Table 2 Examples of dynamics of oppression emerging from coding

Structural adjustment programs (Poverty-generating international economic policy)

“When I was in medical school; starting from like 1985 to 1990, that was the time when we went through a structural adjustment program, the so-called SAP, and there was a drastic reduction in the standard of living. The economy was just really, really, bad. Things looked really bleak as far as the future.” (Nigerian-trained, male, 44 years old, pathology, Tennessee, USA)

Adverse economic impact of SAP on health settings (Required fee for service; closure of public health facilities; meager operating budget; etc.)

“When I did my OBGYN internship in 1994, I was on-call every three days. There wasn’t a day when I didn’t lose a patient due to totally preventable causes, preeclampsia, eclampsia, or bleeding after pregnancy. The patient would come with a retained placenta. It got so bad in the operating theater that the patients had to provide their own halothane anesthetic gas before surgery. So, if they cannot afford those 20 dollars, the woman who was in labor will die. …. So, if you are practicing in an environment like that, you have to run away if you get an opportunity, because the fact is that every single day you lose a patient. And the reason why you went into this profession in the first place was to save lives. So yeah, in the late 80’s to the mid 90’s the system was totally broken.” (Nigerian-trained, male, 41, preventive medicine, Tennessee, USA)

Adverse economic impact of SAP on health workers (Low wages; unpaid salary; delayed pay; depleted savings; limited access to loan, etc.)

“When I left medical school, my salary was about US $40. This was 1988. I couldn’t even afford [to drive] a car if somebody gave it to me for free, because I wouldn’t have the money to buy fuel….

When people talk about frustration over lack of resources to work within the hospital, the question is: What kind of resources are you looking for when working in that environment? You do the best with what you have. Except that, your colleague who you know, was not smart enough to be a doctor, but went to wherever, and became a secretary to a bank or whatever, that colleague earns more than five times what you earn!” (Ghanaian-trained, male, 52, emergency medicine, Maryland, USA)

Inadequate infrastructure (Limited road network, power supply, water supply, schools, etc.)

“Hardly can you have electricity supply running for six out of twenty-four hours a day in most places. In fact, in some places they could go for a whole month without having electricity for three hours. … We even hardly remember the problem of electricity because we've come to live with it. It has become part of us, and it impacts by several magnitudes on our health systems.” (Nigerian-trained, male, 45, community health, Kano, Nigeria)

“I was serving in the obstetrics ward [at Jimma Hospital], and a lady came from the countryside; her relatives brought her in, and she was pregnant. She had a ruptured uterus. … It took them two days just to come to the health clinic. They walked, because there is no public transportation, there is no road, so they had to carry her on a locally-made stretcher.” (Ethiopian-trained, male, 35, internal medicine, Washington, DC, USA)

Substandard working conditions (Inadequate facilities; lack of diagnostic equipment, medical supplies, drugs, running water, electricity in the workplace, etc.)

“The biggest facility where I trained, Korle-Bu Teaching Hospital, which is like the national hospital in Ghana; it is a dirty hospital. So many of its facilities are broken down; nothing is being done to fix it. The system is such that physicians are handicapped in carrying out their duties; it is like working in a jungle. … People come with chest pain, you cannot do cardiac enzymes in the night; you cannot do it on the weekends. And these are things that are time-sensitive; you can’t wait 24 hours to do some of these tests; CT scans unavailability. So, for me practicing medicine in Ghana is frustrating. A lot of physicians may be coming here [in the US] for monetary benefits and all that; it is a plus, but for me coming here makes medicine more fulfilling because I am at least able to practice medicine to the comfort level that I want.” (Ghanaian-trained, female, 35, critical care, Washington, DC, USA)

Bad government (Misallocation of country’s resources; mismanagement of public services; unaccountable leadership, etc.)

“My idea about Africa is that misgovernance is the biggest problem. Like, in the case of Nigeria, I know how people who are in positions of responsibility misuse resources. So, you have one person and he will take a billion dollars, 500 million dollars. This happens in Nigeria. Ok? …So, for me, even though I am a physician, the way I look at it is that the biggest impact is going to come if you can reduce corruption in Nigeria by 50%.” (Nigerian-born and trained, male, 44, pathology, Tennessee, USA)

“There is a big uproar about how much politicians are earning. One of my youngest brothers is a parliamentarian in Nigeria. A typical parliamentarian makes almost close to a million US dollars every month in Nigeria. [Meanwhile], the total grant of the project that we are doing in Nigeria is not up to six months of my brother’s entitlement. Now, my brother is a representative; he is not a senator. The senator is a higher-ranking person who earns about twice what my brother earns.” (Nigerian-trained, male, 45, community health, Abuja, Nigeria)

“The people that have to do something are the politicians who spend our resources. The richest people in Africa are politicians. They produce nothing, they make nothing. They’re rich. How do they get rich? They feed off the national cake.” (Ghanaian-trained, female, 35, critical care, Washington, DC, USA)

Corruption in public health settings (Systemic culture of corruption in government-led healthcare organizations)

“It is such an intricate web. If a contract is being given, the person in the ministry gets a cut, the auditor gets a cut. The contractor inflates the rates. The person who is in-charge of accounts at the ministry and the hospital itself gets a cut. The storekeeper gets a cut.” (Nigerian-trained, male, 41, preventive medicine, Tennessee, USA)

Cynicism about political leadership (Dystopian view of own native country and Africa; distrust of African politicians; civic disengagement, etc.)

“When I was in the UK, there was this Nigerian lawyer who I went to talk to, and then when I told him I was going back to Ghana, he asked: ‘Why do I want to go back? There is no point coming to Africa, there is barely any good in Africa, you better stay in the UK’.” (Ghanaian-trained, male, 48, internal medicine, Accra, Ghana)

Insecurity

(Widespread armed robbery; kidnapping; inadequate policing, etc.)

“What's happening in Nigeria, it's like, despite the democracy and the elections, there is too much insecurity for yourself and your family to kind of take that chance [of returning] no matter how much they may be willing to pay you. So now, the push factor [of emigration] may not be money, it will be more of security and technology.” (Nigerian-trained, male, 45, community health, Abuja, Nigeria)

Cultural threats to healthcare (Illiteracy; reliance on traditional healers; hospital visit as last resort; stigma, etc.)

“From my little experience working in Ghana, a lot of times, people come late to the hospital.” (Ghanaian-trained, female, 35, critical care, Washington, DC, USA)

“Many patronize quacks, and the so-called traditional healers who deceive the unsuspecting general public.” (Nigerian-trained, male, 45, community health, Abuja, Nigeria)

Loneliness abroad (Feeling of estrangement; limited support network; longing for home, etc.)

“Here is very lonely. You don't have people to talk to; that's my biggest problem. I miss that social aspect a whole lot. I need to go back home and reignite that because here it's almost gone.” (Nigerian-trained, male, 45, critical care, Tennessee, USA)

“Coming here you realize that money cannot give you happiness. … Social support is a big issue in America. But, back home there is this support system that I think has a positive impact on people.” (Nigerian-trained, male, 33, internal medicine, Washington, DC, USA)