Christie M. Reed

Introduction

Travel for the purpose of obtaining health care abroad has received a great deal of attention in the popular media recently—even Wikipedia has recently devoted a section to the practice (http://en.wikipedia.org/wiki/Medical_tourism). However, it is not the only form of "medical tourism." The term has also been applied to travel by health-care professionals for the purpose of providing health care. The extent of either form of travel is not well characterized, but the overarching issues for both types of travelers, their primary health-care providers, and travel medicine providers are outlined below.

Travel to Obtain Care

Data from the annual U.S. Department of Commerce in-flight survey during 2003–2006 show an overall annual increase in the number of trips taken by U.S. residents for which at least one purpose was health care. In 2006, there were approximately half a million overseas trips in which health treatment was at least one purpose of travel. Common cited procedures include:

• Dentistry
• Reproductive procedures
• Surgeries (cosmetic, joint replacement, and cardiac)

Lower cost is often mentioned as the motivation for this type of medical tourism, and an entire industry has grown up around this phenomenon. One can search for a provider and research accreditation status of the facility online, opt for an online concierge service that will make all the arrangements or, more recently, find that health insurance coverage may include the option of “outsourced” health care.

The dynamic nature of the field was described in a recent roundtable discussion in Merrell et al.,

However, the quality of facilities, assistance services, and care is neither uniform nor regulated; thus, in most instances, responsibility for assessing suitability of an individual program or facility lies solely with the traveler.

Guidelines for Travelers Seeking Care Abroad

Potential patients should consider that, whatever procedure is being contemplated, travelers undergoing medical treatment outside their accustomed environment are almost always at a disadvantage, particularly if there are complications. Concerns are—

• Resolution of financial issues if costs escalate, such as in the case of complications.
• Language and cultural differences may impede accurate interpretation of both verbal and nonverbal communication.
• Religious and ethical differences may be encountered over issues such as heroic efforts to preserve life or limb or in care of the terminally ill.
• Lack of familiarity with the local medical system, limited access to past medical history, unfamiliar drugs and medicines.
• Legal recourse may be fairly limited, difficult to obtain, or nonexistent.
• Follow-up care back in the United States may be more difficult to arrange and may be fraught with problems, should there be complications.

Potential patients should consider the guiding principles developed by the American Medical Association for employers, insurance companies, and other entities that facilitate or offer incentives for care outside the United States, although in some circumstances it is unclear how realistic they may be (see www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf) (PDF). These principles stipulate that international care must be voluntary and provided by accredited institutions; financial incentives should not inappropriately limit or restrict patient options; there should be continuity of care, including coverage of costs upon return; patients should be informed of their rights and legal recourse before travel; patients should have access to licensing, outcome, and accrediting information when seeking care; medical record transfers should comply with Health Insurance Portability and Accountability Act (HIPAA) guidelines; and patients should be informed of potential risks of combining surgical procedures with long flights and vacation activities. The American Society for Plastic Surgery emphasizes plastic surgery is “real” surgery and outlines the issues every patient undergoing surgery should consider, whether at home or abroad, on their website at www.plasticsurgery.org/patients_consumers/patient_safety/Medical-Tourism.cfm. Several clusters of mycobacterial wound infections in travelers returning from cosmetic procedures abroad have been published. Similarly, the American Dental Association provides informational documents, including: “Traveler’s Guide to Safe Dental Care” through the Global Dental Safety Organization for Safety and Asepsis Procedures at www.osap.org and “Dental Care Away from Home” at www.ada.org/public/manage/care/index.asp.

Individuals researching accreditation status should note that, although facilities may be part of a chain, they are surveyed and accredited individually. They should also check the duration of the accreditation and validate that the information is current by consulting the public portion of the appropriate accrediting agency website (see references below).

Pre-Travel Advice for the Medical Tourist

As discussed in the Planning for Healthy Travel section in Chapter 1, patients who do elect to travel should consult a travel health-care practitioner for advice tailored to individual health needs, preferably at least 4–6 weeks in advance of travel. This is particularly true for patients considering invasive procedures, who should consult as soon as travel is considered to allow for assessment of hepatitis B vaccination status (see the Hepatitis B section earlier in this chapter). Hepatitis B and C viruses and HIV are examples of blood-borne infections that can be transmitted via contaminated equipment, from infected health-care providers during invasive procedures, via transfusion of blood or blood products, or through transplantation of tissue or organs that have not been properly screened. Prevalence rates of these viruses vary considerably around the world and are generally higher in developing parts of the world than in the United States. U.S. policies address hepatitis B vaccination status of health-care workers, but these policies are not uniform worldwide and there are no currently licensed vaccines for hepatitis C and HIV. Blood transfusion programs in the United States and other developed areas rely on voluntary, nonremunerated donors; screen the donated blood for a variety of potentially blood-borne pathogens; and are closely regulated. Standards in other parts of the world vary. Based on data from 2000–2001, the latest available on the WHO Global Database on Blood Safety (www.who.int/bloodsafety/global_database/en/), 70 countries did not test all donated blood for the three major blood-borne viruses, HIV and hepatitis B and C.

