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Social Science & Medicine 72 (2011) 1846e1852

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Social Science & Medicine

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Medical returns: Seeking health care in Mexico

Sarah Horton*, Stephanie ColeUniversity of Colorado, Denver College of Liberal Arts & Sciences, Department of Anthropology, Campus Box 103, P.O. Box 173364, Denver, CO 80217-3364, United States

a r t i c l e i n f o

Article history:Available online 13 April 2011

Keywords:USeMexico borderUS LatinosImmigrantsMedical tourismTransnationalismUninsuredCulture of medicineHealth care deliveryMexicoUSA

* Corresponding author. Tel.: þ1 303 556 3554; faxE-mail address: Sarah.Horton@ucdenver.edu (S. H

0277-9536/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.socscimed.2011.03.035

a b s t r a c t

Despite the growing prevalence of transnational medical travel among immigrant groups in industri-alized nations, relatively little scholarship has explored the diverse reasons immigrants return home forcare. To date, most research suggests that cost, lack of insurance and convenience propel US Latinos toseek health care along the Mexican border. Yet medical returns are common even among Latinos who dohave health insurance and even among those not residing close to the border. This suggests that thedistinct culture of medicine as practiced in the border clinics Latinos visit may be as important a factor ininfluencing medical returns as convenience and cost.

Drawing upon qualitative interviews, this article presents an emic account of Latinos’ perceptions ofthe features of medical practice in Mexico that make medical returns attractive. Between November 15,2009 and January 15, 2010, we conducted qualitative interviews with 15 Mexican immigrants and nineMexican Americans who sought care at Border Hospital, a private clinic in Tijuana. Sixteen were unin-sured and eight had insurance. Yet of the 16 uninsured, six had purposefully dropped their insurance tomake this clinic their permanent “medical home.” Moreover, those who substituted receiving care atBorder Hospital for their US health insurance plan did so not only because of cost, but also because ofwhat they perceived as the distinctive style of medical practice at Border Hospital. Intervieweesmentioned the rapidity of services, personal attention, effective medications, and emphasis on clinicaldiscretion as features distinguishing “Mexican medical practice,” opposing these features to the frequentreferrals and tests, impersonal doctorepatient relationships, uniform treatment protocols and relianceon surgeries they experienced in the US health care system. While interviewees portrayed these featuresas characterizing a uniform “Mexican medical culture,”we suggest that they are best described as uniqueto the private clinics and hospitals returning migrants visit. In short, we suggest that the perceivedcontrast in cultures of medicine derives from the difference in organization of health care services oneach side of the border.

� 2011 Elsevier Ltd. All rights reserved.

Introduction observed among both low-income and relatively wealthy immi-

The literature on transnationalism suggests that the socialdistance between immigrants in sending and receiving communi-ties has shortened due to transformations in transportation andcommunication technologies (Basch, Glick-Schiller, & Szanton-Blanc, 1994; Smith & Guarnizo, 1998), and a growing number ofstudies suggest that this is true in the domain of health care as well(see Collins-Dogrul, 2006). Although much of the scholarly litera-ture on the globalization of health care has focused on medicaltourism among wealthy residents of the global North, immigrantsalso engage in “medical returns”–that is, make trips to theirhomelands for the express purpose of receiving medical services.As immigrant communities have mushroomed in industrializednations across the globe, “medical returns” have been increasingly

: þ1 303 556 8501.orton).

All rights reserved.

grant groups in countries as diverse as the US, Great Britain andNew Zealand (Bastida, Brown, & Pagán, 2008; Bergmark, Barr, &Garcia, 2008; Fong, 2008; YeonJae Lee et al., 2010). Yet despitethe prevalence of this phenomenon, and the diversity of theimmigrant groups involved, few studies explore the specificreasons why immigrants often take considerable pains to seek carein their homelands (see YeonJae Lee et al., 2010 as an exception).

Medical returns are awell-documented phenomenon among USLatinosdand among first-generation Mexican immigrants inparticular (Bergmark et al., 2008; Landeck & Garza, 2002; Wallace,Mendez-Luck, & Castaneda, 2009). A 2009 study found that halfa million of California’s Mexican immigrant adults were estimatedto have sought care in Mexico in 2001 (Wallace et al., 2009, p. 665).Visits to Mexico for health care are particularly common amongborder residents; one study found that 41 percent of Latinohouseholds in Laredo, Texas had used physicians in Mexico(Landeck & Garza, 2002). The existing literature on Mexican

S. Horton, S. Cole / Social Science & Medicine 72 (2011) 1846e1852 1847

immigrants’ medical returns highlights the importance of conve-nience, cost, and lack of insurance in causing them to seek healthcare in Mexico (Bastida et al., 2008; Bergmark et al., 2008; Warner,1991). Brown (2008) suggests that Mexican immigrants may in factforego insurance in the US because of their ability to seek care inMexico, partly explaining the higher rates of the uninsured in statesadjacent to the border. Yet medical returns may be common evenamong Latinos not residing close to the border (Bergmark et al.,2008; Wallace et al., 2009) and even among Latinos who do havehealth insurance in the US (Seid, Castañeda, Mize, Zivkovic, & Varni,2003; Warner, 1991). This suggests that the distinct culture ofmedicine as practiced in the particular border clinics that Latinosvisit may be as important a factor in influencing medical returns asconvenience and cost.

