Episode 13      20 min 58 sec
Medical Tourism in Asia

Dr Andrea Whittaker explores the phenomenon of medical tourism in Asia with Sian Prior. Dr Whittaker also talks about her research in illegal abortions in Thailand.

Guest: Dr Andrea Whittaker from Asia Institute

Topic: Medical Tourism in Asia

" ... governments in the region see it (medical tourism) as a whole new form of foreign exchange and trade for them, and to fill a gap that the [1997] Asian economic crisis has left ..." - Dr Andrea Whittaker




           



Dr Andrea Whittaker
Dr Andrea Whittaker

Dr Andrea Whittaker, Medical Anthropologist and Senior Lecturer at Asia Institute. Dr Whittaker's primary research interests relate to reproductive health, gender and development in Thailand with a major study published in 2004 on abortion in Thailand. Her Australian research includes studies on general practice, gender and diabetes and family formation. Her current research funded by the Australian Research Council involves a study on infertility, assisted reproductive technologies and reproductive tourism in Thailand and the region.

Credits

Host: Sian Prior 
Producers: Kelvin Param, Eric Van Bemmel and Sian Prior
Audio Engineer: Craig McArthur 
Theme Music performed by Sergio Ercole. Mr Ercole is represented by the Musicians' Agency, Faculty of Music
Voiceover: Paul Richiardi

Series Creators: Eric Van Bemmel and Kelvin Param

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute.

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Medical Tourism in Asia

VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities, and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au That!|s upclose.u-n-i-m-e-l-b.edu.au.

SIAN PRIOR
Hello and welcome to Up Close, coming to you from Melbourne University, Australia. I!|m Sian Prior. Now are you suffering from any serious illnesses at the moment? Are you having fertility problems and considering using IVF technology, or have you been thinking about trying cosmetic surgery to change your appearance. Well if the answer to any of these questions is 'Yes', then you might also have been considering taking advantage of one of the 21st century!|s fastest growing industries. I!|m talking about medical tourism, the trade in health services for foreign patients which is being aggressively marketed in countries across Asia. At Bangkok International Hospital, for example, there!|s an advertising sign which reads !¢FDcombine your healthcare needs with a holiday in paradise!|, and it!|s a classic example of the kind of sales strategy being employed to encourage tourists to travel abroad for their medical procedures. I guess today here in Melbourne University Up Close knows more than most people about this subject. Andrea Whittaker has been studying medical tourism in Thailand, Singapore, India and Malaysia as part of her work as a senior lecturer at Asia Institute here at the University of Melbourne, Australia. Andrea has also been taking a close look at the controversial issue of abortion policy reform in Thailand where abortion is still technically illegal but where, nevertheless, several hundred thousand women have terminations every year. And today, we!|ll find out more about her research. Andrea, welcome to Up Close.

ANDREA WHITTAKER
Thanks very much, Sian.

SIAN PRIOR
Well, let!|s start by talking about medical tourism or medical travel as it!|s sometimes called. And Andrea, people have been travelling to foreign countries for medical treatment for centuries, but I suppose, in the recent past it was more likely to be to wealthy western countries like Europe, the UK, the USA. But your research is showing that these days medical tourists are heading off most often to countries in Asia. When did this trend begin and why?

ANDREA WHITTAKER
The trend started in around 1997, after the Asian economic crisis and it!|s been the initiative of a number of Asian governments to really start to promote medical tourism or the use of hospital services in their countries as a way of generating foreign exchange. So, Asia now has a number of places which are promoting themselves as medical hubs in Asia and so we see a lot more people starting to go there because the price makes it very affordable for a large mass market.

SIAN PRIOR
And what kind of treatments are we talking about?

ANDREA WHITTAKER
Well, just about anything really. We!|re talking about things such as facelifts, cosmetic surgery of all types, things such as gender reassignment surgery, cardiac surgery, right through to specialist oncology services for cancer treatment, or orthopaedic surgery.

SIAN PRIOR
And who!|s in the market for this kind of medical tourism? Is it mostly wealthy westerners who want their holiday in paradise, as the ad says, to go with their surgery? Or is it people who are actually having difficulty accessing the medical treatment that they need in their own country?

