Sohini Banerjee, Achutha Menon Centre for Health Sciences Studies
4 October 2010
The expanding universe of Medical Tourism
Medical tourism is emerging as an important socio-medical issue, especially in an era marked by increased globalisation. The field of medical tourism has expanded considerably in recent years and serious debates on medical economics and ethics have emerged as a result of it. Hence, the research by Crooks et al (What is known about the patients’ experience of medical tourism? A scoping review) is not only very timely but also focuses on a range of issues, important to public health, which has not been discussed earlier. The study provides a comprehensive view of patients’ experiences of medical tourism and sheds light on various dimensions of medical tourism, which adds to the knowledge on this important public health topic.
However, the study would have been enriched further and the reader would have found it more interesting if the following issues had been addressed:
1. Inclusion of patients’ experiences travelling from middle-and low-income countries for medical tourism to industrialised nations would have provided a broader perspective of medical tourism. Restricting reports of patients’ experiences travelling from industrialised nations to low-and middle-income countries not only narrows the scope of this article considerably and fails to capture the entire range of dynamics operating in the domain of medical tourism.
2. Alternative or Holistic medicine: Exclusion of patients travelling to healing spas which constitutes a major component of medical tourism also limits the scope of the study. Moreover, exclusion of travel to health spas probably unconsciously reflects the authors’ bias in favour of the biomedical management of illness. Alternative methods of treatment are gaining popularity in recent years and wide sections of the society seek relief from such modes of treatment.<sup 1,2> Many countries have formally adopted such methods within the health system (India for example: the AYUSH- Ayurveda, Unani, Siddha and Homeopath forms an integral part of India’s health system which is practiced and promoted in government health facilities alongside the western biomedical approach to medicine).<sup 3> China is another country where traditional medicine exists along with the western biomedical allopathic system.<sup 4>
3. Although reproductive tourism has been excluded form the study nevertheless it has become a burgeoning industry for which many childless couples travel abroad either for treatment or to seek prospective donors willing to be surrogate mothers. <sup 5>
4. The article clearly acknowledges that the patients’ perspectives reported are mainly anecdotal, and not based on empirical facts. There is very little evidence available in the literature of medical tourism on patients’ perspectives. The study in that sense provides some evidence thereby contributing to the knowledge on patients’ perspectives of medical tourism.
5. The authors have mentioned that 216 articles of the 348 reviewed were accepted, but do not provide reasons for rejecting the remaining 132 articles. Clarifications would be particularly helpful to the readers.
6. The authors mention “Quality” as a pull factor but the article also reports a patients’ view that such a quality of care was inconceivable in their home country. Hence quality acts both as a “push” as well as a “pull” factor and not as a “push” factor alone.
7. While the study does comment on the clinical impact of medical tourism (eg., deep vein thrombosis) it does not mention the recent controversy about superbugs (A new superbug thought to be resistant to nearly every known antibiotic poses a global threat) which have been linked to medical tourism as well. <sup 6> While, it may be true that patients’ may have not reported about it and hence not mentioned by the authors, nonetheless, they could have mentioned such omissions by patients.
References 1. Goldman MP: <bold Technology approaches to the medical spa: art plus science equal rejuvenation>. <i Dermatol Clin> 2008, <bold 26(3)>: 327- 340 2. Frost GJ: <bold The spa as a model of an optimal healing environment>. <iJ Altern Complement Med> 2004,<bold 10(Suppl1)>: S85-92. 3. Fritts et al: <bold Traditional Indian medicine and homeopathy for HIV/AIDS: a review of literature.> <i AIDS Res Ther> 2008, <bold 5:>25 4. Un C et al: <bold Chinese Medicine (CM) matters.> <i Chinese Medicine> 2008, <bold 3:>16 5. Inhorn MC & Shrivastav P: <bold Globalization and reproductive tourism in the United Arab Emirates.> <i Asia Pac J Public Health> 2010, <bold 22(3 Suppl)>: 68S-74S 6. <a href=‘Time bomb' superbug requires global response: doctor. Yahoo News Online 14 September 2010. (http://sg.news.yahoo.com/afp/20100914/tts-health-us disease-india-972e412.html)
Dr. Sohini Banerjee (MPH Scholar) Achutha Menon Centre for Health Sciences Studies, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala
Competing interests
The author wishes to declare that there are no competing interests either financial or non-financial.
