Chapter 9 Travel for Work & Other Reasons
Medical tourism is the term commonly used to describe international travel for the purpose of receiving medical care. Medical tourists may pursue medical care abroad for a variety of reasons, such as decreased cost, a recommendation from friends or family, the opportunity to combine medical care with a vacation destination, a preference for care from providers who share the traveler’s culture, or to receive a procedure or therapy not available in their country of residence. Medical tourism is a worldwide, multibillion-dollar market that continues to grow. Surveillance data indicate that millions of US residents travel internationally for medical care each year. Ongoing reports of infections and other adverse events following medical or dental procedures abroad serve as reminders that medical tourism is not without risks.
Common categories of procedures that US medical tourists pursue include dental care, noncosmetic surgery (such as orthopedic surgery), cosmetic surgery, fertility treatments, organ and tissue transplantation, and cancer treatment. Medical tourism destinations for US residents include Argentina, Brazil, Costa Rica, Cuba, India, Malaysia, Mexico, Singapore, and Thailand. When reviewing the risks associated with medical tourism, travelers should consider both the procedure and destination.
Overseas facilities may not maintain accreditation or provider licensure, track patient outcome data, or maintain formal medical record privacy or security policies. Medical tourists should also be aware that the drugs and medical products and devices used in foreign countries might not be subject to the same regulatory scrutiny and oversight as in the United States. In addition, some drugs may be counterfeit or otherwise ineffective (for example, expired, contaminated, or improperly stored).
Most medical tourists pay for their care at time of service and often rely on private companies or medical concierge services to identify foreign health care facilities. Some US health insurance companies and large employers have formed alliances with health care facilities outside the United States to control costs.
RISKS ASSOCIATED WITH MEDICAL TOURISM
All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. Possible infectious complications associated with medical procedures performed outside the United States include wound infections, bloodstream infections, donor-derived infections, and acquisition of bloodborne pathogens, including hepatitis B, hepatitis C, and HIV. The risk of acquiring antibiotic-resistant infections may be increased in certain countries or regions; some highly resistant pathogens (such as carbapenem-resistant Enterobacteriaceae) appear to be more common in some countries where US residents go for medical tourism (see Chapter 11, Antimicrobial Resistance).
Several outbreaks of infectious disease among medical tourists have been documented. Recent examples include surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic and Q fever in patients who received fetal sheep cell injections in Germany. Noninfectious complications among medical tourists are similar to those seen in patients who receive medical care in the United States and include surgical incision dehiscence, blood clots, or contour abnormalities after cosmetic surgery.
Medical or surgical complications may require follow-up care from a health care provider in the United States. Medical tourists should request a copy of their medical records and provide these to health care providers for any follow-up care.
Medical tourists should be aware of the additional risks associated with traveling while being treated for a medical condition or during recovery after surgery or other procedure. Air travel and surgery independently increase the risk of blood clots, including deep vein thrombosis and pulmonary emboli; travel and surgery together further increase the risks. Commercial aircraft cabin pressures are roughly equivalent to an outside air pressure at 6,000–8,000 ft. above sea level. Medical tourists should not fly for 10 days after chest or abdominal surgery to avoid risks associated with changes in atmospheric pressure.
Furthermore, the American Society of Plastic Surgeons advises people who have had cosmetic procedures of the face, eyelids, or nose, or who have had laser treatments, to wait 7–10 days before flying. The Aerospace Medical Association has published medical guidelines for airline travel that provide useful information on the risks of travel with certain medical conditions (www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf). Medical tourists are also advised to avoid typical vacation activities that can interfere with healing such as sunbathing, drinking alcohol, swimming, taking long tours, or engaging in strenuous activities or exercise after surgery.
PRETRAVEL ADVICE FOR MEDICAL TOURISTS
Medical tourists should consult a travel medicine specialist for advice tailored to their specific health needs, preferably 4–6 weeks before travel. Medical tourists should also communicate with their primary care provider to discuss their plan to seek medical care outside the United States and to discuss any concerns they or their provider might have. Any current medical conditions should be well controlled, and medical tourists should make sure they have enough medication for the duration of their trip. All medical tourists should be up-to-date on all routine vaccinations and consider immunization against hepatitis B virus before travel.
Advise medical tourists to seek prompt medical care, while still traveling or after returning home, if they suspect any complication. Encourage them to disclose information about travel history, medical history, and recent surgeries or medical treatments received during their trip. Seeking prompt medical care may lead to early diagnosis and treatment and a better outcome.
GUIDANCE FOR TRAVELERS PLANNING MEDICAL CARE ABROAD
Several professional organizations have developed guidance that includes template questions that medical tourists can use when discussing care abroad, with the facility providing the care, with the group facilitating the trip, and with their regular health care provider. Medical tourists should be aware of the guiding principles developed by the American Medical Association (Box 9-03). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism, with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to providers in the United States. This helps facilitate continuity of care and proper follow-up, if needed.
