by Stephen Bezruchka, MD
Editorial originally published in Wilderness and Environmental Medicine, 11, 77-78 (2000).
Medical tourism involves short-term overseas work in poor countries by clinical professionals from rich countries. There is considerable interest among medical students, doctors, and other health professionals in going to third-world countries to volunteer in health programs, to work as experts, and to staff relief organizations. Medicins Sans Frontieres received the Nobel Peace Prize this year glamorizing seemingly humanitarian objectives. Is medical tourism beneficial? Or at least, does it do no harm? Can it be justified?
When I talk to individuals and groups of US health care professionals about working overseas, I begin by asking them what they know about the health of populations, beginning at home. Asked to rank the United States’ standing in the Health Olympics (ranking of countries by life expectancy, or infant mortality), most people place the United States in the top 5, or at least in the top 10 countries. They are shocked to find the richest and most powerful country in the history of the world in about 25th place, behind all the other rich countries and a few poor ones as well. So most of us are not well informed about health at home, which should caution us about spreading our ignorance abroad.
Questions about the effect of health care in improving population health are sometimes surprising. I quote the web site data of the US Agency for Health Care Policy and Research (http://www.ahcpr.gov/research/errors.htm), which states that deaths due to medical errors alone are estimated to be 180,000 a year. The recent report from the Institute of Medicine downplays this a bit by drawing attention to medical errors in hospitals, which are only a small part of the full picture of the harm. A more recent report from the Veterans Administration on medical errors suggests that voluntary reporting of errors gives a higher number than can be found on chart review. These data indicate that medical harm is one of the leading causes of death in the United States, and they suggest that we spend one seventh of our entire economy (the US health care budget) on dispatching 350,000 to 400,000 people to their graves annually. Forty percent of all the money spent worldwide on health care is spent in the United States, but it doesn’t buy us health. Do we want to infect other societies with this deadly pox that doesn’t appear, on balance, to do us good?
If “health” care often has questionable benefits for individuals, what is it that makes a population healthy? For rich countries, the association of income distribution with mortality measures of health is the most basic determinant that we know. It has been demonstrated between countries and within countries, and it accounts for our dismal place at the finish line. For poor countries, the provision of basic needs-food, water, and shelter-and the rudiments of economic growth explain the levels of health. But at any level of development, countries that distribute the fruits of development equitably will be healthier than those that do not. (The studies are found on http://depts.washington.edu/eqhlth/.)
If equity is the key determinant of health, what role does foreign assistance play? Medical tourism is a part of the larger picture of foreign aid. Macroeconomic analyses by staff at the World Bank and other financial institutions have demonstrated that foreign aid cannot be shown to improve health, as measured by infant mortality, and that such “help” drives local investment into other, sometimes less productive, sectors. The US presence overseas serves its own economic interests, largely benefiting the huge corporations that dominate government. Realities are hidden under euphemisms. The United States perpetrates massacres, such as in Kosovo, but the newspeak term is “advancing human rights.”
When it comes to foreign aid, or sharing its plunder, the United States is last among all rich countries in the aid Olympics; that is, we spent the least of any rich country, as a percentage of our gross domestic product, on assistance. And the United States continues to be extremely parsimonious in not paying its full United Nations obligations, as Congress quarrels about the bill. So at the macro level, we must rethink the role of the United States in the world today and hope for change in its self-centered policies. Medical tourism, even if humanitarian in intent, is just a part of this bigger US involvement abroad.
If you still want to consider being involved in this form of tourism, what can you do to mitigate its adverse effects? Looking back on 30 years, during which I have traveled abroad as a tourist, worked abroad as a medical tourist, consulted, and acted as an expert, what lessons have I learned? Most of the reasons that we engage in international work sound humanitarian but are self-serving. If you must go, focus on one country or region; learn the local language; and learn about the local health problems, as well as the systems of traditional and introduced care. Respect local cultural norms. Do not further propagation of the US-centered, global monoculture. Consider your strengths and what you have to offer. Teach appropriate skills using the limited locally available resources, and sign up for the long haul, at least in spurts. Meanwhile, we have a lot more work to do at home.
-Stephen Bezruchka, MD
Seattle, WA, USA
Contributed by R. Chavid
