Wednesday, August 28, 2013
Medical tourism--some ideas, and maybe what not to do
There are many ways to visit exotic destinations, including cruises, tours, adventure travel, business-related meetings and just plain going there. I always thought it would be most interesting to visit a place and practice medicine, since it would give me the opportunity to meet interesting people, do interesting things and maybe actually help. I first went overseas as a doctor about 23 years ago after finishing my medical residency. I traveled north from Bangkok to Chiang Mai where I found my way to the McKean leprosy hospital. There I spent a week rounding with the American physician who was the medical director, surgeon and primary doctor for all of the leprosy patients. There were also visiting dentists from Germany and other people who helped in various ways, including carrying on a religious mission for the Episcopal Church. It was one of the most memorable weeks of my life and flavored my ideas about medicine for the decades I have practiced since then.
I have looked for ways to visit developing countries in a medical capacity and learned about what seemed to me to be a disturbing development: medical tourism. For a significant chunk of change, a physician can visit some out of the way destination, be assured of room and board and expect to work as a doctor. I have nothing against paying for travel or donating money to worthy overseas medical causes, but it seemed to me that, if it cost thousands of dollars to go far away and do good, perhaps I ought to just donate that money and stay home. Also it seemed that if it was so very expensive to go ply my trade, perhaps my expertise wasn't actually very valuable in those places.
Haiti in 2010 offered me the opportunity to be a doctor in a faraway place without actually resorting to a medical tourism agency. I traveled with friends to evaluate the needs of a few small communities on the island of La Gonave off the coast of Port Au Prince. My friends' projects included women's rights, gardening and the economics of arts and crafts. I brought a suitcase full of remedies which seemed like they might be useful, saw patients, visited dysfunctional health centers and observed the work of a group of flying doctors who come in for 2 weeks every year to treat patients who lined up for hours to be seen. It turned out that what I could do medically in 2 weeks was close to nothing, since people needing acute care couldn't get to me or had died or gotten well all on their own. Many people did need help, but it was more of an ongoing need, and not something I could provide in the time I was there. There were some advanced cancers, HIV, non-healing wounds and severe hypertension. Undoubtedly there were tropical diseases which I couldn't recognize and there was chronic pain, mainly headaches and belly aches.
When I made the trip a year later I brought close to no remedies and saw only a few patients in a clinic setting. I concentrated on talking to people about their existing health care and its obstacles, encouraging sanitation projects and handing out condoms. I sat in meetings with women and men in which I tried to address their concerns by blowing up condom balloons and telling stories with the help of a skilled creole translator, which made them laugh and perhaps dispelled some rather physiologically implausible myths. In other meetings we talked about what they had and didn't have and what they wanted and what seemed possible and sustainable. Although I can't confidently say I did no harm, we did engage in mutually satisfactory dialogue.
The problem with going to places to help is that it can set up a relationship of dependence, especially if the help that is provided is something that is necessary and not otherwise available in that place. And that kind of help is also exactly what we would want to provide. Our natural impulse is to share our tremendous wealth with people we see as being helpless and destitute. The projects that are most successful in this capacity, I think, are projects that can be completed in a limited amount of time such as cleft palate repairs or cataract extractions, or ones that develop staffing and infrastructure in the country they serve that is at least partly self-sustaining.
Paul Farmer has done this in Haiti, dealing with many aspects of chronic diseases in hospital/health care center settings, as has Jill Seaman in her work treating the deadly tropical disease Visceral Leishmaniasis in South Sudan. Provision of medical care in disaster settings is also a good idea, since its scope is usually time limited, supporting an overwhelmed medical system at a vulnerable time. Providing a higher level of care briefly in a setting where it is needed long term is not particularly useful and can upset the progress in healthcare that may have been developing organically.
Recently I visited Tanzania with some medical students who taught ultrasound to Tanzanian students and medical professionals (see the separate post here), kind of an introduction to bedside ultrasound class. I felt like the techniques were really powerful and the students made sure to coordinate with a school there and a radiologist who would probably continue with the teaching. Ultrasound machines are not so very expensive in the developing world, especially as newer, smaller machines are replacing older, still adequate ones. Increasing the baseline competence of people who will be delivering care has the potential to reduce suffering and improve patients' lives in a country with a staggering deficiency of doctors. The motivation for the project was beautiful in itself, medical students bringing the cool thing they had just learned to a place where it could really make a difference.
Another issue with medical projects overseas concerns scarce resources. When I was in Haiti I noticed that there were lots of small, short haired, gentle dogs who barked at intruders and ate garbage. Most of them were thin, and about half of them eventually had puppies. The puppies were incredibly cute and were treated with complete indifference by most people, even as they appeared to cling so very tenuously to life. Undoubtedly most of the puppies died. We were the only people to feed the puppies food scraps because there wasn't enough food for all of the people, or even the mother dog. If all of those puppies survived, a person would not have been able to put a foot down without stepping on a dog.
The human infant mortality rate in Haiti is high and lifespan is short, which results in a pretty stable population in the very resource limited island I visited. If medical care is really successful and the very young and the old live longer there will not be enough food or anything else to support everybody. In some places healthier people produce more food and shelter which offsets this problem, but we need to be very careful about how we focus our philanthropy. If babies are to survive in families that can care for them, there must also be adequate birth control and improved gardening and other industry.
Should we doctors just stay home? No. Emphatically. Unless we want to. But those of us who are motivated to go forth and help people should pay attention to the complexity of the systems we are driven to change. We should open our hearts to the possibility that it is we who are benefited most by our adventures as we meet, care for and in turn are cared for by people whose backgrounds and social contexts are very different from our own.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
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