Table of Contents
I know I can’t live away from Samoa for too long. I need a sense of roots, of home—a place where you live and you die. I would die as a writer without roots; but when I go home I am reminded that I’m an outsider, palagified (Albert Wendt, in Beston and Beston 1977).
Little has been written on return migration to the island states of the Pacific. More generally and despite its significance in many countries, there is a limited global literature on return migration, and even less that focuses on the return migration of skilled workers. This chapter traces the return migration of skilled health workers, in three Pacific island states (Fiji, Tonga, Samoa) and evaluates the rationale for and consequences of return and their contribution to development. As the short title—the words of a returned health worker—and the opening quotation from the distinguished Samoan author, Albert Wendt, indicate, there is both contradiction and ambivalence in the structure, nature and impact of return. Ambivalence and uncertainty are complicated within a more transnational world, through the flexibility and fluidity of more instantaneous physical and electronic communications and contacts.
The global rise in the migration of skilled workers has been perceived as a response to the accelerated globalisation of the service sector. Such professional services as health care are very much part of the new internationalisation of labour, as demand for skilled health workers in developed countries has remained high, seemingly paradoxically because of relatively low wages and poor working conditions in these destination countries (Connell 2008b). In the Pacific, as elsewhere, the migration of health workers is no new phenomenon. At least as early as 1989 a medical degree from the Fiji School of Medicine was regarded by some as a ‘passport to prosperity’. However there have been few studies of any facet of this migration and those that have been done have until quite recently been largely qualitative (Naidu 1997; Rotem and Bailey 1999), while just as few studies in the Pacific region have examined other forms of skilled migration (cf. Liki 2001; Voigt-Graf 2003; Voigt-Graf, Iredale and Khoo 2007). In short, there is remarkably little information on the migration of skilled workers, let alone their return migration, in the Pacific region. This chapter seeks to help to fill this gap by addressing the significance of return migration of one small group of skilled workers in three island states.
Especially for small states, the migration of skilled workers has been seen largely as a one-way process, a critical component of the brain drain, and thus a major problem. Migration (and attrition) represent a costly loss of scarce and expensively–trained human capital. Loss of significant numbers of key health workers affects core national strategies for health sector development, creating problems for health care, and for human resource planning and development. Conversely, return migration in the Pacific is often seen as a migration movement dominated by retirees and those who have failed elsewhere: return has even been seen as an admission of failure (Maron and Connell 2008). Those who remained overseas were the success stories and though many of these publicly expressed intentions of return, in private they had moved towards permanence (Macpherson 1985). In other words, the returnees were apparently those least likely to make a significant positive contribution to their home countries. However, in the absence of detailed examination of return migration, such conclusions were largely drawn from anecdotes rather than ethnographic or survey data.
More recent studies, especially in the Caribbean, have gradually begun to recognise the diversity of return migration, alongside the diversity of reasons for return (Conway et al 2005; Gmelch 1992; Thomas-Hope 1999). Similarly for many Cook Islands migrants, the acquisition of new skills overseas was a contributing factor in the decision to return, particularly with the accompanying elevation of social status and income, hence there was a significant return movement of those who had succeeded elsewhere (Hooker and Varcoe 1999; Rallu 1997; see also Marcus 1981:60). Likewise in Tonga, returnees represented a cross-section in terms of age and employment, unskilled and skilled, including health workers, poorly educated and those with second degrees (Maron and Connell 2008). Yet in both these two national contexts there were relatively few such skilled migrant returns compared with the number of those who had left, and information on health workers is minimal.
At a global level, the situation is similar. The return migration of skilled health workers is assumed to be relatively limited in most places, though data are scarce, hence benefits from enhanced overseas skills—a compensatory brain gain—are considered to be few. Fragmented evidence from many parts of the world suggests that return migration of skilled health workers fails to occur largely for the same reason that migration previously occurred. Indeed, migrants are less likely to be tempted back by a system that they left, probably at least in part because of its perceived shortcomings. The extent of overall return migration of skilled health workers has been perceived to be so slight that Kingma (2005) has referred to the ‘myth of return’.
Samoa, Tonga and Fiji are all small island states. Fiji with a population of about 825,000 people is the largest in the region, Samoa has about 170,000 people, and Tonga 102,000. Both Tonga and Samoa have about as many ethnic islanders overseas as at home. By contrast, about 10 per cent of Fiji islanders live overseas. Limited land resources, few natural resources, isolation and fragmentation, weak infrastructure and governance all pose problems for administration and development, and economic growth has been weak in recent years. Most countries experience some problems of hardship and poverty of opportunity, and none have significant economic growth. Migration has consequently increased, mainly to the metropolitan states of Australia, New Zealand and the United States.
Metropolitan countries have also traditionally been the destinations for tertiary studies, but both doctors and nurses are educated in the region: doctors (and most other specialised positions) from each of the countries are trained in Fiji and nurses in the home countries. Fiji has the largest health care system in the region, but it has been the most affected by migration since 1987, when ethnic tensions and military coups prompted a series of resignations and departures, and relatively few returns. The health systems of each of the countries have also been significantly affected by migration, particularly of doctors and more specialised occupations such as lab technicians and dentists, for whom human resource planning is more difficult. In all three states the migration of doctors is considered to be more significant than that of nurses in terms of proportions who had migrated, their impact on the health care system and the cost of replacement (Brown and Connell 2004). Since the 1990s, recruitment of Fijian nurses by New Zealand, the UAE, Palau and the Marshall Islands has further emphasised the evolving migration structure and external orientation of health workers.
While the scale of international migration is affected by the vicissitudes of the international economy, migration is primarily affected by uneven development, income levels and the desire for access to education and health services. Each of the countries has experienced significant recent migration both generally and of skilled workers particularly. Skilled workers, and especially skilled health workers, are a significant proportion of immigrants from Pacific island states to metropolitan states. Many developed countries, including Australia, the USA and New Zealand, have a particular shortage of health workers, especially in remote areas.
For each of these countries, but less so for Fiji, where there are distinct, local alternative economic opportunities, there is to a significant extent a ‘culture of migration’ in which migration is pervasive, based on historical precedent, and part of everyday experience; perceived as legitimate, not as either rupture or discontinuity in personal and household experience, but as an integral part of life (Connell 2008a). Migration is normal and mobility, intermittent return visits and return migration are part of that. Moreover it is embedded in strategies for extended household development rather than simply the outcome of decisions taken by a small number of individuals. International migration has long had a critical and virtually uncontested role in island societies and economies. The migration and return migration of skilled workers is embedded in this broad context of continuity.