Surgical tourism in low- and middle-income countries: Current Status and the impact on the poor

Travelling for medical attention has long been an obligation. Obtaining specialist care remains problematic for many, particularly those with rare conditions. Antony Eden, former British Prime Minister, travelled several times to the USA for biliary reconstruction. ¹ Several African presidents have elected to obtain treatment outside their own countries, namely Banda from Malawi to South Africa, Mugabe from Zimbabwe to Singapore, though more for geopolitical than medical reasons.

Army personnel injured in far-flung parts are routinely ferried to trauma centres elsewhere. Anyone with a rarity such as a carotid body tumour would elect to be operated upon by someone who has seen more than one or two in his whole career!

Thus there is a distinct logic behind such migratory medicine.

However, a new dimension has emerged; travel for medical and especially surgical care, has morphed into a totally new and different phenomenon, ² now known as ‘Medical’ or ‘Surgical Tourism’. Worldwide, this is a 100-billion US$ industry where patients travel often far outside their own country for elective interventions, usually over a relatively short term.

In 2019 at least 248,000 UK residents travelled abroad for medical treatment and at least 100,000 residents of foreign countries travelled to the UK, several somewhat clandestinely, including those popularly known as the ‘Lagos Shuttle’, describing ladies in advanced stages of pregnancy arriving daily from Nigeria at Gatwick or Heathrow airports in London. ³

Motivation for such travel is mixed, but driven mostly by affordable cost, favourable reports, and personal recommendation.^4,5 Over 60% were for relatively minor procedures, their more ready availability elsewhere suggesting travel may be for non-standard or somewhat eccentric practice.

However, in India and the Far East, more serious interventions are the norm, ranging over cardiac, orthopaedic, plastic, ophthalmologic, dental and indeed the whole gamut of surgical practice. The three most popular incoming countries include Thailand, India, and Singapore, catering for 2.5–5million patients per year. There are two main driving forces; lower prices and high quality, ⁴ though reasons proffered by patients are complex. ⁶ Business is so extensive and lucrative that Governments are now getting involved; in Malaysia, after the recovery from COVID-19, a doubling of visitors compared to 2011–2018 to 2 million is expected in 2024, and 15,000 beds have been prepared for the influx. ⁷ There is consequently more and more aggressive marketing, and serious medico-legal dilemmas emerge. Surgical tourism is growing rapidly by 30% annually, owing to globalisation, the ease and economy of travel, internet, attractive paired packages, expansion of elective surgery options, and a culture change. Indeed, one marketing justification between South Korea and the United Arab Emirates was indeed cultural exchange! ⁸

Formerly the main interest in journals and amongst Western-based surgeons with regard to surgical tourism was the rate and impact of patients returning with complications,^9,10 and concern with details of procedures performed, and follow-up, ¹¹ even proposing regulatory mechanisms ¹² and guidance^13,14 but acknowledging that little could be policed, except for costs of subsequent necessary treatments and this was limited to local residents. Further, apart from their whistle-blowing value, narratives of nightmare scenarios ¹⁵ had little impact.

Although surgical complications have, on occasion, been alarming, with various exotic Mycobacterial infections being reported, ¹⁶ and even some fatalities, a backlash posited by some plastic surgeons ¹⁷ is hardly likely to dent a 2 billion US$ business. With more efficient and widespread electronic media, much greater knowledge is available worldwide ¹⁸ ; thus the expertise of Brazilian plastic surgeons and their innovative techniques is attracting not only attention but patients. ¹⁹

Nonetheless, there are important downsides to the apparently unstoppable surge in Medical Tourism; these relate firstly to the impact on low-income countries and their health systems, and their professional cadres, and secondly no less importantly to vital ethical questions.

Financial benefits in the incoming country improve its local economy, with injection back into its healthcare system. However, it seems that most finance ends up in the private high-tech sector which delivers the surgery for incoming ‘tourists’ and little, if any, filters into the public hospitals which treat the poor. Inefficient taxation and difficulties in financial regulation for surgical tourism are important factors, but these could provide much input for the local health service. Lack of benefits to poorer citizens in low-income countries offering medical tourism remains a generic equity issue. ²⁰

The surgical tourism field requires a substantial body of professionals; a local internal brain drain therefore occurs, as the best and brightest are drawn to this more lucrative private surgery. The poor, typically, have fewer opportunities to be treated, as the availability of surgeons and other professionals is further reduced. Five billion people worldwide have no access to surgery. The majority are poor in rural areas of low- and middle-income countries (LMICs), for whom surgical tourism is of no benefit.

For countries from which patients are departing, investment to improve local surgical services will likely have positive financial benefits. For instance, if in Nigeria a proportion of the $1 billion lost to outgoing surgical tourism could be salvaged by improving local surgical services, this would contribute considerably to the $10 billion annual overall healthcare expenditure. Unfortunately, structures motivated by financial gain by themselves are unlikely to promote social improvements. ²¹

Finally, consideration of the ethical impact of surgical tourism needs immediate attention. Organ trade remains illegal almost worldwide, ²² but with massive increases in surgical tourism, there has been a corresponding increase in this evil. It is the poor in LMICs who are the primary source of harvested organs. In Egypt, 78% of donors reported negative health consequences and 96% regretted donating their organs. In India, 71% of all organ donors were living in poverty. ²³ In China, condemned prisoners’ kidneys are harvested. ²⁴

The development of so-called ‘niche’ services: banned procedures that are not allowed legally in the home countries of foreign patients, such as experimental treatments, gene editing, stem cell therapy, assisted suicide, fertility treatment, surrogate pregnancy, abortion, or female genital mutilation are all emerging below the radar. Local professionals must co-operate with the WHO and local governments to stamp out such practice which threatens to undermine the very morality of medical and surgical practice.

Nonetheless, some innovative schemes are emerging, such as introducing surgery with a package deal holiday in the Caribbean. ²⁵ It remains important not to neglect the health care needs of ordinary citizens and hesitate to encourage public policy that today subsidises the health care of wealthy foreigners. ²⁶ To quote: ‘Medical tourism contributes to the ongoing privatization of health care facilities worldwide, which risks undermining efforts to reach targets for Universal Health Coverage and exacerbates existing inequities in the global distribution of health and wealth’. ²⁷ ‘In both Thailand and India, where regional areas have been disadvantaged by the migration of health-care workers to hospitals focusing on medical tourism, neo-liberal national financial provision for medical tourism (and related tourism campaigns) and evidence of trickle-down gains is lacking. Medical tourism challenges rather than complements local health care providers, distorts national health care systems, and raises critical national economic, ethical and social questions’. ²⁸

We cannot better conclude with Shetty's words in the Lancet:

‘Outside Kokilaben Dhirubhai Ambani Hospital's gleaming air-conditioned walls, meanwhile, the chaotic reality of India, and the gap between rich and poor, has never been more evident. A sleek black car delivering a patient to the hospital speeds through a monsoon-flooded road, splashing a rag-clad beggar in the process. Used to the inequity of life in his country, he simply shakes himself off, shrugs, and moves to a drier spot’. ²⁹