Matthew Kirkman takes at in-depth look at this growing phenomenon

Medical tourism, the practice of going abroad to seek medical treatment, is thriving; the prospect of cheap, high-quality healthcare attracts many from industrialised countries to South East Asia, South Africa and beyond. When immigrants move to industrialised countries from developing countries, however, the media insists they arrive with the sole intention of free healthcare - so-called ‘health tourists’.

Worldwide immigration has over doubled in the past four decades - from 76 million migrants in 1960 to 175 million in 2000 (1) Reasons for this increase include:

• An increasing and ageing population;
• Widening of differences between rich and poor countries,
• Conflict and political unrest, and
• The need for healthy young workers in developed countries. (1)

Conflicting terminology is often used in referring to immigrants (see box)

Asylum seeker When an individual lodges an application for asylum under the 1951 Convention relating to the Status of Refugees they are described as an asylum seeker.

Migrant A broad term encompassing migrant workers, students, people on work visas as well as refugees, undocumented migrants, and asylum seekers.

Refugee In the UK, someone is a refugee when they have been granted asylum. The 1951 Convention relating to the Status of Refugees defines a refugee as ‘a person who has a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion’.

Refused asylum seeker (‘failed’ asylum seeker) An individual whose application for asylum, and subsequent appeals, has been finally rejected.

Undocumented migrants (‘irregular’ or ‘illegal’ immigrants) Migrants without legal status because they entered the country secretly, using false documents, or because their visa has expired.

Amended UK guidelines on entitlement to free secondary care were introduced by the government in April 2004, imposing charges for most hospital treatment to those considered ‘overseas visitors’, including refused asylum seekers and undocumented migrants. (2) The government cited health tourism as a reason for introducing these changes, yet acknowledged the lack of evidence for its existence. (1) In the UK, whilst treatment for many infectious diseases is exempt from charges, HIV/AIDS treatment is not; the situation on the continent is seemingly better for immigrants - the Netherlands, France, Spain, Belgium and Italy all offer HIV/AIDS treatment as well as most other health services for free to individuals regardless of their status. (1) If the UK government wishes to tackle the HIV/AIDS (and TB) epidemic, this policy needs rethinking. In any case, charging for treatment defies the NHS founding principles: free care to all, based on clinical need regardless of ability to pay. (3)

Having ratified the International Covenant on Economic, Social and Cultural Rights, many governments (including the UK) have obligations under international law to respect, protect and fulfil the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” (4) Whilst many healthcare systems in the developed world suffer gross underfunding, denying free treatment violates human rights. Further, restricting early treatment is cost-ineffective, since many develop complications later requiring immediate costly intervention (according to UK law, immediately necessary treatment must be given regardless of ability to pay).

The situation across the Atlantic is worse; in the US - where there are approximately 12 million illegal immigrants alone (5) - most immigrants work for employers not offering health insurance, and many avoid accessing healthcare to avoid the attention of immigration officials. The cost of medical care or insurance premiums in the US is too high for them and, whilst the free Medicaid healthcare programme exists for the poor, legalisation introduced in 1996 requires immigrants to wait five years after obtaining lawful permanent residency before obtaining federal benefits. (5)

US data shows immigrants have much lower per capita healthcare expenditure than native-born Americans, contributing more to the economy in taxes than they receive in benefits. (5) UK data also contradicts the notion of health tourism in industrialised nations. Project: London is an initiative to improve access to healthcare for vulnerable groups in London - mainly immigrants. Looking at data from 435 consultations with 349 health service users at Project London clinics, individuals had been in the UK for, on average, three years before seeking care. (1) Further, most attended for primary care or antenatal services, not expensive specialist treatment.

So, if immigrants to industrialised countries are not health tourists, what about the genuine health tourists - those from industrialised countries visiting developing countries for cheaper healthcare? The effects of health tourism upon these developing countries and their indigenous populations are profound. Health tourism seems appealing to these countries on first glance; improved healthcare facilities for the country, an economy boost through usage of hotels and other services by tourists, and increased funds to plough back into the healthcare system benefiting the local population. Further, modern health tourism brought with it the hope of a significant reduction in ‘external brain drain’ - the emigration of highly-trained professionals from developing countries such as India to the lucrative western healthcare systems.

Health tourism is not without problems. First, local populations can rarely afford access to the high-quality services set up for tourists, even with the discount system available in India. (6) If anything, health tourism is decreasing equity in access to healthcare for local populations, creating a two-tiered system widening the gap between the ‘have’ and ‘have-nots’. The ‘external brain drain’ is being replaced by ‘internal brain drain’ where professionals move from public to private hospitals in the same country, attracted by money. In the US, many insurance policies promote ‘organ tourism’ in the face of donor organ shortages and high treatment costs, (7) introducing significant ethical dilemmas. What about residents awaiting organ transplant in developing countries - do they go without whilst the affluent take the organs? Australia and New Zealand have tackled this by having two waiting lists, allocating organs to native residents first; after all, guests should not have equal access to organs. (7) The impact of long-distance air travel associated with health tourism upon the environment goes without saying.

Immigrants to industrialised countries are anything but health tourists, whereas the growing health tourism industry in developing countries is fraught with ethical quandaries. Restricting access to healthcare to immigrants in industrialised countries costs more long-term, poses significant public health problems, and infringes human rights. If illness is not prevented and treated among these immigrants, the whole community will suffer. Immigrants often face language and cultural barriers, the stress of emigration, and poverty in a new land; further inequalities in access to healthcare means their health suffers as a result.

The bitter truth is the Inverse Care Law: deprived communities need good-quality healthcare the most, yet are least likely to receive it. (8) Interventions tackling health inequalities necessitate wide-ranging measures addressing poverty, health promotion and disease prevention. Immigrants to industrialised countries should then get the healthcare they need and deserve. Ensuring that the indigenous populations of developing countries get access to the healthcare they need and deserve, however, is difficult and not helped by health tourism.

Matthew A. Kirkman

Fourth year medical student

Newcastle University

matthew.kirkman@gmail.com

(1) Médecins du Monde. Project: London. Helping vulnerable people to access healthcare: Report 2006. London: Médecins du Monde, 2006.

(2) The National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2004. Statutory Instrument 2004 No 614.

(3) NHS. About the NHS: NHS Core Principles. 2007. Available from URL: http://www.nhs.uk/aboutnhs/CorePrinciples/Pages/NHSCorePrinciples.aspx (accessed 29 September 2007).

(4) Office for the United Nations High Commissioner for Human Rights. International Covenant on Economic, Social and Cultural Rights. 2007. Available from URL: http://www.unhchr.ch/html/menu3/b/a_cescr.htm (accessed 29 September 2007).

(5) Okie S. Immigrants and Health Care - At the Intersection of Two Broken Systems. The New England Journal of Medicine 2007; 357 (6): 525-529.

(6) Chinai R, Goswami R. Medical visas mark growth of Indian medical tourism. Bulletin of the World Health Organization 2007; 85 (3): 164-165.

(7) Bramstedt KA, Xu J. Checklist: Passport, Plane Ticket, Organ Transplant. American Journal of Transplantation 2007; 7: 1698-1701.

(8) Hart JT. The Inverse Care Law. The Lancet 1971; 1 (7696): 405-412.

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