Opinion: The ‘brain drain’ narrative about health professionals misses half of the story

OpinionFirst Opinion The ‘brain drain’ narrative about health professionals misses half of the story Returning to a home country to practice medicine brings surprising challenges, opportunities Manage alerts for this article Email this article Share this article By Maia ChankselianiMay 5, 2026 Chankseliani is professor in comparative and international education at the University of Oxford. About 10 years after a breast surgeon we interviewed returned to Dubai to practice, a colleague stopped her in a hospital corridor to tell her: “It’s great — since you came back I no longer see those advanced cases of breast cancer.” She had not stopped to notice. “You get on the wheel,” she told us in an interview for our research. When you return to your home country after training abroad, you run your clinics, train your nurses, drive out to women’s groups in the hinterlands to give talks, design educational videos that explain breast self-examination without showing a breast, because that is what the censors will pass. You argue to have the word “breast” printed on your medical license; the authorities prefer “chest.” You establish a support group, then a drop-in center, likely the only cancer drop-in center in the Middle East. Somewhere in the middle of all that, you alter what late-stage breast cancer looks like in your country.Advertisement She trained in Ireland and Houston. She had job offers from academic centers in London and the United States. She went home anyway, because she had seen what was missing and felt she owed something to the women she had seen as an intern in Dubai, who would arrive with cancers that should have been detected years earlier. I have spent the past several years studying internationally educated professionals who return to their countries of origin, examining what they attempt, what they contribute, and what stands in their way. The study I led interviewed 52 health professionals across 43 countries, alongside 14 domestically educated peers working in the same health systems. Most were from low- and middle-income countries, though the study also includes professionals from higher-income settings, who had studied abroad before returning to work in their home systems. The interviews were conducted in 2023-2024, and the professionals we spoke to had returned at very different points in time, from recent years to several decades ago. What emerged challenges the story global health policy tends to tell about mobility. The dominant frame remains “brain drain”: who leaves, in what numbers, from which countries, and how to slow the flow or compensate for the loss. The WHO Global Code of Practice on the International Recruitment of Health Personnel, now under significant review, is structured around this logic. So are most bilateral agreements, most return incentive schemes, and much of the research. The analytic gaze is fixed on departure.Advertisement Return barely registers. When it does, it is assumed to mean reintegration: A professional comes home, applies acquired skills, and resumes practice. The evidence suggests a more complex and more demanding reality. Across 43 countries, returning health professionals described becoming part of systems that were never designed to receive what they brought back. One recurring experience was epistemic dismissal. Comparative knowledge was treated as irrelevant, naive, or disruptive. A returnee from Uzbekistan told us, “We are like aliens for many people. We have to explain why we need to collect data.” A microbiologist in Côte d’Ivoire recalled colleagues asking, baffled, “But what is it that you do?” The issue was rarely competence. It was how competence was interpreted. Another pattern was legal and policy absence. Professionals returned ready to act and found no enabling architecture. A transplant surgeon in Libya spent years advancing a national organ donation campaign while knowing the legal basis for implementation did not yet exist. A health minister in Ecuador described pursuing reform without an explicit health policy to anchor it, negotiating sector by sector rather than legislating from a coherent framework. Bureaucratic inertia was equally common. Charities took years to register. Innovations stalled while waiting for institutional approval. The breast surgeon in Dubai encountered repeated refusals when trying to distribute awareness materials in shopping centers. Decades later, a pink bus emblazoned with the word “breast” would circulate during October awareness campaigns. The shift occurred because persistence accumulated. Political resistance formed the fourth strand: military governments prohibiting family planning, AIDS information blocked from media to protect tourism revenues, entrenched hierarchies closing ranks against reform. These are structural features of health systems. They reveal an uncomfortable truth: While global policy has invested heavily in tracking mobility and managing recruitment, it has invested far less in creating institutional conditions that allow returning professionals to exercise influence.Advertisement What returning professionals carry home is not primarily technical skill. In our study, both internationally educated returnees and domestically educated peers demonstrated commitment and meaningful system-level impact. The distinction lay elsewhere. Those who had studied abroad had seen health systems organized differently. They had received an envelope inviting them for a free cervical cancer screening. They had observed accountability mechanisms functioning as intended. They had trained in settings where assumptions about patient autonomy, early detection, and institutional transparency were different. What they bring back is not just knowledge, but a different way of seeing. They have seen that things can be done differently, and that changes what they think is normal, what they expect, and what they are willing to push for. One returnee from Uzbekistan, now working within the presidential administration on preventive health policy, recalled receiving a letter as a student in St. Andrews inviting her for a free cervical smear. Twenty years later she was working to introduce a similar program at home. “I know it is possible,” she said. “I’ve seen myself that it is done.” This is not a transferable skill in the narrow sense. It is an altered sense of what is normal, what is necessary, and what is achievable. Health systems currently struggle to absorb that orientation. Comparative awareness can appear as foreign idealism, impatience, or threat. Yet in practice it often allows returnees to question inherited arrangements and endure institutional friction long enough to redesign them. The global health workforce shortfall is projected to exceed 11 million by 2030, concentrated in countries least equipped to address it. The current review of the WHO code and reductions in development assistance for international training make this a particularly precarious moment to persist with a departure-centric narrative. Ministries of health and international funders need to shift attention from managing exit to enabling consequential return. That entails recognizing comparative knowledge as an asset rather than an irritation, addressing legal and policy gaps that immobilize reform, and cultivating institutional cultures capable of absorbing challenge.Advertisement The breast surgeon in Dubai did not change patterns of late-stage breast cancer solely because her surgical training was excellent, though it was. She changed them because she had seen that early detection could become routine and refused to unsee it. When health systems dismiss that refusal as foreign or unrealistic, they are neglecting one of the most consequential resources internationally educated professionals bring home: a reoriented sense of what patients deserve and what institutions can become. Brain drain is a powerful metaphor. But as a governing frame, it obscures as much as it reveals. What health systems owe returning professionals is the space to act on what they have come to know. Maia Chankseliani is professor in comparative and international education at the University of Oxford. She has recently published a study on internationally educated health professionals and health-system change in Global Public Health and an opinion piece on seeing foreign students as threats in Nature. Disclosure: This piece draws on a global research project funded by the U.S. Department of State and conducted at the University of Oxford. global health, nurses, Physicians Submit a correction requestReprints Maia Chankseliani Newsletter The smartest thinkers in life sciences on what's happening — and what's to come Recommended First Opinion May 5, 2026 The cruise ship hantavirus outbreak is a warning sign to the U.S. First Opinion May 4, 2026 Mifepristone court ruling makes drug development riskier for everyone Advertisement First Opinion May 4, 2026 Are blue zones real? 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