Medical Tourists And Medical Refugees

[Guest guest]

Medical Tourists And Medical Refugees

The hoopla surrounding medical tourism and India's five-star

hospitals has shifted the spotlight away from the grim reality of the

medical system for the vast majority of the population. It

dangerously distorts our understanding of recent trends in access to

health care.

Ramnath Subbaraman

" You should stay in India to practice medicine. Our health system is

becoming as good as America's. Now even Westerners are coming here

for medical care! "

I heard similar remarks from family and friends throughout last year,

when I had taken a break from medical school in the US to engage in a

one-year research fellowship in Chennai at India's largest non-

governmental HIV/AIDS hospital. While such comments were partly

affectionate attempts by my relatives to entice their American nephew

into spending more time in India, they also represent a new

enthusiasm about health care in the country. The reference they are

making, of course, is to medical tourism: the growing trend of

foreigners from the Middle East, US, and UK flocking to India to

receive health care.

The Indian government is now investing millions to support medical

tourism, by promoting major private hospitals, creating publicity

brochures, and encouraging tour operators who manage the vacation

aspects of a patient's visit to India. The goal is to have one

million medical tourists a year in India by 2010, with revenues

possibly exceeding $2.2 billion in five years.

For many in the middle-class, the expansion of medical tourism

represents a coming-of-age for India's medical system, much as the

growth of the IT sector does for the economy. Indian and

international media outlets-- from the BBC to the New York Times--

point to a series of breakthroughs as evidence that Indian medicine

has entered a new era: the creation of " five-star " hospitals,

increased access to the most advanced technologies (MRI, CT

angiography, and PET scanners), and the proliferation of super-

specialized doctors with foreign qualifications.

India's five-star hospitals are indeed an accomplishment. Some of my

own relatives have received high-quality, cutting-edge medical care

at these institutions. To my mind, what is disturbing is the general

(though usually unspoken) perception on the part of more well to do

Indians that these new developments have already benefited or will

trickle down to the rest of Indian society. The hoopla surrounding

medical tourism and India's five-star hospitals has shifted the

spotlight away from the grim reality of the medical system for the

vast majority of the population and dangerously distorts our

understanding of recent trends in access to health care.

During my year doing research and clinical work in India, I jumped at

any chance, however brief, to experience the various settings in

which medical care is delivered. I walked through the dank corridors

of gargantuan, overburdened public hospitals and sanatoriums in the

Chennai area. I spent time listening to the stories of HIV-positive

housewives in Namakkal, one of the districts hardest hit by the AIDS

epidemic. I traveled to a remote area of Tamil Nadu, where I met

dedicated doctors providing basic health care to Adivasi communities

which previously had no access to a hospital.

But my most revealing experiences came from speaking with patients on

a day-to-day basis in the inpatient ward of the HIV hospital in

Chennai throughout my year there. While the hospital serves a diverse

cross-section of the population (the HIV virus does not respect

boundaries of class or caste), the bulk of patients came from humble

backgrounds-- they were farmers, storekeepers, lorry drivers, auto

and cycle-rickshaw drivers, and housewives. Listening to their

stories of the ways they navigated the health care system provided a

very different prognosis on the state of medicine in India than one

would glean from the country's English-based media.

Most patients traveled long distances from Andhra Pradesh and far-

flung areas of Tamil Nadu to receive care at the Chennai hospital.

Every day, I was impressed by scores of dedicated patients who

arrived by overnight trains and buses to make their scheduled

outpatient appointments, which usually happen every few months. Even

more unimaginable were the handful of patients who made these

journeys with illnesses severe enough to require inpatient admission,

despite relentless shortness of breath and physical wasting so

debilitating they could hardly stand. I initially assumed that this

phenomenon of long-distance travel by patients was specific to HIV, a

disease requiring specialized treatment that is currently

inaccessible outside of larger cities. But as I talked with more

doctors in diverse specialties, I realized that what I was witnessing

at the HIV hospital was just a more severe version of a generalized

trend.