Patients' experiences of medical tourism: A response to Sohini
Valorie Crooks, Simon Fraser University
13 October 2010
We, the authors, are thankful to Sohini Banerjee for providing very thoughtful comments on our scoping review. The inclusion of a forum for readers to post comments about published BMC articles is a wonderful way for authors to understand how others are interpreting their findings. Since this forum for comments exists, we wanted to take the opportunity to provide a brief response in relation to particular points raised by Sohini. Our responses are noted in italics.
Sohini states: Inclusion of patients’ experiences travelling from middle-and low-income countries for medical tourism to industrialised nations would have provided a broader perspective of medical tourism. Restricting reports of patients’ experiences travelling from industrialised nations to low-and middle-income countries not only narrows the scope of this article considerably and fails to capture the entire range of dynamics operating in the domain of medical tourism. Our response: We agree that having insights from patients traveling from middle- and low-income countries to other countries, including developed nations, for care is an important part of understanding the narrative of medical tourism. We did not restrict our review to certain patient flows. Instead, what our review showed is that these ‘south-north’ or ‘south-south’ narratives are rarely included in the existing medical tourism literature that is available through the search strategy we devised.
Sohini states: Alternative or Holistic medicine: Exclusion of patients travelling to healing spas which constitutes a major component of medical tourism also limits the scope of the study. Moreover, exclusion of travel to health spas probably unconsciously reflects the authors’ bias in favour of the biomedical management of illness. Alternative methods of treatment are gaining popularity in recent years and wide sections of the society seek relief from such modes of treatment. Many countries have formally adopted such methods within the health system (India for example: the AYUSH- Ayurveda, Unani, Siddha and Homeopath forms an integral part of India’s health system which is practiced and promoted in government health facilities alongside the western biomedical approach to medicine). China is another country where traditional medicine exists along with the western biomedical allopathic system. Our response: In our review we distinguish between medical tourism and health tourism. We frame the treatments being referred to here by Sohini as health tourism, and thus they fall outside of our focus on medical tourism. This does not reflect a bias toward the medical/biomedical management of illness, and instead reflects recognition of distinctions within the health/medical travel industry more broadly.
Sohini states: The authors have mentioned that 216 articles of the 348 reviewed were accepted, but do not provide reasons for rejecting the remaining 132 articles. Clarifications would be particularly helpful to the readers. Our response: Under the ‘selecting the literature’ subheading of the methods section we clearly state that articles were excluded or rejected because: “(1) there was no focus on medical intervention, which included articles that dealt with health tourism more broadly such as international travel to healing spas; (2) there was an exclusive focus on 'reproductive tourism' or 'transplant tourism', as the medical intervention (if any) in such cases is not restricted to the international patient and thus raises separate considerations; and (3) there was an overly general focus on international trade in health services or cross-border care, where there seemed to be no explicit reference to medical tourism.” At a subsequent stage of the scoping review a fourth justification for exclusion was added: “if no 'informational points' (i.e., discrete pieces of information found within sources that contributed to answering the scoping question) were extracted from the source it was excluded.”
Sohini states: The authors mention “Quality” as a pull factor but the article also reports a patients’ view that such a quality of care was inconceivable in their home country. Hence quality acts both as a “push” as well as a “pull” factor and not as a “push” factor alone. Our response: Several of the push and pull factors are interchangeable depending upon circumstances. Quality was most often discussed as a pull factor, but can indeed be a push factor at times.
Sohini states: While the study does comment on the clinical impact of medical tourism (eg., deep vein thrombosis) it does not mention the recent controversy about superbugs (A new superbug thought to be resistant to nearly every known antibiotic poses a global threat) which have been linked to medical tourism as well. While, it may be true that patients’ may have not reported about it and hence not mentioned by the authors, nonetheless, they could have mentioned such omissions by patients. Our response: The spread of NDM-1, which came to be reported globally in August, 2010, is most definitely a significant happening within the medical tourism industry. The publication timeline of our article did not allow for discussion of this very recent event. We agree with Sohini that the impact of ‘superbugs’ and other controversies need to be carefully considered in relation to patients’ experiences of medical tourism.
