Transnational Mobility and Global Health

Traversing Borders and Boundaries

Peter H. Koehn

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429679490
• Edition: 1
• Topic: Medicina
• Subtopic: Salute generale

Transnational Mobility and Global Health spotlights the powerful and dynamic intersections of human movement, inequality, and health. The book explores the interacting political, economic, social, cultural, and climatic drivers of health and migration, proposing innovative ways to enhance global health and care provision in an era of transnational mobility. As health security continues to rise up the agenda in international politics, the book also analyses the political determinants of health and migration.

Within the framework of key drivers of unequal mobilities, this book treats interconnected health and migration themes not covered elsewhere under one cover: health tourism, conflict-induced and other vulnerable-population movements, humanitarian crises, human rights, the health-development linkage, migrant health-care, and health-competency education. The book also considers global health vulnerabilities in the wake of climate change, and the biomedical, ethical, and governance challenges of emerging and reemerging infectious diseases. Finally, the book suggests ways of evaluating mobility-influenced health outcomes and equity impacts, and explores how the global circulation of health expertise could help to rectify care-provider shortages.

The challenges to global health considered in this book are only likely to become more intense as the 21st-Century surge in transnational migration continues. Readers will gain interdisciplinary appreciation for the relevance of health for migration and of migration for global health. Researchers, students, practitioners, and policy makers interested in individual and population health, sustainable development, and migration studies will find this book a useful and inspiring guide to contemporary global challenges.

1
Transnational travel as health insurance

Human migration and global health are connected in multiple and diverse ways. Some people cross borders for reasons not directly related to health, bringing along their care needs, vulnerabilities, and any hitchhiking pathogens. Others deliberately venture and invest outward in search of desired remedies or health care. Both movements are captured under the construct “transnational care”¹ and require attention in a book concerned with transnational mobility and global health.²

Transnational medical travel as a recognized, informal, or de facto form of health insurance for some people constitutes a growing manifestation of unequal mobilities. In the case of Mexican Americans who utilize health services for themselves or dependents in both Mexico and California, actual cross-border health insurance is available and bi-national plans are under consideration (Bustamante, 2015). Health-system coverage and insurance options also exist for cross-border migrants in the European Union (see Legido-Quigley and McKee, 2015). South Africa has forged bilateral agreements with 18 countries, including Mozambique, Botswana, Lesotho, and Zimbabwe, that enable their citizens “to access specialized medical treatments in South Africa at subsidized rates” (Crush, et al., 2015, p. 327).

Chapter 1 first treats traveler care. Then, we move on to explore the rising popularity of transnational mobility undertaken specifically for health-care reasons.³ In contrast to the subsequent chapters, which focus on less-privileged migrants, we open here with the other side of the unequal mobility coin: movements that predominantly feature relatively well-off patients.

Travelers’ health care

Transnational tourism has become ever more popular and feasible; today, it is a huge business operation, with more than one billion tourists crossing national borders annually (Mavroudi and Nagel, 2016, p. 8). With few health checks along the way, more tourists travel internationally than “permanent migrants, asylum seekers, refugees, returned refugees, IDPs, and migrant workers added together” (Davies, 2010, p. 101). Long-distance travel involving countries in Africa and Asia has grown particularly rapidly (Leder, et al., 2013, p. 456).⁴

The role of tourism in infectious-disease transmission “too often” is “overlooked” (Davies, 2010, p. 101). In one indicative study, “a Boston-area survey found that about half of international travelers experienced health problems, 7% sought medical care, and 1% required hospitalization” (Chen and Wilson, 2013, p. 1753; also Hodges and Kimball, 2012, p. 117). On the other hand, in spite of the risks of infection, and transmission upon return home, associated with the crowded conditions that prevail during the annual short-term Hajj migration to Mecca, “there have been no major Hajj-related disease outbreaks in recent years” (McCracken and Phillips, 2017, p. 312).

Students who are touring or studying abroad comprise one stream of contemporary transnational mobility possessing health vulnerabilities. Adults who work abroad or volunteer for international educational travel “adventures” are an increasing mobility cohort (Weed, 2018). Although opportunities for pre-travel consultations, travel-health education, and updating immunizations usually are available at student-health centers⁵ and local clinics in the North, both sets of travelers too often overlook these resources (Leder, et al., 2013, p. 466).

