Medical Tourism

Or, for the politically correct..

Cross Border Health Care

Karen L McClean MD FRCPC
University of Saskatchewan

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

Whats 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

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

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

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

So, whats 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

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

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

Issues

Clinical / Medical
Financial
Ethical
Legal

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 underinformed / 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?

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

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

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

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

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

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

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

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..

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

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?

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

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

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 Indias 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

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

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

Transplantation
Tourism

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 dont 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

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)

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

What is the role of the

Travel Health Provider?

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

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

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

Possible Outcomes
Quality, evidence based medical care

Appropriate indications
Well trained, experienced practitioners

Substandard care

Staff / hospital credentials

Unnecessary surgical procedures
Poor infection control procedures

Medically questionable procedures

Unproven efficacy for indication

Fraudulent care

Fake transplants / procedures

Fake credentials

Israel
2001 MOH regulation allowed reimbursement for
kidney transplants done abroad.

Increased competition between brokers

Local physicians with little knowledge of transplantation
medical advisors

Non-selective referral

Increased referral of older, less fit, highly sensitized

patients
Less selective choice of facilities

Downstream effects..

Israel
Complications

Patients required to return to Israel, presenting on arrival with

complications and no medical information

Reduced imperative to develop national donor programs

No increase in donor rates over 10 years

Poor access for non kidney transplants

2006 New MOH regulation to limit referrals abroad to
situations where absence of organ trafficking could be
guaranteed, increase donations locally

Israel
>150 Israelis obtain transplants abroad/yr

50% transplanted prior to dialysis

Alternate route to obtain organs low donor rates in Israel

Ministry of Health gains by saving expense of dialysis
Health insurance agencies gain by selling high priced
policies covering transplants abroad
Donors living related / paid unrelated donors from Israel
(travel with patient to transplant site) or paid donors at
destination

Transplant outcomes
Outcomes of United States Residents who Undergo
Kidney Transplantation Overseas: Canales et al,
Transplant Tourism

10 kidney transplant patients (Sept 02 July 06)

Transplanted in Pakistan (8), China (1), Iran (1)

Mean age: 36.8 years
Follow-up period: 0.4-3.7 years (mean 2.0)
6 serious post op (in 3 months) infections in 4 patients
1 death
1 graft failure due to acute rejection
Graft survival and function generally good
High incidence of post transplant infection
Inadequate communication of information immunosuppressive
regimens and perioperative information

Specific cases
One patient presented to emergency on arrival in US with
wound infection

Spent 2 months in hospital

Acinetobacter bacteremia
Aspergillus CNS infection
Died 4 months post transplant

Two patients diagnosed with urosepsis on arrival home

One patient had a seizure immediately prior to discharge in
Pakistan, treated and allowed to fly home, second seizure
on arrival

Cyclosporine toxicity

Israel - complications post

transplant

3 cases of aspergillosis
2 cases of mucormycosis
1 case of severe hepatitis C

Kidney Transplants - India

India dubbed warehouse for kidneys and the
great organ bazaar
150,000 Indians need transplants annually

Only 3,500 actually performed

Sale of organs illegal Criminal act for foreigners to go to India to obtain

transplants

Kidney Transplants - India

Kidneygate - Illegal transplant ring

400-500 transplants done over past 9 years

Located in residential home in wealthy suburb of Delhi
Donors
Voluntary, paid donations, impoverished people from slums
Migrant workers kidnapped / held at gunpoint / drugged

Recipients
Wealthy Indians, Americans, Europeans, Middle Easterners

Culprits
Ayurvedic doctor Amit Kumar no MD degree
Multiple physicians, nurses and hospitals involved

Kidney transplant - India

So with all the bad press .you would think it would be
difficult to access organ transplants in India, right?
Numerous websites offering surgery in India
Some note the possibility of bringing a potential donor
Small print What if you have not donor.

Kidney Sellers - Pakistan

239 kidney sellers

M:F ratio 3.5:1

90% illiterate
69% bonded labourers
93% sold kidney for debt repayment
19% repaying debts of parents, uncles, grandparents
5% coerced by landlords to repay debts

Kidney Sellers - Paksitan

Promised payment: $1146 - $2950 (mean $1737
+/- 262)
Actual payment: $819 - $1803 (mean $1377 +/196)
No sellers received promised amount
Deductions for hospital stay and travel
88% had no economic improvement
98% had worsened health status

Surgery

USA USD

India USD

BMTx

400,000

30,000

Liver Tx

500,000

40,000

CABG

50,000

5,000

Neuro-surgery

29,000

8,000

Knee surgery

16,000

4,500

Statistics

$60 billion / yr industry*

USA 2006: > million people travelled overseas for care
Thailand 2006: 36.4 million baht (USD: 1.15 million)
Israel 2006: $40 million, 15,000 health tourists
Singapore 2005: 374,000 health tourists
India: 2005: >150,000 medical tourists
Costa Rica 1993: (CMAJ)

14% tourists came for medical reasons

10% of hospital beds in 1 private hospital occupied by foreigners

*Crone, Academic Medicine, Vol 83, No 2, Feb 2008, 117-121

The Transplant Map

India, Pakistan
Turkey
Romania
Moldova
China
Philippines
Egypt

UAE / Oman
130 patients traveled to Mumbai for transplant
Poor donor-recipient matching

Suspected high level of immunosupression to

compensate for poor matching increased risk of
infectious complications and death
18.5% mortality (vs < 2% for other transplant pts)

8 deaths in the immediate post-operative period

16 deaths in the first 3 months post-operatively
24 patients died within 1 year of transplant,
1 patient died after the first year

56% of deaths due to infection

UAE / Oman
Blood and body fluid borne pathogens

3 new diagnoses of hepatitis B

4 new diagnoses of HIV - previously screened negative

Inappropriate transplant decisions

7 patients transplanted despite having been found ineligible for

transplant in home country
1 patient suspected to have AIDS and advised against transplant
but went to Mumbai and transplanted within 2 weeks, HIV
confirmed on return

Stem Cell Transplants - China

Parkinsons:

Human retinal epithelial cells from adults

No immunosuppression required
Cells injected stereotactically into putamen
Daily cocktail of drugs to fertilize the area
Stem cell activation and proliferation treatment (to enhance
the bodys own neural stem cells)

~20 patients treated

No published RCTs

Stem Cell Transplants - China

Stroke

self stem cell activation and proliferation

50 patients treated
Minor to significant improvements

Cerebral plasy, Degenerative neurologic disorders,

Epilepsy, Brain infections

Neural (fetal) stem cells

Bone marrow stem cells (autologous)
Recommended because the immune system is weak

Both types of cells delivered by lumbar puncture cells are said

to flow through the CSF into the brain

Thrombosis
DVT PE risk

Post operative period = increased risk for DVTs / PE

Decreased mobility
Hypercoagulability

High risk: orthopaedic / joint replacement surgery

Prolonged air travel
Economy class syndrome

Convergence of risks
Early post-op travel

Data?