Madam, in recent years, an increasing number of medical graduates from Pakistan are striving for training opportunities in academic set-ups in USA, UK, Canada, Australia, New Zealand, South Africa and the Republic of Ireland.¹ The certifying examinations, application procedures, and interview-related travel expenses all add up in the proximity of £6000 (1 £= 122 Pakistani Rupees), with the more affording medical students spending an additional £3000 on arrangement of overseas elective rotations.²
Undoubtedly the training afforded to the medical graduates through this migration transforms them into competent physicians with knowledge and skill that is state-of-the-art. But there are many sides to the picture. Although the phenomenon has diverse economic, socio-demographic, ethical and moral implications; the human dimension needs to be considered as well. Despite the immediate repercussions of this brain drain to society, can one ignore the ethics and morality of denying human beings the right of pursuing their dreams or realizing their aspirations? ¹
A study in 2005 found that Pakistan had contributed about 13,000 medical graduates to USA, UK, Canada, and Australia.² Local medical schools and international medical graduate certifications provide around 6000 physicians to the country annually. 1,150 of these migrate and an estimated 570 physicians stop practicing for various reasons. It should be acknowledged that the current ratio of physicians to population is inadequate by any measure. Pakistan can\\\'t meet its needs for health care given the current levels of production and dependency on physicians in the organization of the system. Definition of physician roles and improvement of standards through refined assessment require serious consideration.³
However, some factors should be given consideration before impulsively discrediting the trend of migration of Pakistani medical graduates. A questionnaire based study was conducted to uncover the reasons behind this \\\'brain-drain\\\'. This enrolled students from Aga Khan University and Baqai University, two medical schools of good standing in Karachi, Pakistan. The two most important factors, as pointed out by the students, were poor salary structure and poor quality of training in the home country. Other factors captured through the open-ended questions were the poor work environment and lack of rigor in teaching of residents in local hospitals.⁴
Opponents of migration of medical graduates have debated about the moral imperative for strengthening the developing world\\\'s health systems. However, there are alternative and effective ways to promote healthcare in the developing world, for instance, via assistance with infrastructure, biotechnology, sanitation, economic development, and openhanded debt relief.³ The young physicians should have freedom to fulfill their dreams of post-graduate training at international institutions if they so desire. The desire to return to their homeland after completion of their training or opting for training here in Pakistan should stem from personal choice, not coercion. Also, holding them solely responsible for the poor health care of developing countries may not be the most reasonable approach. On the other hand, gains from medical migration are aplenty. Although most directly, recipient countries are able to recruit foreign medical graduates for service, academic and research needs. But perhaps even more importantly, small proportions of these physicians eventually do return to their homeland and become valuable, contributing members of the society.
 
Umair Khalid, Taimur Saleem
Medical Graduates, Class of 2009, Aga Khan University, Karachi, Pakistan.

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2.Talati JJ, Pappas G. Migration, medical education, and health care: a view from Pakistan. Acad Med 2006; 81: S55-62.
3.Syed NA, Khimani F, Andrades M, Ali SK, Paul R. Reasons for migration among medical students from Karachi. Med Educ 2008; 42: 61-8.
4.Shafqat S, Zaidi AK. Pakistani physicians and the repatriation equation. N Engl J Med 2007; 356: 442-3.