By drawing upon the narratives of Mexican immigrants engagedin cross-border health care seeking, this paper constructs an emicaccount of their perceptions of the unique features of medicalpractice in Mexican border clinics. Our paper is methodologicallyunique. Although most studies of cross-border health care seekingrely upon survey data (Bastida et al., 2008; Guendelman, 1991;Guendelman & Jasis, 1992; Landeck & Garza, 2002; Macias &Morales, 2001; Potter, Moore, & Byrd, 2003; Wallace et al., 2009),no studies involve in-depth qualitative interviews with Latinosengaged in the process of seeking care in Mexico. The existingqualitative study on the subject focuses primarily on Mexicanimmigrants who engage in opportunistic visits to doctors duringreturns to their hometowns, rather than on immigrants whoexpressly return to Mexico for the purpose of seeking care(Bergmark et al., 2008, p. 9216). No previous studies involve field-work and interviews conducted in a Mexican border clinic thatcaters specifically to a US Latino population.

Through interviews with 24 Latinos who sought care at BorderHospital (a pseudonym), we suggest that the contrast between theculture of medicine as practiced in private border clinics and thatwhich characterized the clinics Latinos frequented in the US is anequally important factor as convenience, cost, and insurance ininfluencing medical returns. Interviewees described the culture ofmedicine at Border Hospital as being distinguished by rapidity ofservices, personal attention, effective medications, and emphasison clinical discretion, opposing these features to the frequentreferrals and tests, impersonal doctorepatient relationships,uniform treatment protocols and reliance on surgeries they saidthey experienced in the US health care system. Yet while inter-viewees portrayed these features as characterizing a generic“Mexicanmedical culture,”we show that they are best attributed tothe private clinics and hospitals returning migrants visit. In short,we show that the perceived contrasts between distinct “cultures ofmedicine” are in fact rooted in differences in the organization ofhealth care services on either side of the border.

The literature on global medical travel: the missingimmigrant experience

Much scholarly literature has examined the way that advancesin technology and the development of the medical sectors ofdeveloping countries have encouraged the growth of medicaltourism (Bookman & Bookman, 2007; Chee, 2008; Herrick, 2007;Lautier, 2008; Sobo, 2009). This literature points to the soaring costof health care in industrialized nations, combined with their healthinsurance crises, as “push” factors driving residents to seek care inthe global South. Yet the focus on medical tourism often highlightsthe experiences of one very particular group of medical trav-elersdthose relatively privileged residents of the global Northwhose decision to seek health care on the global marketplace is theresult of rational economic calculation (see Kangas, 2007,2010, for

a contrasting discussion of medical travel among residents ofYemen, a low-income country).

Combined with global migration, the same forces that have bredmedical tourism have yielded a related but different phenomen-ondthat of medical travel among transnational immigrants. Immi-grantsmay return to their homelands permanently when injuries ormajor illnesses beset them in advanced industrial societies andinterferewith their permanent emigration (Fong, 2008). Othersmaymake temporary visits back home due to their preference for theparticular organization of health care or the unique doctorepatientrelationship (Yeon Jae Lee et al., 2010). In each particular case, therelationship between immigrants and the domestic health caresystems to which they return differs, as do the motivations thatencourage travelers to seek health care back home. Yet there is littleresearch documenting the growing phenomenon of immigrants’medical returns, and the different reasons immigrants seek care intheir homelands.

Most studies of Latino immigrants’ medical returns place suchbehaviors within the context of the US health insurance crisis. Theynote that Latinos are more likely than non-Latino whites to beuninsured and Mexican immigrants are the sub-group least likelyto use medical services or have a usual source of care (seeGuendelman, 1991; Landeck & Garza, 2002). Only a few studiessuggest that the distinct features of Mexican medical practice mayalso serve as important factors leading immigrants to “head South”(Bergmark et al., 2008;Wallace et al., 2009). In their comprehensivestudy of different factors influencing Mexicans’medical returns, forexample, Wallace et al. note that the lack of “culturally acceptablecare” in the US was an important factor in influencing Mexicans’medical returns. They show that immigrants’ cross-border careseeking is related not only to cost, but also to the availability of carein Mexico and the accessibility and acceptability of care in the US.Yet because their studydlike most of the existing studies onMexican immigrants’medical returnsdrelies exclusively on surveydata, the authors neglect to provide an emic account of howimmigrants construct such “culturally acceptable” care.

Some studies do use qualitative research to examine immigrants’reasons for seeking care in Mexico. Bergmark et al. (2008), forexample, find that Mexican immigrants report three main reasonsfor returning to Mexico for care: unsuccessful treatment in the US,difficulty accessing care in the US and “preference for Mexican care.”Yet Bergmark et al. only offer hints as to why Latinos find receivingcare in Mexico more preferable. They suggest that Mexican immi-grants find that care in Mexico offers “faster relief of symptoms thanin US care, which is driven by diagnostics and a desire to get to theroot of the problem” (2008, p. 9217). Moreover, they state thatLatinos perceive that “medications aremore effective inMexico” anddislike the fact that US doctors typically do not prescribe medica-tions in injectible form (p. 9217). Meanwhile, Wallace et al. find thatMexican immigrants with chronic conditions are more likely totravel for care, and hypothesize that this may be due to the emphasison the ”interpersonal quality of care” in Mexico (2009, 665). Thesestudies point to the possibility of distinct features ofmedical practiceunique to the clinics that immigrants frequent in Mexico, yet do notfully examine what these features are nor why they exist.

