Three Academics Perspective on Medical Tourism ~Reflections on a Trip to Southern India

To date, medical tourism has gone relatively unnoticed by academic researchers when compared to other global health services practices such as health worker migration. Amongst the flurry of business briefings, industry reports and news media coverage that have accompanied the rapid growth of the industry over the past decade, only a handful of accounts from an academic perspective exist. Moreover, very few of these academic accounts are from researchers who have personally visited medical tourism facilities. In an effort to address this gap, our research team, based at a university in British Columbia, Canada, has started to examine medical tourism from the combined perspectives of bioethics, health geography and tourism studies.

After a year of immersing ourselves in the literature on medical tourism, we traveled to a city in southern India for ten days in February, 2010 to get a first-hand understanding of the industry. Our trip was funded by the Canadian Institutes of Health Research.

While this funding was for the purpose of developing networks with Indian academics and physicians who share our interest in understanding why international patients choose to go abroad as medical tourists, we also sought to witness where and how medical tourism actually happens in the city we visited, which is a prominent destination for medical tourists. In the following account, we highlight some of most striking impressions from our trip.

Touring the Hospitals

We visited as many hospitals servicing foreign patients as our time in India would allow. At one of the hospitals, the international patient coordinator was most gracious in arranging for a thorough tour of the facility. One of the recently constructed buildings at the hospital drew in natural light through its glass facade and airy foyer, while the older building on the same property was having its dour, outdated exterior updated to match the aesthetic of the newer building.

In the course of our tour we were shown sleek, new, high-tech medical equipment and an upscale ward targeting international patients and wealthy locals. The aesthetic of the ward departed from the clinical feel of the rest of the hospital, instead resembling a hotel like the one we were staying at.

Throughout the tour, the international patient coordinator was an invaluable source of information. As outsiders to the organization of the hospital, let alone Indian culture, it was evident that the coordinator has a key role in helping foreign patients navigate their care while abroad.
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In visiting the grounds of another hospital, we chose to limit our visit to the publicly accessible areas and not arrange for a guided hospital tour. The opulence of the facility was striking, with manicured lawns, flowering gardens and glittering fountains serving as a complete contrast to the hot, cracked concrete that surrounded the walls of the hospital grounds.

As we explored the full extent of the property, walking from the immaculate central campus of the facility to the outbuildings that housed the international patient quarters, we found ourselves under a hot, noon-day sun crossing a stagnant canal of raw sewage flowing from nearby homes. This discovery uniquely captured the strange asymmetry of the high-tech medical services available in the city with the endemic poverty amongst which they were situated.
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A Chance Meeting with an International Patient

While in southern India we were introduced to a man from the United States in his early fifties who had traveled to the city for back-to-back orthopaedic surgeries. We were very excited to have the opportunity to speak with an international patient given how few published accounts there are of medical tourists’ experiences outside of brief anecdotes and quotes peppering the popular media. The man was recovering from two orthopaedic surgeries, and had been in the city for three weeks.

His decision to travel to India was primarily motivated by cost, as he had no insurance and was unable to access the procedure he wanted at an affordable rate within the United States. We learned that the issue of cost had a number of important impacts on the nature and timing of his trip.

One impact was that he shortened the recovery period between the two surgeries in order to save money. He told us that he wished that he did not have to do this because it caused additional pain, but he felt obligated to keep costs to a minimum as his family had helped to finance his trip. In addition to this hastening of his surgery schedule, he had traveled alone to help keep the cost of his trip low.
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Two issues of concern emerge from this patient’s story. The first worry is the degree to which the clinical decision making informing medical tourists’ treatment is affected by financial concerns. The patient we spoke with was resigned to the necessity of his cost-saving decision, but also believed that the shortening of recovery time between surgeries had made for a more difficult recovery.

While the patient we spoke with had regular contact with family and friends back home via an online telephone service, the second concern is that his trip alone to a foreign country for a life-changing surgery was a source of loneliness, isolation and stress for him.

While not an immediate threat to his welfare, the absence of a traveling companion seemed to make his time abroad more difficult. His experience made us wonder how medical tourists might make decisions based on cost that could have an impact on their wellbeing while abroad.
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The Lasting Health Impacts of Travel

Our flight to India entailed roughly nineteen hours of flying time each way. The physical strain of the long flight was felt by each of us, all in good health and under the age of thirty five. For one of us, the flights resulted in a very painful swelling and stiffness in a leg which remained very painful for a number of months following our trip and required treatment by a physiotherapist.

This happened despite having taken the precautions of stretching regularly and taking walks up and down the aisle of the plane over the course of each flight. Having this painful swelling last for weeks after returning to Canada brought to mind the health risks regularly mentioned with regard to medical tourism, especially those of heightened risks for blood clots.

It was alarming that one of us had a negative health outcome as a direct result of long haul flying, especially given the precautions we took and the low risk makeup of our group. Much higher risks are certainly faced by patients recovering from surgeries, especially those which reduce their mobility.

This experience made us question whether or not medical tourists have access to reliable and accurate information necessary to minimize the risks of travel, whether or not they understand this information, and how common it is for airlines to give them the necessary seating to minimize the health risks associated with travel after surgery.
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Overall Thoughts and Impressions

The time we spent in southern India was a very illuminating experience. By seeing the hospitals treating foreign patients first-hand and speaking with physicians, coordinators and patients, the entire industry took on a human dimension that was previously impossible to grasp from reading the published literature alone.

In speaking with an Indian academic we met with during our trip, we learned that some entrepreneurial people in the city we visited are purchasing houses close to medical tourism hospitals and renting rooms in them to patients and their families. This is a facet of the industry that we had not heard of before, and shows a tangible (though very limited) way that local residents and their communities may benefit from medical tourism.

In contrast to this, an orthopedic surgeon working in a public hospital attested to knowing of the negative impacts of medical tourism on health equity in India through the misallocation of public subsidies. Conflicting accounts such as these make it clear that the impacts of medical tourism demand more comprehensive explorations from academic, industry and popular media perspectives alike.
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Summarizing the Lessons We Learned

International patient coordinators in destination hospitals clearly play an important role in helping international patients while abroad
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There is a sharp juxtaposition between the high-tech medical services available for international patients and wealthy residents in southern India and the endemic poverty that is widespread throughout India
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Industry members must be attentive to the degree to which decision making is being shaped by patients’ financial concerns in a way that might compromise patient wellbeing
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The potential health risks that patients might experience due to long flights are indeed very real
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Visiting hospitals treating foreign patients first-hand and speaking with patients, surgeons and hospital workers on the ground brings a human dimension to medical tourism that is impossible to grasp from reading the published literature alone
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The impacts of medical tourism demand more comprehensive explorations from academic, industry and popular media accounts alike
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Our Ongoing Research

Since returning from India we have started to conduct interviews with Canadians who have gone abroad for surgery to explore their motivations for engaging in medical tourism. When we hear their accounts, our minds often turn to southern India.

We have also conducted interviews with many medical tourism facilitators based in Canada. Some of them refer patients to the very hospitals we visited during our trip. In our research team meetings we also continually refer to stories and observations from our short time in the city we visited. We look forward to visiting other countries engaging in medical tourism and hearing the perspectives of other people involved in the industry.
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