While some poor patients had previously received adequate treatment

in government health centers, the system with which others engaged

was only a shadow of a real health system, with the only medical care

in their localities delivered by unlicensed practitioners, or quacks.

For such practitioners, the universal treatment for every illness

consists of (usually unnecessary) infusions of intravenous fluids or

injections. Other quacks charge patients inordinate amounts of money

for supposed " cures " for diseases such as HIV. I met many patients

who had been exploited by quacks and convinced they were cured of

HIV, only to present years later to the Chennai hospital with

illnesses resulting from a ravaged immune system.

No wonder so many of India's poor flee these shadow systems of health

in their villages and small towns to obtain treatment in overburdened

hospitals in the cities. If India's five-star hospitals are catering

to medical tourists, I often felt as if the hospital at which I

worked served the flip side of the coin-- medical refugees, people

abandoned by the public health system.

Is this perception supported by objective data? Or was I getting a

biased snapshot of reality working at an HIV hospital? What do

statistics tell us about the state of public health in India in the

era of medical tourism?

India has consistently had one of the lowest proportions of

government investment in public health as a percentage of GDP of any

country in the world. By this measure, only five countries invest

less in public health-- Cambodia, Burundi, Myanmar, Pakistan, and

Sudan (the last of which is in the midst of an ongoing genocide).

Since the onset of economic liberalization in the 1990s, government

investment in health only declined further, from an already low 1.3%

of the GDP in 1990 to only 0.9% in 2001. While recent national

budgets provided a mild boost to the health sector, this does little

to correct the overall trend.

This pitifully low investment in health is reflected in poor and even

worsening health outcomes for the overall population over the last

fifteen years. One of the most basic health indicators, infant

mortality rate, declined steeply in the 1980s by 27%. It stagnated in

the 1990s in the face of decreasing public health spending,

diminishing only a further 10% over the decade. Expansion of

childhood immunization services has also stagnated, increasing

marginally from 42% coverage of children seven years ago to 44%

today. The proportion of fully-immunized children actually dropped in

eight states over that time period. Access to oral rehydration

solution for children with diarrhea declined from 27% to 26% over the

last seven years.

The failure of basic health care for children may partly explain

India's shamefully high prevalence of chronic childhood malnutrition,

which is twice as high as the rate in sub-Saharan Africa. Adults

don't fare much better in terms of health-related nutritional

deficiencies-- the rate of anemia among women has increased over the

last seven years from 52% to 56%.

The government's abandonment of the medical sector has made India one

of the most privatized health care markets in the world. The

resulting rapidly escalating costs of care (and the corresponding

atrophy of free government services) have been detrimental for the

poor. From the mid-1980s to the mid-1990s, the proportion of people

who could not access any form of treatment because of the high cost

of health care doubled. More than 40% of those who actually did

manage to gain inpatient admission in a hospital had to borrow money

or sell possession, such as farmland, to pay for care. The poor

become caught in a " medical poverty trap " -- a cycle of illness, debt,

and further impoverishment. Even the government's meager investment

in health care seems to favor the rich. A World Bank study found that

the richest 20% of the Indian population received one-third of all

health care subsidies, while the poorest 20% only received 10%.

This larger reality must be kept in mind, even in the midst of the

celebration surrounding India's supposed medical advances. The same

era that has seen the blooming of high-end private medical care, in

which the rich can access the latest technologies, has also seen the

collapse of the public health sector for the poor into a shadow

system, where many cannot access the most basic chest X-rays and

medications. Given this reality, why is the media focusing most of

its attention on five-star hospitals and medical tourism? Rather than

trying to attract medical tourists, wouldn't the Indian government

provide greater benefits to the common man by addressing very basic

public health issues, like educating the 55% of Indian women who have

never even heard of AIDS about this disease?

It is also not unreasonable to ask whether the rapid expansion of

medical tourism may result in a small-scale internal brain drain.

Ironically, the problem would no longer be the exportation of doctors

to foreign lands but rather the mass importation of patients, which

may exacerbate the already existing shortage of subspecialists in the

country.