Methods

This paper is based on qualitative interviews with 24 Latinoswho sought care at Border Hospital, a three-storey private hospitalin Tijuana that is visible from the port of entry. Open 24 hdas longas the border crossing itself is opendthe Hospital’s white wallproclaims in bright red paint: “We accept American insurances!”The hospital’s founder constructed Border Hospital in the 1970s tocater specifically to the US Latino population after having served as

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a physician in another border town. “I realized that there wasa huge potential in serving the US population, and there was moremovement in the San Diego area,” he said. Border Hospital placesadvertisements in Spanish-language newspapers and radio stationsin Los Angeles and Bakersfield and occasionally employs a callcenter to phone former patients. Because of its convenient locationand outreach, Border Hospital is a household name in Latinofarmworking communities.

Using a semi-structured guide, the authors conducted interviewswith patients in Border Hospital’s waiting room between November15, 2009 and January 15, 2010. We interviewed patients about:1) their reasons for crossing the border for care; 2) their experiencesin the US health care system; 3) their perceptions regarding thedifferent features of medical practice in the US and Mexico; and4) their explanations for the distinctions between the two systems.Weapproacheda total of 32patients for interviews; twodeclined andthree were occupied with paperwork. Three were called into thedoctor’s office shortly afterward and their interviews were notincluded in the overall sample. All US residents of Latino origin whoconsented to give an interview were interviewed. Prospective inter-viewees were informed that the study examined why Latinos soughtcare inMexico and were assured that lack of participationwould notaffect their ability to receive care. When possible, interviews wereconducted in an unoccupied office in the facility; otherwise, theywere conducted in a private corner of the waiting room.

Interviewees came exclusively from southern California. Thirteencame from the Los Angeles metropolitan area, five from Bakersfield(and nearby Delano), two from Riverside, and four from San Diego.Trips to Border Hospital ranged from 20 min to 5 h. Sixteen patientswere uninsured and eight had insurance. Our sample included15 Mexican immigrants and nine Mexican Americans; amongimmigrants, the averagenumberof years in theUSwas29. (The rangewas between ten and 42). The majority of patients worked in agri-cultural or blue-collar jobs; our interviewees included housecleaners, farmworkers, truck drivers, and assembly plant workers.Because family members and partners often accompanied patientsand helped them make the decision to seek care in Mexico, it isdifficult to isolate the discrete effect of immigrant status on cross-border health care seeking. Thus we included both first andsecond-generation Mexican immigrants in our sample.

Interviews were conducted in the interviewee’s language ofpreference and were audio-recorded. Sixteen were conductedprimarily in Spanish and eight primarily in English. Each interviewlasted between 30 min and an hour. Three interviews wereterminated prematurely when patients were called in to see thedoctor and thus were not included in the sample.

The co-authors transcribed all interviews and translated allSpanish-language transcripts into English. The co-authors readthroughall transcripts andcoded them. First, deductive codesdthat is,codes based upon the hypotheses of the study–were drawn from theinterview guide and research questions. Then we read through theinterviews to identify inductive codesecodes that emerged fromthe data itselfdand coded the interviews accordingly (Patton, 2002).Thedatawas summarized intodescriptive charts and tables.Whilewecan only make generalizations from our sample at this one clinic,Border Hospital’s aggressive outreach to US populations is represen-tative of other private border clinics thatUS residents visit (see Bastidaet al., 2008, p. 1988). The study received approval from the Institu-tional Review Board at the University of Colorado, Denver.

Insurance and Medical returns: unpacking the “Uninsured”category

Many studies suggest that Mexico serves as a convenient“escape valve” primarily for Latinos who lack health care insurance

(Bastida et al., 2008; Bergmark et al., 2008). Our data suggestsa more complicated relationship between lack of insurance andmedical returns, however. While sixteen of the 24 patients weinterviewed were uninsured, the category “uninsured’ itselfdeserves further scrutiny. Of these 16, six had purposefully droppedtheir insurance to make Border Hospital their permanent “medicalhome.” Moreover, those who substituted receiving care at BorderHospital for their US health insurance plan did so as much becauseof the distinctive style of medical practice they attributed to BorderHospital as due to cost.

Of the six who had decided to substitute Border Hospital fortheir US health insurance, only two did so because their insuranceplan had become too expensive. Yet in both cases, these inter-viewees had already begun seeking care in Mexico even whileinsured. Mike, a US-born Latino, said that his father had decided tostop paying for the family’s insurance when Kaiser Permanenteraised its copayments for specialists from $40 to $100. The familyhad already been paying $800 in monthly premiums; the spike incopayments was an additional financial strain. Yet even while theyhad had insurance through Kaiser, Mike and his family had alreadybeen receiving care from specialists in his mother’s hometown ofGuadalajaradMike for his kidney troubles, and his mother fora hysterectomy. “We’d go every Christmas and every summer,”Mike said. His mother initially visited a surgeon in Guadalajara fora second opinion, and decided to have the operation there despitethe fact that Kaiser would have covered it. “She just liked hersurgeon there better,” he explained.

