Medical Tourists And Medical Refugees

"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 medicalcare!"

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-yearresearch fellowship in Chennai at India’s largest non-governmental HIV/AIDShospital. While such comments werepartly affectionate attempts by my relatives to entice their American nephewinto spending more time in India, they also represent a new enthusiasm abouthealth care in the country. Thereference they are making, of course, is to medical tourism: the growing trendof foreigners from the Middle East, US, and UK flocking to India to receivehealth care.

The Indian government is now investing millions to supportmedical tourism, by promoting major private hospitals, creating publicitybrochures, and encouraging tour operators who manage the vacation aspects of apatient’s visit to India. Thegoal is to have one million medical tourists a year in India by 2010, withrevenues possibly exceeding $2.2 billion in five years.

For many in the middle-class, the expansion of medicaltourism represents a coming-of-age for India’s medical system, much as thegrowth of the IT sector does for the economy. Indian and international media outlets-- from the BBC to the New YorkTimes-- point to a series of breakthroughs as evidence that Indian medicinehas entered a new era: the creation of "five-star" hospitals, increasedaccess to the most advanced technologies (MRI, CT angiography, and PETscanners), and the proliferation of super-specialized doctors with foreignqualifications.

India’s five-star hospitals are indeed an accomplishment. Some of my own relatives have received high-quality, cutting-edge medicalcare at these institutions. To mymind, what is disturbing is the general (though usually unspoken)perception on the part of more well to do Indians that these new developmentshave already benefited or will trickle down to the rest of Indian society. The hoopla surrounding medical tourism and India’s five-star hospitalshas shifted the spotlight away from the grim reality of the medical system forthe vast majority of the population and dangerously distorts our understandingof recent trends in access to health care.

During my year doing research and clinical work in India, Ijumped at any chance, however brief, to experience the various settings in whichmedical care is delivered. I walkedthrough the dank corridors of gargantuan, overburdened public hospitals andsanatoriums in the Chennai area. Ispent time listening to the stories of HIV-positive housewives in Namakkal, oneof the districts hardest hit by the AIDS epidemic. I traveled to a remote area of Tamil Nadu, where I metdedicated doctors providing basic health care to Adivasi communities whichpreviously had no access to a hospital.

But my most revealing experiences came from speaking withpatients on a day-to-day basis in the inpatient ward of the HIV hospital inChennai throughout my year there. Whilethe hospital serves a diverse cross-section of the population (the HIV virusdoes not respect boundaries of class or caste), the bulk of patients came fromhumble backgrounds-- they were farmers, storekeepers, lorry drivers, auto andcycle-rickshaw drivers, and housewives. Listeningto their stories of the ways they navigated the health care system provided avery different prognosis on the state of medicine in India than one would gleanfrom the country’s English-based media.

Most patients traveled long distances from Andhra Pradeshand 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 byovernight trains and buses to make their scheduled outpatient appointments,which usually happen every few months. Evenmore unimaginable were the handful of patients who made these journeys withillnesses severe enough to require inpatient admission, despite relentlessshortness of breath and physical wasting so debilitating they could hardlystand. I initially assumed that this phenomenon of long-distancetravel by patients was specific to HIV, a disease requiring specializedtreatment that is currently inaccessible outside of larger cities. But as I talked with more doctors in diverse specialties, Irealized that what I was witnessing at the HIV hospital was just a more severeversion of a generalized trend.

While some poor patients had previously received adequatetreatment in government health centers, the system with which others engaged wasonly a shadow of a real health system, with the only medical care intheir localities delivered by unlicensed practitioners, or quacks. For such practitioners, the universal treatment for every illnessconsists 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. Imet many patients who had been exploited by quacks and convinced they were curedof HIV, only to present years later to the Chennai hospital with illnessesresulting from a ravaged immune system.

No wonder so many of India’s poor flee these shadowsystems of health in their villages and small towns to obtain treatmentin overburdened hospitals in the cities. IfIndia’s five-star hospitals are catering to medical tourists, I often felt asif the hospital at which I worked served the flip side of the coin-- medicalrefugees, 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 inthe era of medical tourism?

India has consistently had one of the lowest proportions ofgovernment investment in public health as a percentage of GDP of any country inthe world. By this measure, onlyfive 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, governmentinvestment in health only declined further, from an already low 1.3% of the GDPin 1990 to only 0.9% in 2001. While recent national budgets provided a mild boost to thehealth sector, this does little to correct the overall trend.