ANDREA WHITTAKER
It!|s both. It!|s a very diverse market and in some respects the term medical tourism is a bit of a misnomer because at one extreme you have people who are combining a holiday with a facelift or a tummy tuck !V

SIAN PRIOR
It sounds kind of trivial doesn!|t it?

ANDREA WHITTAKER
It !V it does, it !V it trivialises actually what are fairly complex surgeries in many cases, but they !V they might go and have their surgery and then head off to a resort that specialises in looking after patients post-operatively. And so, it ranges from that to then people who are seeking specialist services such as oncology services or types of surgery not available back home from other countries within the region. So for instance Singapore, the majority of people seeking care there come from Malaysia and Indonesia. So, it!|s !V it!|s both a !V an intra-regional sort of trade, but also you!|ve got a lot of people travelling from the US and Britain and Australia to seek services in Asia.

SIAN PRIOR
How much of it is people seeking treatments that they can!|t get at home, and I!|m thinking of a !V a recent example that we heard about in the media here in Australia of an Australian woman who travelled to India in order to access stem cell treatment for spinal damage that she!|d had, which sounded pretty out there. You know the medical establishment in Australia was sounding quite dubious about it.

ANDREA WHITTAKER
Yeah, that!|s an important aspect of it. People are travelling either for affordability but also those sorts of issues. The regulatory boundaries of care differ from country to country and so for instance in Thailand as yet IVF is unregulated and it is possible to have pre-implantation sex selection there.

SIAN PRIOR
Choose the gender of your baby !V

ANDREA WHITTAKER
Choose the gender of your baby. And so, there is a market for people to actually travel specifically [for] that procedure. And similarly, in China, there!|s forms of spinal surgery which are not done elsewhere. And so often you have people who are desperate for a particular procedure, who can!|t access it at home, and will go to those extremes to access that procedure.

SIAN PRIOR
And how many people are we talking about. What are !V what are the statistics here on the number of people travelling for medical tourism or medical treatment?

ANDREA WHITTAKER
It!|s difficult to get exact statistics and in part because the definition is so ambiguous, it!|s a very difficult to pin numbers down on. If you believe the websites and a lot of the information on this travel comes from the internet, then there!|s a lot of people travelling. For instance in Singapore, they quote that about 150,000 patients went to Singapore in the year 2000 and they!|re saying that that was worth about US$220 million to their economy. Thailand quotes some amazing figures or 400,000 foreign patients, that was in the year 2004, travelling specifically for treatments in Thailand. So !V

SIAN PRIOR
Which would equate to hundreds of millions of dollars.

ANDREA WHITTAKER
That!|s right, and !V and certainly governments in the region see it as a whole new form of foreign exchange and trade for them, and to fill a gap that the Asian economic crisis has left really.

SIAN PRIOR
Well, we!|ve talked about the benefits to the people seeking this kind of treatment and the economic benefits to the nations providing it. Are there disbenefits to people in those countries who are now providing those services? What sort of impact is it having on local people in terms of what medical treatments they can access?

ANDREA WHITTAKER
One of the major disadvantages is that it appears as though this trade potentially is created a two-tiered health system, where poorer locals access hospitals which don!|t have the high tech medicine that!|s available in the sort of export oriented hospitals, whereas foreigners can access superb medical facilities in and oncology services and very high tech medicine in these private hospitals. So, trying to find a balance between that is !V is something that a lot of the countries are struggling with at the moment.

SIAN PRIOR
And, is it actually a concern amongst the governments in the countries you!|ve looked at or is it just an accepted part of globalism?

ANDREA WHITTAKER
It!|s an increasing concern, but the policy makers are a little bit behind to a certain extent in really coming up with ways to ameliorate that situation.

SIAN PRIOR
And what sort of value for money are the patients getting for these trips. Do we know that? Is there are way of judging that?

ANDREA WHITTAKER
If you take again quotes from the hospitals themselves, for example in India, they!|ll say that in general their medical procedures cost about a fifth to a tenth of what those medical procedures would cost in a developed country.