The expanding universe of medical tourism
4 October 2010
The expanding universe of Medical Tourism
Medical tourism is emerging as an important socio-medical issue, especially in an era marked by increased globalisation. The field of medical tourism has expanded considerably in recent years and serious debates on medical economics and ethics have emerged as a result of it. Hence, the research by Crooks et al (What is known about the patients’ experience of medical tourism? A scoping review) is not only very timely but also focuses on a range of issues, important to public health, which has not been discussed earlier. The study provides a comprehensive view of patients’ experiences of medical tourism and sheds light on various dimensions of medical tourism, which adds to the knowledge on this important public health topic.
However, the study would have been enriched further and the reader would have found it more interesting if the following issues had been addressed:
1. Inclusion of patients’ experiences travelling from middle-and low-income countries for medical tourism to industrialised nations would have provided a broader perspective of medical tourism. Restricting reports of patients’ experiences travelling from industrialised nations to low-and middle-income countries not only narrows the scope of this article considerably and fails to capture the entire range of dynamics operating in the domain of medical tourism.
2. Alternative or Holistic medicine: Exclusion of patients travelling to healing spas which constitutes a major component of medical tourism also limits the scope of the study. Moreover, exclusion of travel to health spas probably unconsciously reflects the authors’ bias in favour of the biomedical management of illness. Alternative methods of treatment are gaining popularity in recent years and wide sections of the society seek relief from such modes of treatment.<sup 1,2> Many countries have formally adopted such methods within the health system (India for example: the AYUSH- Ayurveda, Unani, Siddha and Homeopath forms an integral part of India’s health system which is practiced and promoted in government health facilities alongside the western biomedical approach to medicine).<sup 3> China is another country where traditional medicine exists along with the western biomedical allopathic system.<sup 4>
3. Although reproductive tourism has been excluded form the study nevertheless it has become a burgeoning industry for which many childless couples travel abroad either for treatment or to seek prospective donors willing to be surrogate mothers. <sup 5>
4. The article clearly acknowledges that the patients’ perspectives reported are mainly anecdotal, and not based on empirical facts. There is very little evidence available in the literature of medical tourism on patients’ perspectives. The study in that sense provides some evidence thereby contributing to the knowledge on patients’ perspectives of medical tourism.
5. The authors have mentioned that 216 articles of the 348 reviewed were accepted, but do not provide reasons for rejecting the remaining 132 articles. Clarifications would be particularly helpful to the readers.
6. The authors mention “Quality” as a pull factor but the article also reports a patients’ view that such a quality of care was inconceivable in their home country. Hence quality acts both as a “push” as well as a “pull” factor and not as a “push” factor alone.
7. While the study does comment on the clinical impact of medical tourism (eg., deep vein thrombosis) it does not mention the recent controversy about superbugs (A new superbug thought to be resistant to nearly every known antibiotic poses a global threat) which have been linked to medical tourism as well. <sup 6> While, it may be true that patients’ may have not reported about it and hence not mentioned by the authors, nonetheless, they could have mentioned such omissions by patients.
References
1. Goldman MP: <bold Technology approaches to the medical spa: art plus science equal rejuvenation>. <i Dermatol Clin> 2008, <bold 26(3)>: 327- 340
2. Frost GJ: <bold The spa as a model of an optimal healing environment>. <iJ Altern Complement Med> 2004,<bold 10(Suppl1)>: S85-92.
3. Fritts et al: <bold Traditional Indian medicine and homeopathy for HIV/AIDS: a review of literature.> <i AIDS Res Ther> 2008, <bold 5:>25
4. Un C et al: <bold Chinese Medicine (CM) matters.> <i Chinese Medicine> 2008, <bold 3:>16
5. Inhorn MC & Shrivastav P: <bold Globalization and reproductive tourism in the United Arab Emirates.> <i Asia Pac J Public Health> 2010, <bold 22(3 Suppl)>: 68S-74S
6. <a href=‘Time bomb' superbug requires global response: doctor. Yahoo News Online 14 September 2010. (http://sg.news.yahoo.com/afp/20100914/tts-health-us disease-india-972e412.html)
Dr. Sohini Banerjee (MPH Scholar)
Achutha Menon Centre for Health Sciences Studies,
Sree Chitra Tirunal Institute of Medical Sciences and Technology,
Trivandrum,
Kerala
Competing interests
The author wishes to declare that there are no competing interests either financial or non-financial.
