quality of health care."

The fact that these trends are not confined to the Caribbean provides little consolation to the region. In certain ways, its problem is worse. Because English is the native language of most Caribbean countries, their nurses are highly desirable to North American and British recruiters. This exacerbates the region's homegrown shortage.

Noel says recruitment agencies from these and other countries send representatives who in some cases try to lure nurses right off hospital floors. She finds it "interesting" that "a country with the highest ratio of nurses, the United States, which has 97.2 nurses per 10,000 people, is recruiting nurses from Jamaica, where the ratio is just 11.3 nurses per 10,000, and from Guyana, with 8.6 nurses per 10,000." She cites U.S. Bureau of Labor Statistics projections that estimate U.S. demand at an additional 800,000 registered nurses by the year 2020.

The growing demand is due to several complementary factors. People are living longer than before, increasing the numbers of infirm and chronically ill. Improved lifestyles and greater health promotion reduce premature death and illness but add to the health care burden of an aging population. So, too, do seemingly endless medical-scientific discoveries and technological advances in health care.

And that's the good news.

On the downside, Noel points to increases in antibiotic-resistant infections and "cost-cutting pressures of managed care." There is also HIV/AIDS. While antiretroviral therapy increases the numbers of people living with HIV/AIDS, it also increases their need for trained caregivers. The Caribbean is second only to sub-Saharan Africa in terms of HIV rates, with an estimated 2.2 percent of Caribbean nationals living with the virus, according to the Joint United Nations Program for HIV/AIDS (UNAIDS).

Studies have identified other factors underlying the nursing crisis. In the Caribbean, these include inadequate workplace environments, with facilities that are in disrepair and lacking essential equipment. The problem is compounded by inadequate compensation and benefits. Most Caribbean countries have suffered severe economic downturns and have implemented structural adjustment programs that have brought major reductions in health-care budgets.

Nurses also complain of a lack of recognition and professional power, which leads to unsatisfactory social relations at work. "There is no respect for nurses who stay and who make the sacrifices," says Caesar. Under such conditions, even family commitment, patriotism and the opportunity to contribute to national development are insufficient motivators for trained nurses to remain in the national health service.

Caesar has been a nurse for 26 years and is now an assistant secretary with the Public Services Association of Trinidad and Tobago, the industrial relations representative of most local nurses. She says she understands well why many nurses want to leave.

"It is not only for the money. For the most part, it is a matter of improving themselves and their families. Many of us have children at university. We have mortgage payments. We have the car, food, phones and a salary that can barely feed us and pay off the bank. Our colleagues abroad have enough money to pay their mortgages and still have something left for the rainy day. This is why so many of my colleagues think, 'maybe I should get out too.'

"When you look at the hospital where I was trained and worked, there is severe overcrowding. There used to be a staff ratio of five nurses to 109 patients in the medical wards, and that is low by international standards. Now you get three nurses to one ward, if you're lucky."

Contrast that with conditions in recruiting countries such as Saudi Arabia. "All the support facilities are available—the equipment, the staff, are all there," she says. "The linens and packs are changed regularly. This is the big difference." Asked about language and cultural differences, she says, "Patients are patients everywhere. Whatever the language, their needs are the same."

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