Many in India's cities wish to create a replica of the US health

system-- technology-driven services delivered by super-specialized

doctors in large, modern, marble-floored tertiary care hospitals. But

those of us who have trained in US institutions have seen American

medicine for the flawed system that it really is. Beyond a façade of

seemingly miraculous artificial hearts, PET scanners, and MRI

machines, lies a system in which millions of people in the richest

country in the world are denied access to even the most basic

services-- ranging from the 45 million citizens without health

insurance to immigrants and other vulnerable groups. The existence of

such a large uninsured population is partly what fuels the movement

of American medical tourists to India. Despite spending far more per

capita on health care than any other country in the world, the US

ranks 37th among countries in the quality of its health care system--

the lowest of any industrialized nation.

Replicating such an unjust and inefficient medical system would be

unsustainable and undesirable in India.

Indeed, even a hundred more Apollo hospitals will not fundamentally

transform the long-thriving health care crisis faced by the vast

majority of India society. If we wish to see such wide-reaching

changes, we must listen to the alternative voices in the medical

field-- those doctors who dedicated themselves to providing health

care in rural Adivasi communities, who dared to treat HIV patients

when others would not, and who served in government health centers

with humanism in the face of contracting resources. These are people

who choose to use their stethoscopes to address the plight of India's

medical refugees rather than those of the medical tourists, and it is

their ideas and dedication which should form the nucleus for a

rejuvenation of primary health care in India. For a health care

model, India would do better to follow the examples of Cuba or

(within India itself) Kerala, both of which have provided remarkable

health outcomes for even their poorest citizens. Cuba has a lower

infant mortality rate than the US, despite the fact that the US

spends twenty times more per capita on health care. The life

expectancy in Kerala exceeds that of certain minority groups in the

US, despite a twenty-fold disparity in average income.

Health care systems serve as microcosms for the larger status of

social injustice within a society. In a very concrete way,

inequalities within these systems reveal our willingness to place a

differential value on peoples' lives depending on their class, caste,

skin color, or gender. The great American civil rights leader,

Luther King, highlighted this truth when he said, " Of all the forms

of inequality, injustice in health care is the most shocking and

inhumane. " If India chooses to follow the path of American medicine

it may be disturbed when it gets exactly what it asks for: a system

that mobilizes incredible resources to protect the lives of the

privileged while abdicating its responsibility towards poor and

vulnerable sections of society.

Ramnath Subbaraman is a final year student at Yale University School

of Medicine, New Haven, CT, USA.

http://www.outlookindia.com/full.asp?fodname=20070621 & fname=healthcare & sid=1 & pn=\

4

[Guest guest]

Dear FORUM,

I am really impressed with what Ramanath Subbaraman has to say about health

tourism, and primary healthcare in India.

Health tourism is growing in number and patients are coming to India for

treatment and management of diverse afflictions and diseases, no doubt, but

whether they are getting quality management, including safety from infections is

not certain. Aspect of waste management in our healthcare facilities remains

poor, and one is always at risk of contracting hospital acquired infections.

India is going to be the host for Commonwealth Games in 2010 when a large number

of foreigners would come to Delhi. Lot is being done to improve roads and other

infrastructure, but hardly any to improve conditions of hospitals, waste

management (including MSW). It would be a bad publicity if some of the

participants from other Commonwealth countries go back with preventable medical

problems they did not come with.

No doubt, private healthcare has made strong inroads in the overall healthcare

delivery in India, but unless the primary healthcare is improved not much is

going to be achieved at the national level. For this many initiatives such as

improving connectivity, ensuring power supply, improving other infrastructure,

so as to make doctors stay and practice in the rural areas and not run away, or

always try to get away to urban or semi urban areas, will be required; apart

from improving the medical infrastructure.

India does not stand to gain by adopting models of different countries, but has

to devise its own model focused to rural population.

Lalji K Verma

E-MAIL: <vermalk@...>