Similarly, Rogelio, a 52-year-old man from Orange Countydescribed how he and his family decided to drop their US healthinsurance six years ago. The man had insurance through hisemployer, an assembly plant, but objected when his monthlypremium increased to $45. As he put it, it no longer made sense forhim to maintain his insurance in the US while he and his familycontinued to seek care in Mexico. “So we decided that we wouldcome here instead of paying the insurance,” Rogelio says. Thuswhile financial concerns encouraged both Rogelio and Mike’sfamily to drop their US insurance, both had already been coming toMexico to supplement the care they received in the U.S.

For those who dropped their insurance in order to come toBorder Hospital, the distinctive characteristics they ascribed toMexican medical practice assumed as great importance as the cost.Both the uninsured and the insured mentioned features theydeemed unique to Mexican medical practice as primary reasonsthey chose to seek care along the border. Indeed, more than half ofour intervieweesdsix who intentionally canceled their insuranceto come to Border Hospital and eight who had insurancedhad theoption of using health coverage in the US yet chose to use theservices of Border Hospital instead. “It’s worth the trouble to comehere,” says one assembly plant worker whose Blue Cross insuranceplandoffered through his jobdpicked up 80% of the cost of hiscare. These interviewees did not perceive the border as an “escapevalve” reducing the pressure of rising health care costs in the US,but rather as a “safety zone” where they felt more comfortableseeking care.

The following two examples of Latinos who sought care atBorder Hospitaldof Alma, an uninsured Latina, and Ernesto,a Latino with private insurancedserve to illustrate these perceivedfeatures. Alma is an uninsured former agricultural worker whobegan seeking care in Mexico due to her dissatisfaction with thedrawn-out treatment regimen prescribed by her US doctor. Ernestois a truck driver whose frustration with the impersonality of carethrough his employer-provided insurance caused him to drop itand make Border Hospital his medical home instead. Each soughtcare at Border Hospital due to considerations that extended beyondthe issue of cost, illustrating the features Latinos attribute to

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Mexican medical practicedin particular, the rapidity of servicesand personal treatment–that prompt their medical returns.

Alma: cost and the speed of treatment

Alma, for example, is an uninsured former agricultural worker inher fifties who drove 2 h to Border Hospital from Riverside, Cal-ifornia. Originally from Jalisco, Mexico, Alma has lived in the U.S. for37 years. She came to the clinic to address the lower back pain shehas experienced since a fall about ten years ago; the pain eventuallyinterfered with her work and caused her to leave her job in thepacking house where she had worked.

Alma had received intermittent care after leaving her job andbecoming uninsured. In the summer of 2009, however, the paingrew acute. “I couldn’t stand it anymore; I couldn’t even get out ofbed. All I wanted was for the pain to stop,” she says in Spanish. Sheinitially paid to see a doctor in Riverside. Yet the doctor wantedAlma to undergo a series of tests before performing an MRI; he alsosuggested a regimen of physical therapy. Alma wanted moreimmediate relief. At her sister’s suggestion, she visited BorderHospital.

The doctor at Border Hospital prescribed her pills and gave heran injection–most likely an epidural. “I don’t knowwhat it was, butit worked,” she says. The doctor also ordered an MRI that revealedshe had a herniated disc in her lower back; Alma received theprocedure the same day she visited the clinic. For Alma, the speedof the treatment she received at Border Hospital provided her therelief she wanted. She says that she comes to Mexico for tworeasons. “In the first place, because of the cost,” she says. “But alsobecause everything’s faster. There studies take a long time. Hereyou can get immediate results.” Thus even uninsured Latinos likeAlma visit Mexico for reasons that extend beyond the pragmaticneed to obtain inexpensive health care services; for Alma, the speedof treatment remained an important consideration.

Ernesto: the impersonality of care in the US

While Alma decided to visit Border Hospital in search ofimmediate results, Ernesto came in search of a more personalrelationship with his doctor. Ernesto is a truck driver who lives inLos Angeles. For seven years, Ernesto had opted in to his employer’sinsurance plan through Kaiser. He paid $109 a month for hisinsurance and had a $100 deductible. Yet after an unsatisfying visitto his doctor three months ago, Ernesto decided to drop hisinsurance in order to make Border Hospital his permanent medicalhome. “From now on, I’m just coming to Mexico,” Ernesto said.

Ernesto had visited his US doctor because he had been experi-encing stomach pain for a month. His US doctor, he says, had dis-missed him in the course of 5 min. For Ernesto, such treatment wascharacteristic of the lack of time and attention he had received fromUS doctors. “They always just give you Tylenol and tell you, ‘you’refine,’” he says. “So I decided to stop paying for my insurance. Whydo you want to pay if they’re only going to tell you, ‘you’re fine’?”Contributing to Ernesto’s frustration was the fact that he had onlyvisited the doctor one other time in his seven years of paying forKaiser and had an unsatisfactory experience as well. At thesuggestion of a coworker and friend, Ernesto drove the 5 h toBorder Hospital, where he was prescribed antibiotics for a stomachinfection. Ernesto says he feels that the medications have worked.

