Medical Tourism

1. Medical Tourism Or, for the politically correct….. Cross Border Health Care Karen L McClean MD FRCPC University of Saskatchewan

2. Case …. • Elderly man, osteoarthritic knee not severe enough to warrant joint replacement, advised to maximize non surgical therapy • TKA done in India at a JCI accredited institution • Mycobacterium fortuitum joint infection 3 months post op • Required 4 surgical procedures • Debridement & salvage procedure, two stage revision, open Bx • Cost: > $140,000 vs patient costs for surgery in India - $8,600 • Cost of arthroplasty in Australia: ~ $15,000 • Frequency of infections post total knee arthroplasty: 1-2% • Frequency of infection post arthroplasty tourism: unknown • Denominator unknown • Numerator patients present to many different clinicians

3. What’s the evidence? • Data is limited • Largely anecdotal reports • Few case series or studies – mostly in transplant field • Data is subject to bias • Health care providers at destination are motivated to emphasize good outcomes to protect commercial interests • Health care providers at home are more likely to see / report poor outcomes than good ones • Follow-up is limited • Patients stays at providing institution are brief – f/u variable • Procedures are done in a variety of locations • Patients return home to many different locations • Ability to determine short and long term outcomes is limited

4. Definitions / Scope • Medical tourism – usual use • Travel to a foreign country (especially exotic locations) to obtain medical care • Medical tourism – less common uses • Physicians engaging in unapproved medical activities while travelling to remote locations for tourism (impromptu roadside clinics) • Medical students / physicians travelling for the purposes of elective experiences, volunteer medical work

5. Terminology • Alternate terms • Health tourism • Medical journeys • Global healthcare / Cross border healthcare • Medical value travel • More specific terms • Surgical tourism • Transplant tourism • Reproductive tourism • Dental tourism • Suicide / Euthanasia tourism

6. Medical Tourism: not a new phenomenon • Renowned centres / physicians have always attracted patients from afar • Healing shrines • Spas • Pilgrimages • Wealthy citizens of countries with limited health resources travelling to access care / expertise that cannot be obtained locally • Desperate patients with incurable conditions seeking miracle cures

7. So, what’s new? • Average citizens • Range of procedures available • Third world / emerging economies destinations • Development of an industry catering to medical tourists • Travel agencies and brokers • Journals • Conferences • Systematic government support of industry • Insurance company promotion of medical tourism

8. Why do countries promote medical tourism? • Money! • Boost tourism revenues • Generate foreign exchange • Increase gross domestic product • Improve medical services • Upgrade services / resources available to citizens • Stem ‘brain drain’ to other countries

9. Why do patients want medical tourism? • Lower cost • Timely alleviation of pain and disability • Access to innovative procedures • Exotic locations and travel ‘mystique’ • Privacy – particularly for some cosmetic procedures

10. Clinical / Medical Financial Ethical Legal Issues

11. Clinical Decision Making in Medical Tourism • How does the ‘commoditization of care’ affect clinical decision making? • Potential predisposition to recommend surgical / more complex procedures over conservative Rx • Potential risk of minimizing risks to avoid “losing a client” • Potential risk of focus on visible signs of quality / luxury over medical quality assurance • Are patients overly optimistic about potential benefits, and under-informed / inadequately aware of potential risks? • Once patients have paid a broker fee, are they pre-disposed to opt for surgery even if this is not the most appropriate care?

12. Other Clinical concerns • Are innovative techniques evidence based? • Are providers properly trained and accredited? • Are medical quality standards comparable to home? • Complication rates? – late complication rates usually unknown • Infection control / MDR pathogens • Exposure to exotic / opportunistic pathogens

13. Ethical issues • “Islands of excellence in a sea of medical neglect” • Infrastructure priorities may be focused on industry rather than local needs • Infrastructure costs may be passed on to local population in form of increased taxes or reduced services • Emphasis on high tech care at the expense of “appropriate technology” • Brain drain from public to private sector • Special issues pertaining to transplant tourism