Patients' experiences of medical tourism: A response to Sohini
13 October 2010
We, the authors, are thankful to Sohini Banerjee for providing very thoughtful comments on our scoping review. The inclusion of a forum for readers to post comments about published BMC articles is a wonderful way for authors to understand how others are interpreting their findings. Since this forum for comments exists, we wanted to take the opportunity to provide a brief response in relation to particular points raised by Sohini. Our responses are noted in italics.
Sohini states: Inclusion of patients’ experiences travelling from middle-and low-income countries for medical tourism to industrialised nations would have provided a broader perspective of medical tourism. Restricting reports of patients’ experiences travelling from industrialised nations to low-and middle-income countries not only narrows the scope of this article considerably and fails to capture the entire range of dynamics operating in the domain of medical tourism.
Our response: We agree that having insights from patients traveling from middle- and low-income countries to other countries, including developed nations, for care is an important part of understanding the narrative of medical tourism. We did not restrict our review to certain patient flows. Instead, what our review showed is that these ‘south-north’ or ‘south-south’ narratives are rarely included in the existing medical tourism literature that is available through the search strategy we devised.
Sohini states: Alternative or Holistic medicine: Exclusion of patients travelling to healing spas which constitutes a major component of medical tourism also limits the scope of the study. Moreover, exclusion of travel to health spas probably unconsciously reflects the authors’ bias in favour of the biomedical management of illness. Alternative methods of treatment are gaining popularity in recent years and wide sections of the society seek relief from such modes of treatment. Many countries have formally adopted such methods within the health system (India for example: the AYUSH- Ayurveda, Unani, Siddha and Homeopath forms an integral part of India’s health system which is practiced and promoted in government health facilities alongside the western biomedical approach to medicine). China is another country where traditional medicine exists along with the western biomedical allopathic system.
Our response: In our review we distinguish between medical tourism and health tourism. We frame the treatments being referred to here by Sohini as health tourism, and thus they fall outside of our focus on medical tourism. This does not reflect a bias toward the medical/biomedical management of illness, and instead reflects recognition of distinctions within the health/medical travel industry more broadly.
Sohini states: The authors have mentioned that 216 articles of the 348 reviewed were accepted, but do not provide reasons for rejecting the remaining 132 articles. Clarifications would be particularly helpful to the readers.
Our response: Under the ‘selecting the literature’ subheading of the methods section we clearly state that articles were excluded or rejected because: “(1) there was no focus on medical intervention, which included articles that dealt with health tourism more broadly such as international travel to healing spas; (2) there was an exclusive focus on 'reproductive tourism' or 'transplant tourism', as the medical intervention (if any) in such cases is not restricted to the international patient and thus raises separate considerations; and (3) there was an overly general focus on international trade in health services or cross-border care, where there seemed to be no explicit reference to medical tourism.” At a subsequent stage of the scoping review a fourth justification for exclusion was added: “if no 'informational points' (i.e., discrete pieces of information found within sources that contributed to answering the scoping question) were extracted from the source it was excluded.”
Sohini states: The authors mention “Quality” as a pull factor but the article also reports a patients’ view that such a quality of care was inconceivable in their home country. Hence quality acts both as a “push” as well as a “pull” factor and not as a “push” factor alone.
Our response: Several of the push and pull factors are interchangeable depending upon circumstances. Quality was most often discussed as a pull factor, but can indeed be a push factor at times.
Sohini states: While the study does comment on the clinical impact of medical tourism (eg., deep vein thrombosis) it does not mention the recent controversy about superbugs (A new superbug thought to be resistant to nearly every known antibiotic poses a global threat) which have been linked to medical tourism as well. While, it may be true that patients’ may have not reported about it and hence not mentioned by the authors, nonetheless, they could have mentioned such omissions by patients.
Our response: The spread of NDM-1, which came to be reported globally in August, 2010, is most definitely a significant happening within the medical tourism industry. The publication timeline of our article did not allow for discussion of this very recent event. We agree with Sohini that the impact of ‘superbugs’ and other controversies need to be carefully considered in relation to patients’ experiences of medical tourism.
Competing interests
None.