While Alma came to Mexico due to her US doctors’ inability toprovide rapid pain relief, Ernesto came because of his frustrationwith the lack of attention he received from US doctors. For Ernesto,not only the 5 min visit but also his doctor’s reliance on Tylenol asa standard response to illness complaints illustrated the imper-sonality of care in the U.S. The examples of Alma and Ernesto

illustrate that Latinos visit Mexican doctors not only due to prag-matic reasons such as lack of insurance, but also due to theirpreference for what they perceive as the distinct “culture of care” inborder Mexican clinics.

Describing the “Culture of Medicine” in Mexico

An examination of the reasons Latinos sought care along theborder reveals other characteristics of Mexican medical practiceperceived as culturally specific. We describe the following charac-teristics that featured in Latinos’ narratives below: the personalattention patients receive, patients’ preference for the speed andefficacy of Mexican medications, the rapidity of tests and treat-ment, and doctors’ emphasis on primary care and use of clinicaldiscretion. In describing these desired features of Mexican medicalpractice, interviewees opposed them to features they deemedcharacteristic of medical practice in the US: the short time of doctorappointments and their impersonality, the delay of treatment dueto long waits and referrals, and finally doctors’ need to followuniform treatment protocols.

Personal attention

Interviewees often reported that they felt the doctors they sawin border clinics rely onmore patient-centeredmethods of care anddevote more time to directly speaking with and examining thepatient. Because they are not constrained by treatment protocolsthat limit the time of their patient visits, interviewees said thatdoctors in Mexico are less rushed. Lalo, a Mexican immigrant,described what he saw as a routine doctorepatient interaction inthe US: “In the US, they sit with you for 1e2 min. You tell them, ‘Idon’t feel so well.’ And they tell you, ‘you’re fine’ and they give youTylenol. That’s it. Here doctors talk with you more.” Similarly, Mike,the US-born Latino who sought care for kidney stones, reportedthat he preferred the comprehensive physical exam that doctorsperform in border clinics. “Over there they just look at you and tellyou what you have. Here the nurse will check your whole body (heimplies with touch).” Conversation with the patient and directphysical touch are the hallmarks of the “personal touch” that Latinoimmigrants seek at Border Hospital.

Patients maintained that the personal attention that borderdoctors devote to patients in turn translates into better diagnosticsand more personalized, effective treatment. For example, Lupe, aninsured US-born 32-year-old Latina, came to Border Hospital fromLos Angeles in order to obtain more information about the raremedical condition with which she had been diagnosed. Lupe hadbeen diagnosed with vasculitis by her primary care physician in LosAngeles in 2005, and had seen 15 different specialists since then.Her doctors in the US had told her that she was “just steps awayfrom dialysis.” Lupe came to Border Hospital for a series of testsdablood test to check her kidney function, a urine test, and an Xray tocheck her lungs–to confirmwhether the doctors in LA were indeedgiving her the correct diagnosis. “I was hoping that maybe therewas amisdiagnosis. And I wanted to find out ‘is there anything else Ican do?’” She said.

Although the doctors at Border Hospital did ultimately confirmthe diagnosis her US doctors had given Lupe, she was pleased withthe time they devoted to explaining her condition and treatmentoptions. Her visit to Border Hospital was productive, she said, ingiving her more alternatives to pursue. “One thing I learned thatwas helpful is that the doctors here said that there’s a pre-dialysisstage rather than actual dialysis and I’ve never heard that overthere.So if I can get pre-dialysis over there, that would be great.”In short, the personal attention that border doctors devote to theirpatients allows them to obtain more information about rare

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illnesses and potential treatments. This may help unpack theobservation by Wallace et al. (2009) that patients with chronicillness were more likely to travel to Mexico for care. Patients likeLupe who suffer from chronic, rare, or poorly-understood condi-tions particularly appreciate the greater time that border doctorsspend with their patients.

Preferences for the strength and efficacy of Mexican medications

Many interviewees mentioned Mexican medication practices asone element of the personal attention that Mexican doctors devoteto patients. They contrasted the strength and efficacy of Mexicanmedications with the facile prescription of over-the-countermedications by US doctors, which they perceived as a symbol oftheir lack of concern. Six interviewees specifically complained thatUS doctors routinely prescribed “Tylenol” for complaints rangingfrom pain to flu to gastritis. Not only were they distressed at theapparent lack of concern conveyed by the prescription of a rela-tively impotent medication, but also by the prescription of Tylenolas a universal treatment for ailments. “In the US, they just give youTylenol for everything,” said one mother. “They just give youTylenol and send you on your way,” agreed one Mexican immigrantwho was prescribed it for a stomach infection. Because in Mexico,there are distinct over-the-counter medications for distinct ill-nessesdsuch as NeuroBion for nerve problems and Desenfriol forcoldsdmany interviewees believed that each illness should have itsown particular treatment.