14. Financial / Resource issues • Potential ‘plus’ for uninsured patients / procedures • Potential undesirable results • Cost of complications is carried by home country • Impact on local resources if outsourcing becomes a major source of care • Potential for decreased access to specialized services • Decreased training resources • Development of transplant programs stunted in countries where transplant tourism is a major method of obtaining transplantation • Coercive use of medical tourism by insurance companies • Potential shortage of nurses / physicians if foreign trained professionals remain in their country of origin

15. Legal Issues – Medical standards • Canadians ‘protected’ against substandard care by: • Professional licensing & credentialing • Institutional policies • Legal remedies • Care provided in other countries may not meet Canadian legal standards • Disclosure of risks, benefits, alternatives • Certification of professionals training, expertise • Access to legal remedies • Limitations of liability awards

16. Legal Issues – Liability • Brokers require clients to sign waivers absolving them of any liability for medical negligence, substandard care…. • Clients may be unable to bring a case against care providers in the Canadian courts • Recourse to legal remedy in country of care is variable & complex

17. Legal Issues - Transplantation • In some countries it is illegal to: • Sell / Buy organs for transplant • India / Pakistan • South Africa • Provide transplants to foreigners • China • To enter the country (as a foreigner) for the purpose of obtaining an organ donation

18. Justifications • Consumer choice • Global competition in health care • Supply and demand pressures on costs / prices • Increased GDP for countries • Bystander benefits • Decreased wait times when patients remove themselves from wait lists by going out of country • Economic and social spin off benefits to communities in host countries – employment, better quality health care

19. What actually happens? • Does medical tourism raise the quality of care and accessibility to care for the local population? • Does medical tourism widen the gap between rich and poor and decrease access to care for the local population? • Either is possible…..

20. Bumrumgrad Hospital - Bangkok • 554 beds, 2,600 staff • International patients from 150 countries • Foreign patients = 50% clientele • 2003 – 1 million patients overall • 2005 – 55,000 American patients • First hospital in Asia to receive JCI accreditation • Provides services in 26 languages • Expansion plans in other Asian and Middle Eastern countries

21. Thailand • Private health care in Bangkok has more • Gamma knife • Mamography services • CT scans …….. than all of England! • Does that translate into improved access for local Thais?

22. India • Medical tourism is a key industry • Government subsidies, fiscal Incentives and tax breaks • 2003: Finance minister called for India to become a “global health destination” • Promoted measures to improve infrastructure to support the industry • Ministry of tourism promotes 45 “centres of excellence”: cardiac surgery, minimally invasive surgery, oncology, orthopedics and joint replacement, and holistic care

23. The context of medical tourism in India • Great divide between facilities focusing on medical tourism and those providing health care to the average Indian • “The potential for health tourism to translate into benefits for the local population seems to be limited to increasing the wealth of the rich and has done little to improve health care for the average Indian.” • Bulletin of the World Health Organization. March 2007, 85 (3) 164-165

24. The context of medical tourism in India • WHO – 2003 data: health expenditure • Private expenditure – 75% of total • Public expenditure – 25% of total • Addressed health needs of the majority of India’s population • Health care facilities serving the Indian poor • <50% have a labour room or laboratory • <20% have a phone line • <33% adequately stocked with essential drugs • Shortages of physicians and other health care workers • Corruption and lack of funds

25. Medical Tourism in Canada • 15 medical tourism companies • 1 each in Manitoba and Alberta • 3 each in Ontario and Quebec • 7 in British Columbia • And other agencies providing medical tourism services in additional to traditional travel services • Clients are sent to a wide range of countries: • Argentina, Brazil, China, Costa Rica, Cuba, France, Germany, India, Malaysia, Mexico, Pakistan, Poland, Russia, Singapore, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, UAE, US

26. Medical Tourism • Brokers / Medical Tourism agencies • Middlemen • Find hospitals, physicians • Arrange transfer of information • Buy tickets / arrange flights • Reserve hotels • Arrange sightseeing • Do not verify credentials or licensing of facilities or physicians • Make money from hotel commissions and kickbacks • No licensing requirements for brokers and agencies • Early developments in USA for licensing

