Medical tourism: globalization of the healthcare marketplace

The citizens of many countries have long traveled to the United States and to the developed countries of Europe to seek the expertise and advanced technology available in leading medical centers. In the recent past, a trend known as medical tourism has emerged wherein citizens of highly developed countries choose to bypass care offered in their own communities and travel to less developed areas of the world to receive a wide variety of medical services. Medical tourism is becoming increasingly popular, and it is projected that as many as 750,000 Americans will seek offshore medical care in 2007. This phenomenon is driven by marketplace forces and occurs outside of the view and control of the organized healthcare system. Medical tourism presents important concerns and challenges as well as potential opportunities. This trend will have increasing impact on the healthcare landscape in industrialized and developing countries around the world.     

Global sharing of COVID-19 vaccines: A duty of justice,not charity

Global scarcity of COVID-19 vaccines raises ethical questions about their fair allocation between nations. Section I introduces the question and proposes that wealthy nations have a duty of justice to share globally scarce COVID-19 vaccines. Section II distinguishes justice from charity and argues that beneficiaries of unjust structures incur duties of justice when they are systematically advantaged at others expense. Section III gives a case-based argument describing three upstream structural injustices that systematically advantaged wealthy countries and disadvantaged poorer countries, contributing to global disparities of COVID-19 vaccines. Section IV examines more closely the duties of justice owed, including a duty to relinquish holdings, restitute victims, and restore relationships. Section V concludes that wealthy nations have a duty of justice to share COVID-19 vaccines with poor nations and to restore relationships damaged by injustice. All nations should take steps to transform unjust structures.     

Comforting the (exile) afflicted in Croatia--around and beyond the analytical approaches of critical medical anthropology

Recently, there has been a growing recognition that any research conducted with those that suffer should definitely be critical of the continuing policy of group equalizing, either in relation to ones ethnicity or any other salient parameter. However, it is seldom that this critical knowledge is applied from "outsiders" when a negation and re-evaluation of history, especially concerning the medical systems and their historical development within nations and populations, is used. The propositions within this paper are given on the basis of knowledge gained in the course of a long-term study dedicated to the exiled in Croatia, and are tightly linked to theoretical perspectives of critical medical anthropology, yet exceed its limits. Critical medical anthropologists deeply engage in ongoing debates that stress how there needs to be more understanding of the necessity to study the wider social context of any population we approach and analyze. However, the knowledge about wider social contexts is unachievable without the new grounds of dialogue being created between professionals and researchers of all disciplines and equally--regardless whether they are "insiders" or "outsiders" to the problem in focus. The knowledge about developments in developing countries, and especially of countries in post-war transition cannot be solely built on strategies of globality and theoretical explorations disconnected from people and their experiences on ground, especially when they concern the delicate issues of social and health care. Hopingly, the given examples in this paper will add to dialogues of corrective kind that should be raised more often.     

HUMAN RIGHTS AND THE REQUIREMENT FOR INTERNATIONAL MEDICAL AID

Every year approximately 18 million people die prematurely from treatable medical conditions including infectious diseases and nutritional deficiencies. The deaths occur primarily amongst the poorest citizens of poor developing nations. Various groups and individuals have advanced plans for major international medical aid to avert many of these unnecessary deaths. For example, the World Health Organization's Commission on Macroeconomics and Health estimated that eight million premature deaths could be prevented annually by interventions costing roughly US$57 bn per year.
This essay advances an argument that human rights require high-income nations to provide such aid. The essay briefly examines John Rawls' obligations of justice and the reasons that their applicability to cases of international medical aid remains controversial. Regardless, the essay argues that purely humanitarian obligations bind the governments and citizens of high-income liberal democracies at a minimum to provide major medical aid to avert premature deaths in poor nations. In refusing to undertake such medical relief efforts, developed nations fail to adequately protect a fundamental human right to life.     

Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health?

Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or "illegal," basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants' exclusion intuitively "makes sense." As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice.     

The problematization of medical tourism: a critique of neoliberalism

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that have, to date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term 'medical tourism' and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces.     

