1. science
2. medicine
3. surgery
4. transplants

Medical Tourism
Or, for the politically correct…..
Cross Border Health Care
Karen L McClean MD FRCPC
University of Saskatchewan
Case ….
• Elderly man, osteoarthritic knee not severe enough to
warrant joint replacement, advised to maximize non
surgical therapy
• TKA done in India at a JCI accredited institution
• Mycobacterium fortuitum joint infection 3 months post op
• Required 4 surgical procedures
• Debridement & salvage procedure, two stage revision, open Bx
• Cost: > $140,000 vs patient costs for surgery in India - $8,600
• Cost of arthroplasty in Australia: ~ $15,000
• Frequency of infections post total knee arthroplasty: 1-2%
• Frequency of infection post arthroplasty tourism: unknown
• Denominator unknown
• Numerator patients present to many different clinicians
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
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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
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Health tourism
Medical journeys
Global healthcare / Cross border healthcare
Medical value travel
• More specific terms
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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?
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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?
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Lower cost
Timely alleviation of pain and disability
Access to innovative procedures
Exotic locations and travel ‘mystique’
Privacy – particularly for some cosmetic
procedures
Issues
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Clinical / Medical
Financial
Ethical
Legal
Clinical Decision Making in Medical
Tourism
• How does the ‘commoditization of care’ affect clinical
decision making?
• Potential predisposition to recommend surgical / more complex
procedures over conservative Rx
• Potential risk of minimizing risks to avoid “losing a client”
• Potential risk of focus on visible signs of quality / luxury over
medical quality assurance
• Are patients overly optimistic about potential benefits, and underinformed / inadequately aware of potential risks?
• Once patients have paid a broker fee, are they pre-disposed to
opt for surgery even if this is not the most appropriate care?
Other Clinical concerns
• Are innovative techniques evidence based?
• Are providers properly trained and accredited?
• Are medical quality standards comparable to home?
• Complication rates? – late complication rates usually
unknown
• Infection control / MDR pathogens
• Exposure to exotic / opportunistic pathogens
Ethical issues
• “Islands of excellence in a sea of medical neglect”
• Infrastructure priorities may be focused on industry rather
than local needs
• Infrastructure costs may be passed on to local population
in form of increased taxes or reduced services
• Emphasis on high tech care at the expense of “appropriate
technology”
• Brain drain from public to private sector
• Special issues pertaining to transplant tourism
Financial / Resource issues
• Potential ‘plus’ for uninsured patients / procedures
• Potential undesirable results
• Cost of complications is carried by home country
• Impact on local resources if outsourcing becomes a major
source of care
• Potential for decreased access to specialized services
• Decreased training resources
• Development of transplant programs stunted in countries where
transplant tourism is a major method of obtaining transplantation
• Coercive use of medical tourism by insurance companies
• Potential shortage of nurses / physicians if foreign trained
professionals remain in their country of origin
Legal Issues – Medical standards
• Canadians ‘protected’ against substandard care by:
• Professional licensing & credentialing
• Institutional policies
• Legal remedies
• Care provided in other countries may not meet
Canadian legal standards
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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
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<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
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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
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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….
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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…
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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
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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
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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)
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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
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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
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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
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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
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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)
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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
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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
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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 …
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$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
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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)
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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:
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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?