Almost every morning at around 5am, Bianca Bandarra, a young doctor from Rio de Janeiro, leaves her home in a leafy suburb of south east Dublin for work.
But Bandarra is not heading to work in a city hospital. She is driving to Craigavon, in Northern Ireland, where she’s training to become a general practitioner in the Republic.
Back in Rio, she says, she was trained to perform operations as a general surgeon.
“Yes, you could say that I’m down skilling,” she says, laughing.
Bandarra graduated in 2011 from Petrópolis Medical School, in a Brazillian city of the same name, some 40 miles north of Rio.
After that she worked for one year, before joining a general surgery training programme.
“It is not the equivalent of the training here, but it’s very intense, and it was a two-year programme,” she says, on a Zoom video call on her day off.
“Like here, trainees work 40 hours a week, in Brazil, it’s 60 hours.”
In May 2017, Bandarra moved to Dublin with her husband, who is an Irish citizen. That same year, she realised that her training qualifications, as a general surgeon in Brazil, was not recognised in Ireland.
Some non-European doctors in Ireland are limited by red tape and regulations that prevent them from landing permanent positions or moving up the medical ladder in Irish hospitals. For international, female doctors, workplace barriers often prompt personal predicaments.
Under the Medical Practitioners Act (2007) people who complete their medical studies and mandatory internships from non EU countries, with a few exceptions, do not qualify to practice medicine in Ireland.
Current legislation makes exceptions for doctors from eight non-European countries including Australia, New Zealand, South Africa, Sudan and Malaysia.
Graduates of non-European medical schools are also not automatically eligible to register with the Medical Council of Ireland, the country’s regulatory body of the medical profession.
Without a recognised certificate of experience, international doctors cannot apply to the trainee specialist division of the medical register — a programme which allows medical postgraduates to train and become specialist doctors — which means they can’t climb up to the position of a consultant.
In order for Bandarra to even qualify as a junior doctor in Ireland, which gives her access to short-term contracts, she had to take a medical exam and an English proficiency test. But as a graduate of non-European medical schools, she is still barred from entering training programmes.
Bandarra said that it’s challenging to work as a junior doctor under short, precarious and often temporary contracts.
The reason Bandarra goes to Northern Ireland for her training is because the NHS does not impose the same set of obstacles on non-EU doctors when it comes to entering trainee specialist programmes.
She says that getting a training position in Northern Ireland was relatively easy but now Bandarra worries that a no-deal Brexit may ruin her career prospects in the Republic.
“If there is a no-deal Brexit, there is a chance my training might not even be recognised in Ireland, because the UK training would be recognised as non-EU then,” she said.
On their website, the Irish Medical Council has addressed the issue, saying that if the UK leaves the bloc with no deal from 31 October, UK qualification will no longer be recognised in Ireland.
That means, Bandarra says, she has to pay over €3,000to the Irish Medical Council to apply for an assessment of her UK qualifications in Ireland, like other non-European trained doctors whose duration of residency abroad was three or more years.
Bandarra said the unstable nature of her life has caused her to postpone major life decisions like having a child.
“Oh my god, I wouldn’t be able to do all this travelling if I had kids,” she said.
Andrea Carolina Salina, another doctor from Fortaleza, a seafront city in Brazil, agrees.
“I wouldn’t think about having kids, because my life is so unstable, I don’t know where I’m going to be a few months from now,” she says.
Increasing Brain Drain
“My husband has a very stable position here, and we love Ireland very much, but it makes no sense for me to spend my life as a junior doctor, that’s my future in Ireland,” says Salina, who worked as a in St Vincent’s hospital for a few months and is now working in another city hospital, on a short-term basis.
She said being a non-European woman makes the life of a doctor doubly difficult.
“We sometimes have to deal with sexism, seeing more responsibility is given to our male colleagues, and not being able to get these specialist training positions just makes it even harder,” she said.
While non-European Irish doctors like Salina decide to leave the country for the UK, the Irish healthcare system suffers from an enduring brain drain.
Although Ireland has a higher rate of medical graduates than any country of relatively similar population size, it is still more reliant on internationally trained doctors than all 37 member countries of the Organisation for Economic Co-operation and Development.
More than 2,800 doctors pulled out of the Irish Medical Register between 2015 to 2017, according to the Irish Medical Council
The country’s healthcare system presently relies on over 6,000 internationally trained doctors.
Dr Eimear Nolan, an assistant professor of international business at Trinity College Dublin, says it’s no secret that Irish doctors don’t stay in Ireland.
Nolan says that doctors tend to go to Australia because the Irish healthcare system is difficult to work in and resources are stretched.
“They would be paid a lot more money in Australia, and their quality of life would be better,” she says.
Nolan says despite Ireland’s heavy reliance on non-EU doctors, the law treats them unequally.
Even for non-EU students who have paid high fees to graduate from Irish medical schools, access to internship programmes is limited, regardless of their academic merits, according to an OECD report.
The current procedure prioritises Irish and other European applicants in the first round of intern offers. According to the Health Service Executive, this policy has been adopted to protect the public investment in the education of these students.
Ireland’s intake of non-EU medical students is high as they compose half of the medical student body in Ireland. This was noted in a 2016 report published in the journal Human Resources for Health.
“In Irish medical schools, enrolling non-EU nationals is seen as an income-generating activity” the report states.
“They service the people of our country; we should put the same value that we put on our own doctors on them,” says Nolan.
Nolan said she heard doctors describing current legislation as racist, but her view is slightly different.
“I don’t think the law is purposely racist, as in I don’t think it was drawn up with any sense of racism, but they’re unfair,” she said.
She believes that since lawmakers didn’t anticipate heavy reliance on non-EU doctors, they failed to provide adequate legislative support for them.
Bandarra, who said her husband was furious to find out about the country’s unequal laws, also avoids referring to them as racist.
“I think racism is a heavy word. I think the law is unfair,” she said.
A spokesperson for the Department of Health says that a new bill aimed at facilitating access to specialist training positions for non-EU doctors is in its final stages of being signed into legislation.
Known as The Regulated Health Professions (Health and Social Care) (Amendment) Bill, (2019) this bill is due to amend previous legislation meaning that non-EU doctors won’t have to hold an Irish or European certificate of experience to be able to apply for a spot in the trainee specialist division.
The law aims to enforce and give “further effect” to an EU Directive which states that countries must not create an obstacle on the way of recognising “the professional qualifications acquired outside the territory of the European Union.”
“It is expected that this will take place in the near future,” the Department of Health says.
A spokesperson for the Irish Medical Council also said that they had lobbied for the introduction of the new bill with the Department of Health, for many years.
Salina, however, is not optimistic.
“It’s a big step, it’s a game-changer, it would make us eligible for training, but it’s still going to be difficult for non-European doctors because there is a preference that the position should be given to a European.”