People, particularly Southern-born persons and their Northern-born children who visit friends and relatives in origin places, account for a major proportion of trips abroad and the contraction of high-risk infectious diseases (Angell and Cetron, 2005, pp. 67–68). Among travelers who cross health-condition divides to visit, pre-departure barriers to the delivery of preventative-health services and advice include inaccurate traveler perceptions of low personal risk or threat⁶ leading to failure to seek precautionary advice (see, for instance, Brody, 2016) and secure necessary vaccinations, lack of insurance coverage, and inadequate knowledge of travel medicine and absence of transnational competency on the part of Northern providers (Angell and Cetron, 2005, pp. 68–70; Leder, et al., 2013, pp. 459, 465–466). Because they often engage in local and unfamiliar health-related behavior, “travelers visiting friends and relatives… are emerging as a group at substantial risk of travel illness” (Leder, et al., 2013, p. 456). Jill Hodges and Ann Marie Kimball (2012, p. 120) note that “travelers who are visiting friends and family tend to be at higher risk because they’re more likely to stay longer, visit remote areas and consume local food and water, and less likely to take precautions.” Lack of awareness of potential health risks in unfamiliar environments (Davies, 2010, p. 101) and treatment by local medical and dental providers can compound these risks (Angell and Cetron, 2005, p. 68).

With 53 specialized travel or tropical-medicine clinical sites located around the world, GeoSentinel is uniquely situated to report on the incidence of traveler illnesses and diseases. Analysis of anonymous GeoSentinel data from patients who presented on return from travel between 2007 and 2011 provides insights into travel-health patterns. Among all travelers, gastrointestinal infections were most common, followed by febrile illness (mainly malaria and dengue) and dermatological problems. A majority of the returned travelers acquired their health problem in Asia or Sub-Saharan Africa (Leder, et al., 2013, pp. 456–458).

Analysis by travel reason reveals that tourists and students are most likely to incur gastrointestinal illnesses. Tourists also present with a high proportion of dermatological problems and a low proportion of febrile diseases. Overseas backpackers are contributing to the spread of antimicrobial resistance (Whiting, 2017). In contrast, persons visiting friends and relatives are particularly prone to contract febrile diseases and less likely to present with dermatological problems. Among students, neurologic as well as gastrointestinal diagnoses were particularly common and febrile illness less common.⁷ Among all travelers, “microbes may hitch a ride back to the home of the patient, potentially introducing new and unknown bacteria into the community or clinic where the patient next seeks care” (Hodges and Kimball, 2012, p. 115).

Medical tourism in North and South

Medical tourists or international medical travelers (see Bell, et al., 2015, p. 285) are children,⁸ women, and men who journey to a foreign land for the specific purpose of securing health-promoting services.⁹ An individual’s intent-based trans-national travel for medical purposes can be elective or obligatory; in the latter case, place-of-origin treatment is not available or illegal (Jones and Keith, 2006, p. 251; Connell, 2015, p. 22; Turner and Hodges, 2012, p. 9).¹⁰ In the face of perceived cost, expertise, time, and insurance coverage shortcomings associated with exclusive in-country health care (Connell, 2015, pp. 21–22), transnational-health outsourcing has become an increasingly popular option across the planet.

For revenue-generation purposes, Southern government and private entities in countries like Thailand and India actively compete for health tourists among prospect patients from the North (Supakankunti, 2014, p. 680; Frenk, et al., 2010, p. 1949; Chanda, 2015).¹¹ Spurred by daily access to “internet sources of information and imagery” (Lunt, Horsfall, and Hanefeld, 2015b, p. 12; also p. 10; also see Cheung, 2015, pp. 138–139; Gan and Frederick, 2015, p. 144; Horsfall and Lunt, 2015a; Holliday and Bell, 2015, pp. 423–424), individuals and families are attracted by and connecting with foreign providers.¹² Neil Lunt, Daniel Hors-fall, and Johanna Hanefeld (2015b, p. 8) assert that

at the heart of the growth in medical tourism lies commercialization and in some part this is premised on the availability of web-based resources to furnish the consumer with information, imagery, and market destinations, and to connect consumers with an array of healthcare providers and brokers.

Health tourism markets are mediated by the informal networks – including web fora, connected clinicians, and personal recommendations by family, friends, and acquaintances – that influence patient choice of destination and provider as well as treatment itineraries (Hanefeld, et al., 2015, pp. 356, 362; Bochaton, 2015a).