Claiming respectable American motherhood: homebirth mothers, medical officials, and the state

Based on ethnographic research regarding public policy and grassroots organizing for midwifery in Virginia, this article explores how medical discourses around appropriate health care practices intersect with state discourses about what practices are considered "respectable" versus "pathological" for its citizens. In recent legislative debates about the legalization of direct-entry midwifery, medical officials have extended their criticism of midwifery and homebirth to mothers who resist state-sanctioned childbirth practices. This article examines how medical officials challenge the respectable mothering practices of homebirthers by linking them with women they deem pathological--child abusers, negligent mothers, and drug users--and placing them outside the cadre of "normal" American mothers who acknowledge the "logical" and "natural" superiority of biomedical childbirth practices. I also address homebirth mothers' responses, which assert that their political advocacy for midwives is a respectable mothering practice because they are responsible citizens who desire what they deem the best care for their children.     

'India Shopping': Indian Grocery Stores and Transnational Configurations of Belonging

The cost of health services within the USA has increased in recent years, limiting access for many Americans. In response, a growing number of Americans are traveling to medical border towns in Mexico to meet their needs. However, many US patients feel uncomfortable traveling to Mexico for healthcare because they are unsure how the system works and believe that Mexico is dangerous, unregulated, unsanitary, and premodern. To reconcile these beliefs with the need for quality medical care, Mexican medical providers appropriate aspects of the US medical system to encourage patronage and alleviate the concerns of patients. This paper examines how some Mexican dentists, pharmacists and physicians in the Mexican border town of Nuevo Progreso have broadened their appeal to American patients by (a) associating their procedures with US biomedical standards, (b) building facilities that shadow US counterparts, and (c) facilitating access to the Mexican medical system.     

US public support for vaccine donation to poorer countries in the 2009 H1N1 pandemic

Background

During the 2009 H1N1 pandemic, the global health community sought to make vaccine available “in developing nations in the same timeframe as developed nations.” However, richer nations placed advance orders with manufacturers, leaving poorer nations dependent on the quantity and timing of vaccine donations by manufacturers and rich nations. Knowledge of public support for timely donations could be important to policy makers during the next pandemic. We explored what the United States (US) public believes about vaccine donation by its country to poorer countries.

Methods and Findings

We surveyed 2079 US adults between January 22^nd and February 1^st 2010 about their beliefs regarding vaccine donation to poorer countries. Income (p = 0.014), objective priority status (p = 0.005), nativity, party affiliation, and political ideology (p<0.001) were significantly related to views on the amount of vaccine to be donated. Though party affiliation and political ideology were related to willingness to donate vaccine (p<0.001), there was bipartisan support for timely donations of 10% of the US vaccine supply so that those “at risk in poorer countries can get the vaccine at the same time” as those at risk in the US.

Conclusions

We suggest that the US and other developed nations would do well to bolster support with education and public discussion on this issue prior to an emerging pandemic when emotional reactions could potentially influence support for donation. We conclude that given our evidence for bipartisan support for timely donations, it may be necessary to design multiple arguments, from utilitarian to moral, to strengthen public and policy makers'' support for donations.     

Vaccination campaigns in postsocialist Ukraine: health care providers navigating uncertainty

Vaccination anxieties grew into a public health issue during the 2008 failed measles and rubella immunization campaign in Ukraine. Here I explore how health care providers bend official immunization policies as they navigate media scares about vaccines, parents' anxieties, public health officials' insistence on the need for vaccination, and their own sense of expertise and authority. New hierarchies are currently being renegotiated, and I follow health care providers as they attempt to parcel out their new position in the Ukrainian society and beyond. Public health control is reframed in a postsocialist context as a condition of acceptance into the European community as a sanitary democracy, and a contestation point between citizens and state. I untangle how relationships between citizens and states shape the construction of medical risk.     

Access to medical care for documented and undocumented Latinos in a southern California county.

To determine local access to medical care among Latinos, we conducted telephone interviews with residents of Orange County, California. The survey replicated on a local level the national access surveys sponsored by the Robert Wood Johnson Foundation. We compared access among Latino citizens of the United States (including permanent legal residents), undocumented Latinos, and Anglos, and analyzed predictors of access. Among the sample of 958 respondents were 137 Latino citizens, 54 undocumented Latinos, and 680 Anglos. Compared with Anglos, Latino citizens and undocumented immigrants had less access to medical care by all measures used in the survey. Although undocumented Latinos were less likely than Latino citizens to have health insurance, by most other measures their access did not differ significantly. By multivariate analysis, health insurance status and not ethnicity was the most important predictor of access. Because access to medical care is limited for both Latino citizens and undocumented immigrants, policy proposals to improve access for Latinos should consider current barriers faced by these groups and local differences in access to medical care.     

