Patients once traveled on foot from Afghanistan to see my father, a Cleveland Clinic-trained doctor who practiced in Peshawar, Pakistan. It is easy to attribute such health care to a developing country. But California’s economy outperforms whole nations, and patients in the Central Valley still drive for hours to get life-saving treatment. I have lived and studied in both of these “doctor deserts,” one arid and one fertile. Both are plagued by the same crisis: the exodus of the very people trained to heal them. Doctors are trained to save lives. But in Pakistan and California’s Central Valley, their absence speaks louder than their presence. The very systems that are meant to anchor physicians are designed in ways that push them elsewhere. And when medicine becomes unlivable for providers, it becomes unreachable for patients.
Every year, Pakistan trains thousands of new doctors. And every year, it loses them. In 2022, more than 2,500 physicians left the country to work abroad. Surveys show this is not a short-term blip. Nearly one in three medical students openly plan to build their careers overseas.
This “brain drain” has spiraled into a pipeline. Wealthy countries depend on Pakistan’s steady export of medical talent, while Pakistan itself is left with barely 1.1 doctors per 1,000 people, which is half the level the World Health Organization recommends.
Why do doctors leave? The reasons are as much about politics as pay: low salaries, limited residency opportunities, insecurity, and a daily grind that makes staying feel like professional suffocation. The cruelest irony is that the country spends years and public money to train doctors who then flee precisely because the system they trained in offers no future. Patients wait in overcrowded wards while their doctors treat strangers overseas.
The story in California’s San Joaquin Valley is less about international migration and more about internal abandonment. The region has the lowest supply of primary care physicians in the state, and nearly one-third of its current doctors are nearing retirement. Yet the problem is not that California does not train enough doctors. It is that they do not stay. UCSF Fresno, the Valley’s major medical training hub, graduates new physicians every year. But in 2024, fewer than half chose to remain in the Valley after residency. Family medicine saw only 42 percent retention. Internal medicine, 58 percent. By contrast, 72 percent of graduates stayed in California overall. Doctors for California, but not San Joaquin County. The message is clear: Even when doctors are trained in the Central Valley, the gravitational pull of California’s coast draws them away, with its higher pay, better working conditions, and greater prestige. What is left are federally designated “Health Professional Shortage Areas.”
At first glance, Pakistan’s exodus and California’s shortage look unrelated: one is global emigration, the other domestic redistribution. But the underlying logic is the same. Health workers move toward the places that value them most. The sicker and poorer the community, the weaker its grip on the people it needs to survive. This is structural neglect, not bad luck. Patients in Karachi and Fresno are not both waiting for doctors by coincidence. They are waiting because both their underfunded, undervalued, and understaffed health systems make those waits inevitable.
There are efforts to slow the bleed. In California, programs like the San Joaquin Valley PRIME track recruit students who grew up in the region, betting that local roots will keep them anchored. Early returns are promising: in 2024, entire graduating classes in psychiatry and pediatrics stayed in Fresno.
Pakistan’s path is steeper. Retention will require more than appeals to patriotism. It means reshaping the system itself: competitive pay, reliable postgraduate training, and political stability that makes medicine a viable future at home. Without that, the country will continue training doctors for someone else’s patients.
Physician shortages are about values. When doctors cannot envision sustainable futures in the places that need them most, the result is predictable: They leave. And when they leave, the communities left behind absorb the cost in longer waits, delayed diagnoses, and diseases that should have been caught earlier.
Doctors leave. Patients wait. And in the silence between the two, entire health systems unravel.
Samah Khan is a premedical student.