Organ Transplantation

Organ transplantation in the United States is also a voluntary, closely monitored process coordinated by the United Network for Organ Sharing (www.optn.org). The need for transplantable organs, however, far exceeds the available supply worldwide. Travel to a country with less rigorous methods of distribution for the purpose of obtaining a transplant has been termed “transplant tourism” or “organ trafficking.” Recently, there have been reports in the media of investigations and arrests associated with “rings” that use unscrupulous methods to obtain organs. In 2004, the World Health Assembly Resolution 57.18 encouraged member countries to protect vulnerable populations. Some countries have begun experimenting with controlled programs to relieve the shortage, support the health of the donor, and remove incentives for clandestine operations. A revised set of eleven WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation will be presented to the World Health Assembly in 2009 (www.who.int/transplantation/).

Travel for the Purpose of Delivering Health Care

There are many structured opportunities for health-care professionals, students, or trainees to participate in established programs in developing areas of the world that are mutually beneficial to both the local population and the traveler. Travel by health-care workers in their professional capacity should be governed by the principle of Primum non nocere, or “first, do no harm.” The traveling health-care worker should have sufficient experience or be at a stage in training to be able to contribute labor, knowledge, and skills to the host community. Benefits to the traveling health-care worker include exposure to patients with tropical diseases and conditions that are not commonly seen or are at a more advanced stage than in the country of residence; local diagnostic skills which are often less dependent on technology; and new cultures and new ways of thinking, in addition to any personal gratification. Many medical schools and universities have established reciprocal relationships with institutions in developing areas in which there is an exchange of students and faculty. A variety of organizations match volunteers with local needs for skills-building or to address specific problems. Doctors Without Borders/Médecins Sans Frontières (MSF), which received the Nobel Peace Prize in 1999 for humanitarian efforts around the world, requires a minimum 6-month commitment from physicians and a shorter commitment for surgeons. Interventional programs such as dentistry or surgery simultaneously provide reparative or reconstructive services to the population and train local staff to perform the procedures and provide follow-up care, often donating excess supplies. Other ongoing volunteer relationships exist between faith-based or service organizations and local communities. The involvement of the local health establishment is key to determining needs and maximizing benefit to the local population, as well as educating the visitors on local customs and medical issues and providing translation, if needed, to adequately assess the patients, obtain consent, and advise on postprocedure care.

These forms of international capacity-building should be differentiated from—

• medicine that is practiced on local populations ad hoc by independent travelers to areas that seem to have no system of health care,
• the development of adventure holidays sold to groups of doctors specifically for the purposes of research or providing health care in the absence of prior consultation, and
• students or trainees who travel to “gain practical experience” beyond their training with minimal supervision or absence of structured learning, or practitioners performing outside the area of their expertise.

The acts performed in a life-threatening emergency are justified, but if a local health-care system exists there should still be follow-up with the nearest local provider. Health-care professionals contemplating an international clinical experience should also consult the Humanitarian Aid Workers section in Chapter 8 for a discussion of emotional and physical fitness to participate, preparation, and after-care issues.

The Primary Health-Care Provider

Primary health-care providers play a crucial role in several aspects of medical tourism. For un- or under-insured patients who cannot afford their prescribed course of treatment, the primary care provider may be asked to provide counsel regarding international treatment options, assist with vetting available options, optimize patient status prior to travel, or coordinate care on return. Each provider will need to assess individually his or her ability to address travel health issues or refer to a travel medicine provider.

Clinicians who care for immigrant populations should also be aware that the majority of health-seeking travelers in 2004 were current U.S. citizens born outside the United States, followed by non-U.S. citizens. Health-care needs, such as dentistry, are often included in visits home, due to familiarity with care in the country of origin, the high cost of health care in the United States, and lack of insurance coverage in these populations. There are also recent reports that patients on transplant waiting lists may also travel abroad for the procedure and return to the developed country of residence for continued care, often requiring immediate hospitalization and intense initial management with little documentation. Options for dialysis care are also increasing in developing areas; thus patients requiring this level of care may return home for visits and obtain local care. Acute hepatitis B infections have been diagnosed in patients returning to developed countries from both scenarios. Clinicians providing care to immigrant populations should consider routinely inquiring about future or recent travel home to visit friends and relatives, whether health care will be sought or occurred during travel and advise accordingly (see the VFR section in Chapter 8).

Travel Medicine Providers

Patients who plan to seek medical care abroad may not divulge this activity during the consultation. The desire for anonymity may be a reason for seeking procedures, such as cosmetic surgery or sex-change operations, abroad. As previously mentioned, cost is often an issue, and patients may be uncomfortable self-disclosing. Clinicians may find that routine discussion of hepatitis B vaccination with all patients in the context of risk due to tattoo, sex, emergency medical care, and invasive procedures offers an environment for patients to initiate further discussion.

Health-care providers may also find that the medical industry and associated resources that are rapidly expanding in the developing world related to medical tourism intersect directly with the medical care options for patients with pre-existing illness who travel, emergency care for travelers, and health-care options for expatriates (see the Obtaining Health Care Abroad for the Ill Traveler section later in this chapter).

Additional Resources for Medical Tourism and Accreditation

• Joint Commission International (jointcommissioninternational.org/)
• Trent International Accreditation Scheme (trentaccreditationscheme.org/)
• Australian Council for Healthcare Standards International (www.achs.org.au/ACHSI/)
• Canadian Council on Health Services (www.cchsa.ca/)
• International Society of Plastic Surgery also certifies international surgeons who meet U.S. standards (www.isaps.org)

References

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2. U.S. Department of Commerce. Office of Travel and Tourism Industries survey of international air travelers US to overseas and Mexico by birth and citizenship. 2004 report, 2004 January–December. 2005.
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