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Medical tourists and medical refugees

By Ramnath Subbaraman

By 2010, India aims to have 1 million medical tourists a year in its five-star hospitals. Are we headed towards a system that mobilises incredible resources to protect the lives of the privileged, while abdicating its responsibility towards the poor, asks a doctor who spent a year in the HIV ward of a Chennai hospital

"You should stay in India to practise 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 the comments were partly affectionate attempts by my relatives to entice their American nephew into spending more time in India, they also represented a new enthusiasm about healthcare 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 the UK flocking to India to receive medical care.

The Indian government is currently 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.1 The goal is to have 1 million medical tourists a year in India by 2010, with revenues possibly exceeding $ 2.2 billion in five years.2

For many in the middle-class, the expansion of medical tourism represents a coming-of-age of 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-specialised 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 isdisturbing 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 healthcare.

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 travelled to a remote area of Tamil Nadu, where I met dedicated doctors providing basic healthcare to adivasi communities that 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 healthcare 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 travelled 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 was 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 specialised treatment that is currently inaccessible outside of larger cities. But as I talked with more doctors in diverse specialties, I realised that what I was witnessing at the HIV hospital was just a more severe version of a generalised trend.

While some poor patients had previously received adequate treatment at government health centres, 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 themselves years later at the Chennai hospital with illnesses resulting from a ravaged immune system.

No wonder so many of India's poor flee these shadow systemsof 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 the 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.3, 4 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).5 Since the onset of economic liberalisation in the 1990s, government investment in health declined further, from an already low 1.3% of GDP in 1990 to only 0.9% in 2001.6 While recent national budgets provided a mild boost to the health sector, this does little to correct the overall trend.7, 8

This pitifully low investment in health is reflected in poor and even worsening health outcomes for the overall population, over the last 15 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.9 Expansion of childhood immunisation services has also stagnated, increasing marginally from 42% coverage of children seven years ago to 44% today. The proportion of fully-immunised children actually dropped in eight states over that time period. Access to oral rehydration solution for children with diarrhoea declined from 27% to 26% over the last seven years.10 The failure of basic healthcare 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.10, 11

Adults don't fare much better in terms of health-related nutritional deficiencies -- the rate of anaemia among women has increased over the last seven years from 52% to 56%.12

The government's abandonment of the medical sector has made India one of the most privatised healthcare markets in the world. The resulting rapidly escalating costs of care (and the corresponding atrophy of free government services) have been detrimental to 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 healthcare doubled.9, 13 More than 40% of those who actually did manage to gain inpatient admission in a hospital had to borrow money or sell possessions such as farmland to pay for care.5

The poor become caught in a "medical poverty trap" -- a cycle of illness, debt and further impoverishment.14, 15 Even the government's meagre investment in healthcare seems to favour the rich. A World Bank study found that the richest 20% of the Indian population received one-third of all healthcare subsidies, while the poorest 20% only received 10%.16, 17

This larger reality must be kept in mind even in the midst of the celebration over 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?12

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 export of doctors to foreign lands but rather the mass import of patients, which may exacerbate the already existing shortage of sub-specialists in the country.

Many in India's cities wish to create a replica of the US health system -- technology-driven services delivered by super-specialised 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 healthcare than any other country in the world, the US ranks 37th among countries in the quality of its healthcare system -- the lowest of any industrialised nation.18 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 healthcare crisis faced by the vast majority of Indian 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 healthcare in rural adivasi communities, who dared to treat HIV patients when others would not, and who served in government health centres 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 that should form the nucleus for a rejuvenation of primary healthcare in India. For a healthcare 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.11, 19 Cuba has a lower infant mortality rate than the US, despite the fact that the US spends 20 times more per capita on healthcare.20 The life expectancy in Kerala exceeds that of certain minority groups in the US, despite a 20-fold disparity in average income.21

Healthcare 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 people's lives depending on their class, caste, skin colour, or gender. The great American civil rights leader, Martin Luther King, highlighted this truth when he said: "Of all the forms of inequality, injustice in healthcare 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 mobilises incredible resources to protect the lives of the privileged, while abdicating its responsibility towards poor and vulnerable sections of society.

(Ramnath Subbaraman is a resident physician at the University of California in San Francisco. This article first appeared on www.outlookindia.com).

InfoChange News & Features, June 2007

References

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