These interviewees contrasted US doctors’ overreliance onTylenol with the use of stronger medications in Mexican clinics andtheir availability in injectible form. Onewoman from San Diego saida US doctor had prescribed her infant daughter Motrin and Tylenolwhen she developed a throat infection. When the infant did notimprove, she took her to Border Hospital, where the infant receivedan injection. She began eating again within an hour, the womansaid. As a US-born Latino from Bakersfield said: “The medicationsthat they give you over there, it’s good but it takes longer to makeyou better. Like over there they just give you Tylenol. Here theyhave stronger things.” As a patient born in Jalisco put it succinctly:“In Mexico they give you medicine that cures you quickly. You getbetter or you die, but quickly.” Thus Latinos sought care in Mexicoin part because of the perceived efficacy and strength of Mexicanmedications; these medications in turn helped guarantee imme-diate results.

The rapidity of services

Perhaps the most common response among interviewees as towhy they sought care in Mexico was the rapidity of both diagnostictests and therapeutic treatment. Interviewees consistently juxta-posed the rapidity of care in Mexico with the delays in tests andtreatment, long waits for appointments, and referrals that pro-longed relief in the U.S. Several interviewees took this difference inthe rapidity of care into account when deciding where to seek care.For example, one man from Bakersfield related how he sought carein Mexico when he needed immediate results, and in the US whenhe had a non-urgent concern. “In the US, it will take 10e15 days toget an appointment with a specialist, and then it will take evenlonger to get the results,” he said in Spanish. “So I go to Mexicowhen I need lab tests or something more quickly, so I can get theresults right away.” Similarly, a US-born woman related how herparents decided to stop seeking care for her father’s swollen limbsin Bakersfield when the doctors kept ordering new tests. “They justwanted to do additional tests and refer him to specialists. It wouldtake weeks to get an appointment. Every time they went to thedoctor it was, “referral this, referral that,’ they had to get everything

authorized. So [my parents] finally ended up saying, ‘Forget it. Let’sgo to Mexico.’” Yet these referrals delayed her father’s treatment.The doctors at Border Hospital diagnosed him as having end-stagerenal failure, from which he eventually died.

The rapidity of medical attention in Mexico was a particularconcern of patients facing urgent illnesses or conditions. Forexample, Blanca, an immigrant from East Los Angeles who hasMedicaid, came to Border Hospital because she had had vaginalbleeding for two months. She had given birth five months ago andwas told that there was a large fibroid in her uterus; the bleeding,she thought, was likely due to the fibroid. When she first went toher doctor two months before, he had prescribed her iron pills.“They told me, ‘wait a week,’” she said. She did. Yet when shereturned to the clinic to complain that the bleeding had notstopped, she was told to take “double iron.” She saw her doctor theday before traveling to Border Hospital and was told she wouldhave to wait three weeks before her next appointment; Medicaidregulations do not allow patients to be seen in such rapid succes-sion. Yet by that point, she was pale and dizzy. “I can’t wait threeweeks,” she protested.

After this unsatisfying encounter, her husband and a friendsuggested that Blanca go to Mexico instead. At Border Hospital, shewas told she would receive an ultrasound to see what was causingthe bleeding. The doctor told her that her anemia was sopronounced that she might need a blood transfusion. Blanca saidshe was surprised her US doctor had never performed a hemo-globin test. Her doctor just recently took blood to check herhormones, she said, anddof all things, she snorteddgave hera cholesterol test. “In the US, that’s how they do it—they do it littleby little, test by test.” Her doctor had told her that the medicalliterature showed that most fibroids disappear within six months;from this she deduced that her doctor was not planning to act onthe fibroid until the six months had passed. “But with all mybleeding, I can’t wait so much time,” she said. Thus in urgent caseslike Blanca’s, insured patients seek care in Mexico to avoid thestandardized treatment protocols that often characterize treatmentin the US. As in Blanca’s case, such protocols can lead to a delay inurgent treatment.

The use of physician discretion and the Emphasis on “the Skill ofTheir Clinical Hand”

Many Latinos we interviewed reported that they preferredseeking care in Mexico because of doctors’ greater reliance ondiscretion and the “skill of their clinical hand.” While US doctorstypically must follow a prescribed series of tests before arriving ata diagnosis, border doctors are bound by no such regulations.Similarly, while US doctors must follow uniform treatment proto-cols, doctors along the Mexican border are able to attempt alter-native treatments. In particular, Latino interviewees appreciatedthat Border Hospital doctors often advocated less-invasiveapproaches to surgery. Several patients explained that they cameto Border Hospital for a second opinion after having been advisedthat they needed surgery in the U.S. These patients expressedconcern that US doctors are too quick to operate rather than firstattempt other therapeutic approaches.

David is an example of a patient whose trip to Mexico revealedthat the surgery his US doctors had recommended was unneces-sary. Four months ago, David, who had private insurance, beganexperiencing a sharp pain in his side. He had seen several doctors inthe US but none could diagnose his problem with precision. Eachonly spent a few minutes with him. They did four separate ultra-sounds. Three told him he had a hernia; one was agnostic. Despitethe lack of clarity about David’s ailment, the consensus was that heneeded surgery.