27. Transplantation Tourism

28. Tissue and Organ Transplantation • Cyclosporine and newer immunosuppressants opened the door to transplant tourism • WHO estimates that 10% transplants worldwide involve developed world recipients travelling to resource limited countries to purchase organs • Why? • Wait times due to organ shortages • Eligibility – patients declined for transplant in home country are often readily accepted for transplant in a for profit system • Non evidenced based transplants • Fetal tissue / cell transplants • Accessibility / cost

29. Ethical issues – transplant tourism • Source of transplanted organs • Potential for coerced organ ‘donation’ • Involuntary donations – executed prisoners, kidnappings • Transplant flow is overwhelmingly…. • South to north • Female to male • Black / brown to white • Poor to financially secure • Association with organized crime • India, Brazil and other areas

30. Recipient Risks • Commercial influences on medical decision making • Inappropriate transplantation • Poor donor – recipient matching - to reduce wait times • need for more intense immune suppression  risk OIs, toxicity • Exposure to drug resistant bacteria, opportunistic infections, blood borne pathogens • Lack of continuity of care • Pre-transplant work-up and decision making through long term care post transplant • Incomplete information provided post transplant • Substandard care / fraudulent transplant

31. Recipient Risks • Poor donor recipient matching  intense immune suppression exposes recipients to increased risks… • Increased risk of rejection • Increased risk of infection • Increased cancer risk • Increased risk of graft failure • Due to rejection, drug toxicity, infection

32. Renal Transplant – Favourable Outcomes • Morad et al 2000 • 515 Malaysian patients transplanted in China or India • >90% graft and patient survival • Sever et al 1997 • 540 Saudi patients transplanted in India • 96% graft survival • 89% patient survival • Similar results to those transplanted in Saudi Arabia

33. Renal Transplant - Inferior Outcomes • Kennedy et al 2005 • 16 Australian patients • 66% graft survival • 85% patient survival • Sever et al 2001 • Turkish patients • 84% graft survival • patient survival similar to locally transplanted patients

34. Canadian experience • Canadian data - 1998-2005 • 20 transplanted abroad - unrelated donors • 22 transplants • South Asia (12), East Asia (5), Middle East (4), SE Asia (1) ……..compared to…… • 175 living biologically related donors transplanted in Canada • 75 living emotionally related donors transplanted in Canada

35. Canadian experience - 2 • 33% - no records, 77% - incomplete records • 1/3 hospitalized on return, primarily for sepsis • Hospital stays of 4-113 days (mean 19 +/- 36) • Complications: • 27% systemic sepsis • 52% opportunistic infections • 23% CMV • 9% fungal infections • 14% tuberculosis • 5% cerebral and spinal abscesses • 25% wound infections • 38% pyelonephritis (incl. MDR E coli) • 10% each: allograph nephrectomy, wound dehiscence, lymphocele • 5% each: obstructive hydronephrosis, urine leak, metastatic cancer

36. Compared to Canadian Transplants…. • Inferior graft survival at 3 years • 98% biologically related donors • 86% emotionally related donors • 62% transplanted abroad • Patient survival at 3 years • 100% for those transplanted in Canada • 82% for transplant tourists

37. Donor Risks • Exploitation • Inadequate informed consent process • Donors treated as organ sources not patients • Safeguards ensuring free and fully informed consent are weakest in countries where most transplants occur • Brokers target poor, disadvantaged • Diminished health status post donation leads to further economic disadvantage that is sustained over the long term • Stigma • Kidney sellers in Iran suffered ‘extreme shame’ in their community

38. Kidney sellers - India • 305 kidney sellers in Chennai, India • 71% females, at least 2 coerced by husbands • 70% sold through a middleman, 30% sold direct to clinic • Almost all sold their kidneys to pay off debt • 47 - spouse had also sold a kidney • Economic outcomes • On average brokers and clinics promised ~1/3 more than they actually paid. • Average payment = $1070

39. Kidney sellers - India • Local conditions - significant improvements in economic status over the last 10 years • Poverty decreased by 50% since 1988 • Per capita income increased by 37% over 10 years • Most kidney sellers reported worsened economic status • Average family income declined from $660 at time of sale to $420 at time of survey • Percentage of participants below the poverty line increased from 54% to 71% • Of those who sold a kidney to pay off debts, 74% were still in debt • Increased time since selling a kidney associated with greater decline in economic status