Local standards for facility accreditation and provider certification vary and may not be the same as US standards. ACS recommends that medical tourists use internationally accredited facilities and seek care from providers certified in their specialties through a process equivalent to that established by the member boards of the American Board of Medical Specialties. ACS, the American Society for Aesthetic Plastic Surgery, the American Society of Plastic Surgeons, and the International Society of Aesthetic Plastic Surgery all accredit overseas physicians. However, accreditation does not necessarily ensure a good outcome, and medical tourists should be encouraged to do as much advance research as possible on a health care provider and facility they are considering using.
Many medical tourism websites market directly to travelers. These sites may not include comprehensive details on the qualifications or certifications of a facility or provider. For travelers seeking dental care while abroad, the Organization for Safety, Asepsis and Prevention provides the “Traveler’s Guide to Safe Dental Care” (Box 9-04), which contains several questions to help travelers find a dental clinic and identify potential infection control concerns in a dental clinic. Additional resources exist to assist both providers and medical tourists (Box 9-05).
Box 9-03. Guiding principles on medical tourism
The American Medical Association advocates that employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States adhere to the following principles:
- Medical care outside the United States must be voluntary.
- Financial incentives to travel outside the United States for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients, or restrict treatment or referral options.
- Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (such as the Joint Commission International or the International Society for Quality in Health Care).
- Prior to travel, local follow-up care should be coordinated and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
- Coverage for travel outside the United States for medical care must include the costs of necessary follow-up care upon return to the United States.
- Patients should be informed of their rights and legal recourse before agreeing to travel outside the United States for medical care.
- Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
- The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
- Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.
From American Medical Association (AMA). New AMA Guidelines on Medical Tourism. Chicago: AMA; 2008. Available from: www.medretreat.com/templates/UserFiles/Documents/Whitepapers/AMAGuidelines.pdf
“Transplant tourism” refers to travel for the purpose of receiving an organ or stem cells purchased from an unrelated human donor for transplantation. This practice may be motivated by cost or in effort to reduce the waiting period. Xenotransplantation refers to travel to receive other biomaterial (cell, tissue) from nonhuman species. It is regulated differently among countries; no scientific evidence supports its therapeutic benefit, and adverse events have been reported, including the outbreak of Q fever described above.
In 2004, to protect vulnerable populations from becoming victims of transplant tourism, the World Health Assembly Resolution 57.18 encouraged member countries to “take measures to protect the poorest and vulnerable groups [the donors] from ‘transplant tourism’ and the sale of tissues and organs.” A meeting in 2008 in Istanbul addressed the issue of transplant tourism and organ trafficking, which resulted in a call for these activities to be prohibited. In view of those events, in 2009 the World Health Organization released the revised Guiding Principles on Human Cell, Tissue, and Organ Transplantation, emphasizing that cells, tissues, and organs should be donated freely without any form of financial incentive.
Several studies have identified potential medical issues associated with transplant tourism. Patients may receive fewer immunosuppressive drugs than is the current practice in the United States and might not receive antimicrobial prophylaxis. Immunocompromised travelers are more susceptible to infection, which can pose additional challenges while traveling.
Box 9-04. Patient checklist for obtaining safe dental care during international travel1
Before you leave:
- Visit your dentist for a checkup to reduce the chances you will have a dental emergency.
- Consider appropriate vaccinations.
When seeking treatment for a dental emergency during your trip:
- Consult hotel staff or the American Embassy or consulate for assistance in finding a dentist.
- If possible, consider recommendations from Americans living in the area or from other trusted sources.
For the items below, if the answers to any of the asterisked (*) items are “No,” you should have reservations about the office’s infection-control standards. If the answer to a two-star item (**) is “No,” consider making a gracious but swift exit.
When making the appointment, ask the following:
- Do you use new gloves for each patient?*
- Do you use an autoclave (steam sterilizer) or dry heat oven to sterilize your instruments between patients?**
- Do you sterilize your handpieces (drills)?* (If not, do you disinfect them?)**
- Do you use new needles for each patient?**2
- Is sterile (or boiled) water used for surgical procedures?** (In areas where drinking water is unsafe, the water also may cause illness if used for dental treatment.)
Upon arriving at the office, observe the following:
- Is the office clean and neat?
- Do staff wash their hands, with soap, between patients?**
- Do they wear gloves for all procedures?**
- Do they clean and disinfect or use disposable covers on surfaces touched during treatment?
Although it is important to be sensitive to cultural differences when making inquiries about the safety of dental care, remember that it is your health and well-being that are at stake.