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Not wishing to risk a hernia operation unless he in fact hada hernia, David came to Border Hospital for a second opinion. Bytaking David’s medical history and doing a clinical exam, thedoctors at Border Hospital ruled out a hernia as the culprit. “Theyspent 45 min with him. But they didn’t need to do an ultrasound;here it was bien simple,” explained David’s father, who accompa-nied him to his appointment. The doctors diagnosed David withsevere gastritis– inflammation and infection in his stomach. Theygave him an antibiotic and his pain cleared up within a week. “Andthere they wanted to do surgery on him,” his father said, shakinghis head. He credits the diagnosis of gastritis to Mexican doctors’greater emphasis on clinical attention. “There they’re alwaysworried about money, but here they give you more attention,” hesays. “Aquí les importa más el paciente al doctor,” he says. (“Here thepatient is more important to the doctor.”).

Different payment mechanisms: explaining the difference inthe “Culture of Medicine”

Latinos said they sought care in Mexico not only due to cost andconvenience, but also due to the different style of medical practicein Mexico. When pressed to explain the differences between thetwo systems, several patients made reference to the differentstructures of health care delivery that influenced the culture of carethey received in each. First, they said that the treatment protocolsdictated by insurance companies in the US delayed care anddetracted from the personalized attention doctors could provide,instead channeling care through predictable, known mechanisms.These treatment protocols emphasized the use of tests and surgicalprocedures rather than enabling the doctor’s discretionary relianceon clinical care. Secondly, they said that a fear of lawsuits impededdoctors’ use of alternative treatments in the US and hindered theirprescription of appropriate dosages of medications. According toseveral of our interviewees, the result of these two differences inthe structure of health care delivery was that in the US “no te curan”(“they don’t cure you”) whereas in Mexico, “o te matan o te alivias”(“either they kill you or you get better.”).

Treatment protocols of insurance plans Shape care in the US

According to our interviewees, in the US, standardized treat-ment protocols of insurance plans specified the kind of treatmentpatients could receive and detracted from the clinical aspect of care.Because insurance companies often hold US doctors to ordainedtreatment plans, they cannot attempt personalized treatments thatmight be better tailored to individual patients’ needs (see Good &Good, 2003). For example, an immigrant truck driver relateda story in which standardized treatment protocols interfered withhis receipt of medications to lower his cholesterol level. When hewas 31, his HMO doctor in Los Angeles informed him he had highcholesterol. His doctor said he was unable to prescribe him medi-cations to lower his levels, however, because hospital proceduresonly allowed him to prescribe them for patients over 50. Instead,his doctor told him to exercise. He snorted at the futility of this. “If Icould exercise, I would. But I often drive a truck for days.” He saidthat when he had his appointment at Border Hospital, however,they were able to prescribe him a cholesterol-lowering medication“without problem.” In short, the standardized treatment protocolsadopted by US managed care organizations led to a perception ofdepersonalized treatment that neglected individual patient needs.

Such specified treatment plans also led to a style of practice inthe US that many Latinos found offensive for its lack of personalattention. This can be seen in the lack of a personal relationshipwith one’s doctor in the US as well as shorter patient visits thatfollow predictable scripts. “In the US, it’s a business, but here they

actually care,” one immigrant said. In contrast, in Mexico, patientsreported that the self-pay mechanism led to a greater rapport withtheir doctors. Doctors remembered their names and personaldetails and even gave them their cellphone numbers. Some saidthat doctors gave them copies of their MRIs, Xrays, and lab results.“Nothing is kept secret,” a US-born Latino said. Another echoed theprevious immigrant’s statement: “There they treat you like cattle,cattle going by. Here they actually care.”

Because the insurance company pays for patient care in the US,many interviewees perceived patients as being a kind of “cash cow”

justifying the hospital’s billing for treatment. As one immigrantwho gave up his insurance through Kaiser in favor of coming toBorder Hospital said in Spanish: “There it’s more of a business withthe insurance companies. Here, because there aren’t insurancecompanies, they actually care more for the patient. There they justwant to hospitalize you to charge your insurance company moremoney. Everyone knows that.” A US Latino seconded this opinion:“In the U.S. it’s all about money. Doctors in the U.S. treat theproblem but they don’t treat the cause. The longer you areunhealthy the more money they make. Doctors there don’t careabout their patients. Here they actually care.” Because doctors inthe US are reimbursed by insurance companies rather than bypatients, there is a perceived incentive in the US to draw outtreatment. In short, the patients we interviewed said that USdoctors were not in the business of “curing” but rather of “milking”the patient for as many appointments as possible.

For example, one Mexican immigrant gave an example of hisand his sister’s persistent gastritis to illustrate the fact that USdoctors only “keep you alive” as opposed to “relieving your pain.”He said that he and his sister developed the stomach ailment atapproximately the same time. While his sister went to a US doctorand was prescribed Riopan, he went to Border Hospital and wasprescribed double the dosage. He paid $25 for his prescription; shepaid $60. Yet while his gastritis eventually disappeared, his sisterremained illdin his mind, due to the low dosage of her medication.According to this immigrant, the lower dosage his sister wasprescribed was a strategic ploy by US doctors to keep charging herinsurance for repeat appointments. “The most interesting thing isthat I was prescribed twice the dosage,” he said. “Why? Because inthe US, they don’t want to cure you, they just want you to keepcoming back. They don’t give you adequate medications so youhave to keep coming back and then they can charge the insurance.”