Maya mobile medicine in Guatemala: the "other" public health

Maya mobile medical providers in highland Guatemala and the goods and services that they offer from "soapboxes" on street corners, local markets, and on buses exemplify an important yet underinvestigated domain of localized health care, one that I refer to as the "other" public health. This medical and linguistic examination of traveling medical salespeople calls for a reconsideration (on a global scale) of what has come to be understood as "public health," arguing that "othered," local forms of public health that are often overlooked by anthropologists as "nontraditional" and delegitimized by bio-medicine as nonscientific merit serious consideration and investigation. This ethnography of marginalized forms of public health offers global insights into emerging heterodoxical forms of public health care that contest bio-medical authority and challenge our preexisting definitions of what counts as "access," wellness seeking, and even health care itself.     

News media reports of patient deaths following 'medical tourism' for cosmetic surgery and bariatric surgery

Contemporary scholarship examining clinical outcomes in medical travel for cosmetic surgery identifies cases in which patients traveled abroad for medical procedures and subsequently returned home with infections and other surgical complications. Though there are peer-reviewed articles identifying patient deaths in cases where patients traveled abroad for commercial kidney transplantation or stem cell injections, no scholarly publications document deaths of patients who traveled abroad for cosmetic surgery or bariatric surgery. Drawing upon news media reports extending from 1993 to 2011, this article identifies and describes twenty-six reported cases of deaths of individuals who traveled abroad for cosmetic surgery or bariatric surgery. Over half of the reported deaths occurred in two countries. Analysis of these news reports cannot be used to make causal claims about why the patients died. In addition, cases identified in news media accounts do not provide a basis for establishing the relative risk of traveling abroad for care instead of seeking elective cosmetic surgery at domestic health care facilities. Acknowledging these limitations, the case reports suggest the possibility that contemporary peer-reviewed scholarship is underreporting patient mortality in medical travel. The paper makes a strong case for promoting normative analyses and empirical studies of medical travel. In particular, the paper argues that empirically informed ethical analysis of 'medical tourism' will benefit from rigorous studies tracking global flows of medical travelers and the clinical outcomes they experience. The paper contains practical recommendations intended to promote debate concerning how to promote patient safety and quality of care in medical travel.     

Safety monitoring of disposable medical products

In 1988 medical devices have become a part of the German AMG. According to this law safety monitoring similar to the one with drugs should be introduced. In the United States the so called medical device report regulation is responsible for safety monitoring. They have demonstrated that the risks of these instrument cannot be neglected. Therefore medical organisations or technical supervising institutions in Germany should take care of safety monitoring with medical devices, because otherwise supranational organisations, which are already present in different countries, or European community authorities will become responsible after the introduction of the free European market in 1992.     

Defining standard of care in the developing world: the intersection of international research ethics and health systems analysis

In recent years there has been intense debate regarding the level of medical care provided to 'standard care' control groups in clinical trials in developing countries, particularly when the research sponsors come from wealthier countries. The debate revolves around the issue of how to define a standard of medical care in a country in which many people are not receiving the best methods of medical care available in other settings. In this paper, we argue that additional dimensions of the standard of care have been hitherto neglected, namely, the structure and efficiency of the national health system. The health system affects locally available medical care in two important ways: first, the system may be structured to provide different levels of care at different sites with referral mechanisms to direct patients to the appropriate level of care. Second, inefficiencies in this system may influence what care is available in a particular locale. As a result of these two factors locally available care cannot be equated with a national 'standard'. A reasonable approach is to define the national standard of care as the level of care that ought to be delivered under conditions of appropriate and efficient referral in a national system. This standard is the minimum level of care that ought to be provided to a control group. There may be additional moral arguments for higher levels of care in some circumstances. This health system analysis may be helpful to researchers and ethics committees in designing and reviewing research involving standard care control groups in developing country research.     