This section identifies the motivations, principal source places, popular treatments, and diverse approaches favored by health tourists. Factors determining transnational access to elective care are analyzed in terms of social determinants and policy facilitators and constraints. Medical tourism both influences and is influenced by conditions of global and domestic inequality. The impact of medical outsourcing on population-health care in Southern-treatment countries merits particular attention in the context of unequal mobilities.

Popular treatments, source places, and patient motivations

With more than 100 million persons crossing borders in search of health benefits (Jones and Keith, 2006, p. 252), medical tourism takes on the characteristics of big business. Particularly appealing low-cost Southern services include “dentistry, cosmetic surgery, and increasingly advanced medical and surgical procedures” (Frenk, et al., 2010, p. 1949; also Holliday and Bell, 2015; Chanda, 2015). In Thailand, the appeal of medical tourism has shifted from the original emphasis on alternative medicine (e.g., herbal treatments, spas, traditional massages) to “niche markets in elective medical procedures, such as plastic surgery” carried out at private hospitals (Supakankunti, 2014, p. 680; also see Noree, 2015). Countries in South and Central America and the Caribbean are expanding from cosmetic surgery, dental treatment, and drug and alcohol rehabilitation into additional health services (Lunt, Horsfall, and Hanefeld, 2015b, p. 7).

Private hospitals in India are drawing medical tourists from Persian Gulf countries, the North, and elsewhere in Asia for high-cost and cutting-edge procedures such as bypass surgeries and transplants (Mullan, 2006, p. 383). Pakistan, China, and the Philippines also serve as enticing hubs for flourishing clandestine organ-transplant tourism (He, 2015, pp. 411–416; also see Martin, 2012, pp. 142–150).¹³ Tokuda Hospital Sofia (Bulgaria), operated by Japan’s Tokushukai Medical Corporation, draws patients with knee and joint injuries from Persian Gulf states and Libya (Issenberg, 2016, pp. 10–11). Elsewhere, reproductive or fertility tourism for the purpose of assisted conception is increasingly sought after (Whittaker, 2012; Jones and Keith, 2006, p. 252; also see Hudson and Culley, 2015). Unproven, problematic, and perilous stem-cell treatments offer another therapeutic-intervention market that attracts contemporary medical travelers; China and Russia are among the most popular destinations (Martin, 2012, pp. 152–162). Along with renown and sustained operations, faddism and volatility afflict transnational-medical tourism (Lunt, Horsfall, and Hanefeld, 2015a, pp. xvi–xvii). Today, anti-ageing medicine and “active ageing” are ascendant (Hyde and Higgs, 2016, pp. 146–151, 167–174). Will euthanasia tourism be the next hot draw?

As Max Hadler (2015, p. 313) points out, “when people cross borders to obtain care, even as willing tourists, it is generally a sign of a real or perceived problem with the local healthcare system.” Northern patients are inspired to seek service abroad by multiple and diverse motivators, including high costs (see Box 1.1) and long waits in their home country (Frenk, et al., 2010, p. 1949; Jones and Keith, 2006, p. 252; Johnson, et al., 2012, p. 29; Smith, et al., 2012, p. 41; Frakt and Carroll, 2018; Crooks, et al., 2013, p. 2). Surgery costs in South Africa, for instance, can be as little as one-third the price charged in London (Renzaho, 2016, p. 186). Transplant and open-heart surgeries as well as knee and hip replacements in India can be secured for 10 percent or less of the cost for similar treatment in the USA (Crone, 2008, p. 120; Chen and Wilson, 2013, p. 1753; Turner and Hodges, 2012, p. 10).¹⁴

Box 1.1 David’s physical therapy treatment in Cuba

Consider David McBain, 47, a Canadian landscaper with a fractured back from an automobile accident. McBain ventured to Cuba for extensive physical therapy three times in 2014. In an interview, McBain reflected on his experience: ‘The physiotherapists and the doctors are extremely knowledgeable and well trained in Cuba and you just can’t beat the price.’

Source: Neuman (2015, p. A7)¹⁵

However, advertised costs can be misleading. When transportation, supplies, drugs, and accommodations are factored in, anticipated savings often disappear (Horsfall and Lunt, 2015b, p. 27). In addition, the risks involved in combining long-distance air travel with surgery typically are undisclosed by providing facilities and brokers (Turner, 2012, pp. 260–261). Leigh Turner (2012, p. 267) further points out that

one reason that it is possible for international hospitals and clinics to advertise inexpensive medical procedures is that these facilities know there is little chance that they will be held financially accountable if medical travelers experience postoperative complications and require costly follow-up care.

Although cost typically is an important...