1 Excerpt from Organization for Safety, Asepsis, and Prevention. Traveler’s guide to safe dental care. Annapolis, MD: Organization for Safety, Asepsis, and Prevention; 2001. Available from: www.osap.org/?page=TravelersGuide.
2 CDC recommends a new needle and new syringe for each injection. For further information, see https://www.cdc.gov/injectionsafety/1anonly.html
Box 9-05. Helpful resources on medical tourism
- Aerospace Medical Association’s Medical Guidelines for Airline Passengers (2002) provides useful information on the risks of travel with certain medical conditions: www.asma.org/asma/media/asma/Travel-Publications/paxguidelines.pdf
- American Academy of Orthopaedic Surgeons Bulletin, July 2007, discusses safety issues that patients should consider: www.aaos.org/news/bulletin/jul07/cover1.asp (requires paid access)
- American Academy of Orthopaedic Surgeons Bulletin, February 2008, discusses liability implications of medical tourism: www.aaos.org/news/aaosnow/feb08/managing7.asp (requires paid access)
- American College of Surgeons (ACS). Statement on medical and surgical tourism: www.facs.org/about-acs/statements/65-surgical-tourism
- American Society for Aesthetic Plastic Surgery (ASAPS). Guidelines for patients seeking cosmetic procedures abroad: www.surgery.org/consumers/consumer-resources/consumer-tips/guidelines-for-patients-seeking-cosmetic-procedures-abroad
- American Society of Plastic Surgeons (ASPS). Dangers of plastic surgery tourism: www.plasticsurgery.org/patient-safety/dangers-of-plastic-surgery-tourism
- ACS’s Find a Surgeon tool helps identify ACS members including fellows and associate fellows: www.facs.org/search/find-a-surgeon
- ASAPS’s Find a Plastic Surgeon tool helps identify ASAPS member surgeons in the United States and overseas: www.surgery.org/consumers/find-a-plastic-surgeon
- ASPS’s plastic surgeon match tool helps identify ASPS member surgeons in the United States and overseas: https://find.plasticsurgery.org
- International Society for Aesthetic Plastic Surgery’s Find-a-surgeon tool helps identify a surgeon: www.isaps.org/find-a-surgeon
- Joint Commission International list of its accredited facilities outside of the United States: www.jointcommissioninternational.org/JCI-Accredited-Organizations/
- Organization for Safety, Asepsis, and Prevention. Traveler’s guide to safe dental care: www.osap.org/?page=TravelersGuide
- World Health Organization. Guiding principles on human cell, tissue and organ transplantation: https://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf
- US Department of State: Your Health Abroad https://travel.state.gov/content/travel/en/international-travel/before-you-go/your-health-abroad.html
- Adabi K, Stern C, Weichman K, Garfein ES, Pothula A, Draper L, et al. Population health implications of medical tourism. Plast Reconstr Surg. 2017 Jul;140(1):66–74.
- Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant. 2008 May;8(5): 925–9.
- Chen LH, Wilson ME. The globalization of healthcare: implications of medical tourism for the infectious disease clinician. Clin Infect Dis. 2013 Dec;57(12): 1752–9.
- Gaines J, Poy J, Musser KA, Benowitz I, Leung V, Carothers B, et al. Notes from the field: rapidly growing nontuberculous mycobacteria associated with plastic surgery in the Dominican Republic, 2017. MMWR Morb Mortal Wkly Rep. 2018 Mar 30;67(12).
- Melendez MM, Alizadeh K. Complications from international surgery tourism. Aesthet Surg J. 2011 Aug;31(6):694–7.
- Merion RM, Barnes AD, Lin M, Ashby VB, McBride V, Ortiz-Rios E, et al. Transplants in foreign countries among patients removed from the US transplant waiting list. Am J Transplant. 2008 Apr;8(4 Pt 2):988–96.
- Organ Procurement and Transplantation Network, Scientific Registry of Transplant Recipients. United States organ transplantation annual data report, 2011. Rockville (MD): US Department of Health and Human Services; 2012 [cited 2016 Sep 22]. Available from: http://srtr.transplant.hrsa.gov/annual_reports/2011/default.aspx.
- Reed CM. Medical tourism. Med Clin North Am. 2008 Nov;92(6):1433–46, xi.
- Robyn MP, Newman AP, Amato M, Walawander M, Kothe C, Nerone JD, et al. Q fever outbreak among travelers to Germany who received live cell therapy—United States and Canada, 2014. MMWR Morb Mortal Wkly Rep. 2015 Oct;64(38):1071–3.
- Schnabel D, Esposito DH, Gaines J, Ridpath A, Barry MA, Feldman KA, et al. Multistate US outbreak of rapidly growing mycobacterial infections associated with medical tourism to the Dominican Republic, 2013–2014. Emerg Infect Dis. 2016 Aug;22(8):1340–7.