40. Kidney sellers - India • Health consequences (5 point likert scale) • 13% no change in health status • 38% reported 1-2 point decline in health status • 48% reported a 3-4 point decline • 50% had persistent pain at nephrectomy site • 33% had persistent back pain • 79% would not recommend selling a kidney to others

41. Kidney sellers - India • Nephrectomy was associated with decline in both economic and health status • Economic decline persisted and worsened with increasing time since transplant • Health decline may have contributed to economic worsening through decreased fitness • Most sellers would not recommend it to others - ?was informed consent adequate

42. “Risk – free” donation? • “Transplant surgeons have disseminated an untested hypothesis of “risk-free” live donation in the absence of any published longitudinal studies of the effects of nephrectomy among the urban poor anywhere in the world. Live donors from shantytowns, inner cities, or prisons face extraordinary threats to their health and personal security through violence, injury, and infectious disease that can all too readily compromise the kidney of last resort.” Nancy Scheper-Hughes

43. Stem cell transplants - China • Tiantan Puhua Stem Cell Centre • Applies stem cell treatments to a wide range of neurologic disorders • Stroke, Parkinson's, cerebral palsy, hereditary degenerative conditions • Unique stem cell treatments • Self stem cell activation and proliferation program • Stem cell delivery by lumbar puncture or stereotactically • Use of autologous bone marrow stem cells (to boost the immune system) and fetal stem cells in combination • Claim a “high level of recovery”

44. Efficacy? • “We are not aware of any double blind, placebo controlled trials showing benefit and safety of stem cell transplants…” • Improvements often slight / transient • “come back for another treatment cycle” • Long term follow-up is very limited • “patients don’t have time to wait” • Treatments accompanied by intensive physiotherapy / occupational therapy / massage / accupuncture / Chinese traditional therapy to: • promote improved mobility and function • stimulate the new cells into becoming functional • helps the cells migrate into the correct area

45. Solid Organ Transplants – China • 1 million Chinese awaiting transplant • Paying foreigners given priority (transplants at military hospitals) • Organs derived from executed prisoners • # organs transplanted exceeds number of reported executions by 41,500 (2000-2005) • Organ procurement takes weeks (vs. 2.5 years in most countries) • Research by David Kilgour and David Matas (Canada) documents evidence that Falun Gong practitioners under detention are being used as organ sources • China has indicated that it will ban sale of organs from living donors and require consent from prisoners • ….many loopholes • Applies only to Ministry of Health Hospitals (not military hospitals)

46. Bottom line • Medical tourism is a reality… and a growth industry • Both risks and benefits exist • Difficult to determine the extent of risks • Quality of care is variable • Buyer beware • Many ethical issues • Travel clinic has a role in preparing medical tourists for travel

47. What is the role of the Travel Health Provider?

48. What is the role of travel clinic? • Provide usual general pre-travel advice • Vaccinations • Malaria prophylaxis • Pre-travel counselling • Make traveller aware of key issues in medical tourism • Effects of commoditization of care on medical decision making • Consider potential risks specific to medical tourism

49. Buyer Beware • Joint Commission International accredits hospitals (US standards) • List of accredited hospitals easily accessible on line • http://www.jointcommissioninternational.com • Trent International Accreditation Scheme • UK accreditation scheme • Beginning to accredit overseas institutions • Accreditation standards adjusted to reflect local standards and culture • Local staff conduct accreditations • No inspections • Healthcare Tourism International • www.healthcaretrip.org • New, non profit US group, accredits non clinical aspects of medical tourism

50. Providing Advice • Consider the potential for legal complications • Be aware of legal restrictions • May require special visa if travel is specifically for medical care • Consider the “what ifs” • Will there be recourse to compensation if problems occur? • What if there are complications? Who pays for extended hospital stays? Additional surgery? • Specific medical tourism health risks • Avoid sunburn – increased scar pigmentation • Infection – multidrug resistant or unusual pathogens • Thromboembolic disease • Complications of early air travel post op - patients are typically sent home 10-14 days post op • Anecdotal reports of patients being sent home within 2-3 days of surgery, with active complications