This pitifully low investment in health is reflected inpoor and even worsening health outcomes for the overall population over the lastfifteen years. One of the mostbasic health indicators, infant mortality rate, declined steeply in the 1980s by27%. It stagnated in the 1990s inthe face of decreasing public health spending, diminishing only a further 10%over the decade. Expansion ofchildhood immunization services has also stagnated, increasing marginally from42% coverage of children seven years ago to 44% today. The proportion of fully-immunized children actually droppedin eight states over that time period. Accessto oral rehydration solution for children with diarrhea declined from 27% to 26%over the last seven years. Thefailure of basic health care for children may partly explain India’sshamefully high prevalence of chronic childhood malnutrition, which is twice ashigh as the rate in sub-Saharan Africa. Adultsdon’t fare much better in terms of health-related nutritionaldeficiencies-- the rate of anemia among women has increased over the last sevenyears from 52% to 56%.

The government’s abandonment of the medical sector hasmade India one of the most privatized health care markets in the world. The resulting rapidly escalating costs of care (and the correspondingatrophy of free government services) have been detrimental for the poor. From the mid-1980s to the mid-1990s, the proportion of people who couldnot access any form of treatment because of the high cost of health caredoubled. More than 40% of those who actually did manage to gaininpatient admission in a hospital had to borrow money or sell possession, suchas farmland, to pay for care. Thepoor become caught in a "medical povertytrap"-- a cycle of illness, debt,and further impoverishment. Eventhe government’s meager investment in health care seems to favor the rich. A World Bank study found that the richest 20% of the Indian populationreceived one-third of all health care subsidies, while the poorest 20% onlyreceived 10%.

This larger reality must be kept in mind, even in the midstof 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 collapseof the public health sector for the poor into a shadow system, where many cannotaccess the most basic chest X-rays and medications. Given this reality, why is the media focusing most of its attention onfive-star hospitals and medical tourism? Ratherthan trying to attract medical tourists, wouldn’t the Indian governmentprovide greater benefits to the common man by addressing very basic publichealth issues, like educating the 55% of Indian women who have never even heardof AIDS about this disease?

It is also not unreasonable to ask whether the rapidexpansion of medical tourism may result in a small-scale internal brain drain. Ironically, the problem would no longer be the exportation of doctors toforeign lands but rather the mass importation of patients, which may exacerbatethe already existing shortage of subspecialists in the country.

Many in India’s cities wish to create a replica of theUS health system--technology-driven services delivered by super-specializeddoctors in large, modern, marble-floored tertiary care hospitals. But those of us who have trained in US institutions have seen Americanmedicine 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 richestcountry in the world are denied access to even the most basic services--rangingfrom the 45 million citizens without health insurance to immigrants and othervulnerable groups. The existence ofsuch a large uninsured population is partly what fuels the movement of Americanmedical tourists to India. Despitespending far more per capita on health care than any other country in the world,the US ranks 37^th among countries in the quality of its health caresystem-- the lowest of any industrialized nation. Replicating such an unjust and inefficient medical system would beunsustainable and undesirable in India.

Indeed, even a hundred more Apollo hospitals will notfundamentally transform the long-thriving health care crisis faced by the vastmajority of India society. If wewish to see such wide-reaching changes, we must listen to the alternative voicesin the medical field-- those doctors who dedicated themselves to providinghealth care in rural Adivasi communities, who dared to treat HIV patients whenothers would not, and who served in government health centers with humanism inthe face of contracting resources. Theseare people who choose to use their stethoscopes to address the plight ofIndia’s medical refugees rather than those of the medical tourists, and it istheir ideas and dedication which should form the nucleus for a rejuvenation ofprimary health care in India. For ahealth care model, India would do better to follow the examples of Cuba or(within India itself) Kerala, both of which have provided remarkable healthoutcomes for even their poorest citizens. Cubahas a lower infant mortality rate than the US, despite the fact that the USspends twenty times more per capita on health care. The life expectancy in Kerala exceeds that of certain minority groups inthe US, despite a twenty-fold disparity in average income.

Health care systems serve as microcosms for the largerstatus of social injustice within a society. In a very concrete way, inequalities within these systems reveal ourwillingness to place a differential value on peoples’ lives depending on theirclass, caste, skin color, or gender. Thegreat American civil rights leader, Martin Luther King, highlighted this truthwhen he said, "Of all the forms of inequality, injustice in health care is themost shocking and inhumane." IfIndia chooses to follow the path of American medicine it may be disturbed whenit gets exactly what it asks for:a system that mobilizes incredible resources to protect thelives of the privileged while abdicating its responsibility towards poor andvulnerable sections of society.

Ramnath Subbaraman is a final year student at Yale University School of Medicine, New Haven, CT, USA.