Medical Tourism

Karen L McClean MD FRCPCUniversity of Saskatchewan

Or, for the politically correct…..

Cross Border Health Care

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

What’s 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, what’s 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 under-informed / 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 India’s 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 don’t 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: >½ 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 body’s 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?