Fear of lawsuits hamstring care in the US

Besides the different payment mechanisms in the US and inMexico, patients at Border Hospital also mentioned a fear oflawsuits in the US as significantly constraining the speed and effi-cacy of care. While private-paying patients receive services on thesame day in Mexico, in the US doctors are perceived as too ham-strung by the fear of lawsuits or by the treatment protocols ofmanaged care agencies to treat patients rapidly or effectively. Forexample, one US Latino who visited Border Hospital for care said:“Even when a doctor suspects something or may know your diag-nosis, he will make you go through all the standard tests andprocedures anyway.” In contrast, he said, in Mexico doctors are lesshamstrung by fears of lawsuits so that they are able to take greaterrisks with medical care. “They risk more, they give you strongermedicines and therapies. It’s also one hundred percent quicker. Youget the results immediatelydsometimes in the same day.”

Discussion: a unique Mexican “Culture of Medicine”?

Patients who sought care at Border Hospital described therapidity of services, personal attention, effective medications, and

S. Horton, S. Cole / Social Science & Medicine 72 (2011) 1846e18521852

emphasis on clinical discretion as features distinguishing “Mexicanmedical practice,” opposing these features to the frequent referralsand tests, impersonal doctorepatient relationships, uniformtreatment protocols and reliance on surgeries they experienced inthe US health care system. Yet these contrasting “cultures of care”were rooted in the different organization of the health care systemsof each country. While the features ascribed to the US are charac-teristic of the standardization of treatment protocols brought aboutby managed care, it should be noted that those attributed toa Mexican “culture of medicine” may be unique to the privateclinics and hospitals returning migrants visit.

The features of medical practice that Latinos perceived asattractive may be viewed as particular to clinics and practitionerswith a private fee mechanism. Because the Latinos we intervieweddid not have insurance in Mexico, they received care at privateclinics and hospitals, whether along the border or in Mexico’sinterior. Whether our interviewees discussed visiting doctors inGuadalajara or at Border Hospital, they paid out-of-pocket for carein each case. Doctors at clinics relying upon private-paying patientsmay devote more time to patients and provide more personalizedattention than doctors at government-run clinics, which in fact arecharacteristic of Mexico’s health care system (OECD, 2005). Finkler(1994), for example, observes that the average time for anappointment in a public hospital in Mexico City was 21 min; borderdoctors, in contrast, routinely devoted 45 min to a first visit witha patient. Indeed, giving patients cellphone numbers and medicalrecords are ways not only of providing “personal treatment” butalso of offering good customer service. It should be noted that thefeatures Latinos ascribe to a “Mexican culture of medicine” are notgeneralizable to all Mexican medical practice. Instead, the distinc-tive features interviewees attributed to Mexican medical practi-cedrapidity of services, personal treatment, more potent andeffective medications, and even an emphasis on clinical skill ratherthan surgeryecharacterize a fee-for-service environment in whichcare must be concentrated within short visits.

Conclusions and future Directions for research

Drawing on the narratives of first and second-generationMexican immigrants who sought care in Border Hospital, weexamine the features they perceive as specific to Mexican medicalpractice. While barriers to access and availability of services in theUSmay prompt some Latinos to “head South” (Wallace et al., 2009),we show that the distinctive features of medical practice in privateborder clinics were as important a consideration as cost andconvenience in prompting medical returns. Returning immigrantsjuxtapose border clinics’ rapidity of services, personalized atten-tion, and reliance on physician discretion with the uniform treat-ment protocols dictated by managed care organizations. Theirnarratives serve not only as descriptive of the kind of care they seekin Mexico but also as indictments of the care they receive in the UShealth care system.

Yet the characteristics interviewees attribute to the culture ofmedicine “in Mexico” are unique to clinics and hospitals witha private fee mechanism. Although previous studies examiningwhy Mexican immigrants return to Mexico for care do not specifywhat kinds of clinics they visit, it is likely that the majority visitprivate clinics as well. Future research on immigrants’ medicalreturns should pay attention towhat kinds of clinics they patronize,as well as how their emigration and altered class status in the USaffects their health care consumption in Mexico. We hypothesizethat the majority of our immigrant intervieweesdwho themselvesoften came from poor peasant origins in Mexicodhad been unableto access the kind of care they received in Border Hospital prior totheir emigration. We suggest that unlike the relatively privileged

Korean immigrants Yeon Jae Lee describes (2010), most Mexicanimmigrants return not because they are nostalgic for a distinct kindofmedical practice they remember from “home” but rather becausetheir US salaries enable them to access a quality of care previouslyunavailable to them. Comparative research on the “medicalreturns” of different immigrant groupsdstill in its infancy–mustexplore the distinct circumstances under which each group returnsas well as their differing relationships to their “home” health caresystems.

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