If you have ever wondered why Pakistan earned a reputation of being the “global kidney bazaar”, or why a British resident might choose to travel to India for bypass surgery, or why Americans travel to India seeking surrogacy or an in vitro fertilization, Risks and Challenges in Medical Tourism will satisfy your curiosity. You would particularly find it of interest if you were an academic in the health care, tourism, trade, or economic development, a health care professional, policy maker, or a human resource specialist.
By drawing together contributions from researchers in different disciplines, Hodges et al., whose background is in global health care policy and epidemiology, seek to conceptualize and interpret recent developments concerning the multi-billion dollar industry of medical tourism in the global market. However, perhaps due to the lack of sufficient quantifiable data, this topic has unfortunately not been the subject of extensive analysis by academics. The authors fill in this gap by not only taking the reader through medical tourism prevalent in some of world's largest and significant regions, but also discuss some of the deeper social, political, legal, and ethical issues that arise from it.
Several issues ranging from the impacts that medical tourism has on the local economies, health systems, and health outcomes are discussed in several contexts and presented from different perspectives. It certainly helps the reader understand the different motivations of individuals to travel overseas to seek medical treatment. Specifically, by comparing and contrasting the types of medical tourists that different countries receive – ranging from the rich elites of developing countries to uninsured people from the developed world – it provokes the reader to reflect on what health care means to people of different incomes classes. Additionally, the incentives of health care providers and governments in foreign countries receiving medical tourists are also discussed in an articulate manner.
Hodges et al. put medical tourism in perspective by highlighting its costs to the society. It is indeed a lucrative initiative embraced by several countries to their economic advantage, but also has its shortcomings. Medical tourists mostly are those who cannot afford the expensive care in their own countries, and therefore travel to poorer countries to receive high-quality medical care delivered by private specialty hospitals. When compared to equivalent facilities in their home country, these hospitals perform procedures at relatively low prices. For instance, a knee replacement surgery that would cost a patient around $48,000 in the USA is priced at only one-fifth the cost in India ($8,500).
While medical tourism has arguably benefited the destination countries by encouraging the development of labs, clinics, and hospitals with access to the latest sophisticated technologies and procedures, not everyone in these countries has access to them (p. 176). Private hospitals are further incentivizing medical specialists with higher salaries that in turn contribute to an internal brain drain away from the public hospitals that are generally the lifeline of the poorer local masses. In addition, while supporters of international trade in organs defend the practice by highlighting the financial advantages the practice offers to the donors in developing countries, there is vast evidence of poor people being exploited to donate their organs. For instance, in Pakistan, the kidney vendors not only suffer psychological distress and social stigma but receive as little as $1,200 – much lesser than the promised amount.
The book also includes an extensive discussion of the risks and challenges to patients who engage in medical tourism. Specifically, the book describes specific risks involved in procedures such as organ or stem cell transplants, sex-selective abortion, surrogacy, or female genital cutting – that are illegal in some countries and precisely the reasons why some individuals choose to travel overseas receive them. India is one of the popular destinations for surrogacy in the world because it permits commercial surrogacy. Akansha Infertility Clinic in a village in India charges American medical tourists approximately $15,000 to $20,000 for assisted fertility and pays the surrogate mothers between $5,000 and $6,000, a price that is much higher than they would expect to make in several years from doing daily labor work.
In the absence of adequate regulations and effective oversight in the destination countries, Martin and Whittaker raise some thought-provoking concerns about the harmful consequences that such interventions can have on human health. Other risks pertaining to the quality of care are also highlighted. Through a normative prism, Cohen further explains why it might be in the right of a sending country to criminalize “circumvention tourism” under international law. For instance, in case of abortion, the state may view the unborn fetuses as their citizens and hence consider it their moral obligation to prevent any harm to them.
Medical tourists are also subject to the risks of combining long-distance travel and surgery, or complications that could arise after the surgery has been performed. Another global health risk of medical tourism market that the authors draw the readers’ attention to is that of infectious diseases being spread by travelers across country borders. It is particularly concerning when these travelers are medical tourists who are indeed at a higher risk of spreading infectious and multi-drug resistant agents in their home country. For example, many common medical destinations, including India and Thailand, are countries where infectious diseases such as TB and malaria are endemic. This not only puts the medical tourists at a very high risk of contracting and spreading the disease to the larger community, but on returning to their home countries, it also imposes a potential financial burden on the public health system that has to treat the infected individual or the community. Hodges and Kimball discuss this issue at length and provide solutions of how to mitigate these risks.
The book also discusses some of the legal ambiguities that surround the medical tourism market. Of particular concern is the fact that the cross-border transactions that are usually consummated in foreign jurisdictions are legally not under the purview of a traditional regulatory system. And in the event of medical errors or mishaps, the rights of the patients are often never defended in the court of law. Consequently, this may result in the medical doctors not being held accountable for their actions. While on the one hand, suing the doctors is not realistic in the home country due to procedural limitations, the legal systems in the host countries might be downright hostile to medical malpractice lawsuits. In addition to the arduous waiting times for legal settlements, it is also unlikely that the patients will be adequately compensated by the standards of their home country, not making the effort and time spent worth its while. As Cortex explores some of these concerns, he suggests accreditation and certification of hospitals or health providers by international agencies as one of the tools to regulate the industry.
While regulations may not be effective in protecting the rights of the medical tourists who have allegedly been treated unfairly by the overseas health system, the providers may have an incentive to improve quality due to the benefits that arise from getting their hospitals and clinics accredited. The advantages of being accredited by US-based agencies such as the Joint Commission International or National Committee for Quality Assurance are well recognized. Although they are known to be effective marketing or value improvement tools, they are expensive and hence not easily affordable by providers in less-developed parts of the world.
South East Asian countries, particularly Malaysia, the Philippines, Singapore have actively taken steps to promote medical tourism as a means to bolster their economies in the wake of the Asian economic crisis. Although India and Pakistan in the South Asian sub-continent, receive a significant number of medical tourists, these countries could draw some lessons from their neighbors. The government could help in the expansion of the health care markets in a more targeted and systematic manner. Owing to its growing number of private sector health care providers, and some of the finest specialty hospitals, medical tourism in these countries could be a tool to foster economic growth and generate foreign exchange. Medical tourism initiatives are also a means to invest in hospital infrastructure and generate employment opportunities. The governments in some countries promote it by eliminating tariffs on imported medical devices and providing financial benefits to hospitals and clinics serving international patients.
That said, one needs to keep in mind that corporatization of the health care market can have negative repercussions. People without any medical background run medical tourism agencies, with the sole purpose of making profits that consequently leads to poor quality of care and affect the health outcomes in a negative way. One should not lose sight of the moral dimensions of certain practices such as organ trade or stem cell transplants that are often reasons for medical travel. Properly enforced laws and regulations should therefore protect the domestic masses from any unfair and unethical practices at the expense of medical tourists. Additionally, governments may implement ways to distribute the benefits broadly to the local community. For instance, the Philippines Department of Health required all private hospitals to allocate 10 percent of their bed capacity for charity beds in order to get licensure.
While this book discusses several dimensions of medical tourism, it does not analyze any of the issues in a theoretical framework, specifically on how international trade can boost economic growth. Second, due to the haphazard way statistics on medical tourism are documented, the perspectives are not supplemented with any estimates of the volume, size, benefits, and costs associated with medical tourism. The authors, however, repeatedly point this limitation out throughout the book. Alternately, they provide a lot of anecdotal evidence, the vividness of which makes the narratives very persuasive.