IMPROVING GLOBAL HEALTH: COUNTING REASONS WHY

This paper examines cumulative ethical and self-interested reasons why wealthy developed nations should be motivated to do more to improve health care in developing countries. Egalitarian and human rights reasons why wealthy nations should do more to improve global health are that doing so would (1) promote equality of opportunity, (2) improve the situation of the worst-off, (3) promote respect of the human right to have one's most basic needs met, and (4) reduce undeserved inequalities in well-being. Utilitarian reasons for improving global health are that this would (5) promote the greater good of humankind, and (6) achieve enormous benefits while requiring only small sacrifices. Libertarian reasons are that this would (7) amend historical injustices and (8) meet the obligation to amend injustices that developed world countries have contributed to. Self-interested reasons why wealthy nations should do more to improve global health are that doing so would (9) reduce the threat of infectious diseases to developed countries, (10) promote developed countries' economic interests, and (11) promote global security. All of these reasons count, and together they add up to make an overwhelmingly powerful case for change. Those opposed to wealthy government funding of developing world health improvement would most likely appeal, implicitly or explicitly, to the idea that coercive taxation for redistributive purposes would violate the right of an individual to keep his hard-earned income. The idea that this reason not to improve global health should outweigh the combination of rights and values embodied in the eleven reasons enumerated above, however, is implausibly extreme, morally repugnant and perhaps imprudent.     

Nutrition transition and dietary energy availability in Eastern Europe after the collapse of communism.

After the economic transition of the late 1980s and early 1990s there was a rapid increase in overweight and obesity in many countries of Eastern Europe. This article describes changing availability of dietary energy from major dietary components since the transition to free-market economic systems among Eastern European nations, using food balance data obtained at national level for the years 1990-92 and 2005 from the FAOSTAT-Nutrition database. Dietary energy available to the East European nations satellite to the former Soviet Union (henceforth, Eastern Europe) was greater than in the nations of the former Soviet Union. Among the latter, the Western nations of the former Soviet Union had greater dietary energy availability than the Eastern and Southern nations of the former Soviet Union. The higher energy availability in Eastern Europe relative to the nations of the former Soviet Union consists mostly of high-protein foods. There has been no significant change in overall dietary energy availability to any category of East European nation between 1990-1992 and 2005, indicating that, at the macro-level, increasing rates of obesity in Eastern European countries cannot be attributed to increased dietary energy availability. The most plausible macro-level explanations for the obesity patterns observed in East European nations are declines in physical activity, increased real income, and increased consumption of goods that contribute to physical activity decline: cars, televisions and computers.     

All Africa conference on tobacco control.

Although the health hazards of smoking are now generally accepted in most Western countries, the arguments have not had much impact on poorer nations. A conference on tobacco control held in Harare, Zimbabwe, in November last year was the largest to tackle this problem. The conference heard how threats of epidemics of tobacco related disease in the distant future held little weight with governments of countries that often already had massive public health problems. More immediate effects needed to be emphasised. Speakers gave three cogent arguments; firstly, the loss of capacity for foreign trade in essential goods, since most African countries are net importers of tobacco; secondly, the extensive deforestation which is occurring to fuel the flue curing of tobacco; thirdly, evidence from Papua New Guinea that raising taxation on tobacco provides governments with increased income for many years before a decrease begins.     

Ethical issues for vaccines and immunization

Vaccination is the only type of medical intervention that has eliminated a disease successfully. However, both in countries with high immunization rates and in countries that are too impoverished to protect their citizens, many dilemmas and controversies surround immunization. This article describes some of the ethical issues involved, and presents some challenges and concepts for the global community.     

Are Patents Impeding Medical Care and Innovation?

Background to the debate: Pharmaceutical and medical device manufacturers argue that the current patent system is crucial for stimulating research and development (R&D), leading to new products that improve medical care. The financial return on their investments that is afforded by patent protection, they claim, is an incentive toward innovation and reinvestment into further R&D. But this view has been challenged in recent years. Many commentators argue that patents are stifling biomedical research, for example by preventing researchers from accessing patented materials or methods they need for their studies. Patents have also been blamed for impeding medical care by raising prices of essential medicines, such as antiretroviral drugs, in poor countries. This debate examines whether and how patents are impeding health care and innovation.