SIAN PRIOR
That!|ll pay for your airfare.

ANDREA WHITTAKER
Well a lot of their websites actually say that it!|s first world medicine at third world prices. And very bluntly put that up on their websites as you can afford a holiday once you have your procedures here. So yeah, that!|s !V that!|s how they market themselves.

SIAN PRIOR
And I guess along with that are there risks involved for people travelling for these kind of treatments? If it!|s cheap, is it nasty?

ANDREA WHITTAKER
Not necessarily. A lot of the hospitals involved, their specialists are trained overseas so they!|ll be trained in the US or Britain or Australia indeed, but there are risks and as with any biomedical procedure there!|s always going to be things that go wrong. And the problem is for patients travelling from overseas, they don!|t necessarily have the same levels of legal protection that they would expect from their home countries, and they may have very little recourse for damages if !V if something does go wrong. Part of the problem too is that if things do go wrong, they!|re often not going to be in the country where they had the services. So, all of those costs of complications are going to be handled back in their home country again. So they may end up, despite all of their efforts to keep things cheaper, they may end up with very expensive health bills back home.

SIAN PRIOR
I!|m Sian Prior and you!|re listening to Melbourne University Up Close. We!|re !V today, we!|re discussing medical tourism with Andrea Whittaker who!|s a senior lecturer at Asia Institute here at the University of Melbourne, Australia. Andrea I know that IVF treatment has been a !V a particular interest of yours. You mentioned for example IVF technology which will allow people to choose the gender of !V of the child they!|re trying to have. What other things are available that aren!|t available perhaps in their home countries?

ANDREA WHITTAKER
Well I don!|t particularly want to make an advertisement for anything, but I guess one of the !V the big issues where there!|s a whole lot of ambiguity and possibilities of exploitation of course is surrogacy arrangements. And, countries in the region differ in the extent to which they regulate surrogacy arrangements, as to whether they!|ll have paid surrogacy, and also in terms of donor gametes, so donor eggs, or donor sperm, as to whether they!|ll pay for donations. And when you!|re talking about a developed country and developing country situation there!|s enormous room for poorer women for example to be heavily exploited when money becomes the motivation for donating eggs or undergoing surrogacy procedures.

SIAN PRIOR
Well, you say exploited but others may describe that as a legitimate means for people without other means to earn some money.

ANDREA WHITTAKER
That is an argument but I guess one of the main issues ethically and from a public health point of view is whether or not women understand fully all the risks that they undertake in these procedures. It!|s not an unproblematic thing to be an egg donor or indeed a surrogate. And also what legal protections are in place for those women if there!|s complications. For example, it!|s very ambiguous at the moment if the child is born disabled, and the parents don!|t necessarily accept that child !V

SIAN PRIOR
Who is responsible?

ANDREA WHITTAKER
Who!|s responsible and who legally [is]? In many of the countries, the law!|s about who is actually the parent, [they] often still don!|t recognise the social parent. So, there!|s also risks for the people who are undertaking the surrogacy arrangement as to whether or not they!|ll be legally recognised as the parents. So a lot of those things still need to be sorted out and in Thailand certainly the law!|s about parenthood, are yet to be really legally sorted out.

SIAN PRIOR
Well, and this leads us on very neatly to the other main area of !V of your recent research. You!|ve done a lot of work in the area of abortion politics in Thailand. Can you give us ,Andrea, a brief overview of the situation for women in Thailand who currently want to access abortions?

ANDREA WHITTAKER
Again the whole situation is one of legal ambiguity, Sian. Technically abortion is illegal in Thailand. There!|s legislation since 1957 which bans abortion under circumstances except things like rape or seduction of a child under 15. And those have to be documented by the police. So, it!|s !V it!|s actually very difficult to get a technically legal abortion in Thailand. So, for women that!|s been very much a case that they might attempt to get a legal abortion but invariably often end up having to sort of go behind the legal processes and access an abortion through illegal practitioners. Now that can vary. It could be either a trained medical person who will provide those services, but for the women that I studied it more often than not is an untrained practitioner and leads to a large number of unsafe abortions. So, despite all the illegalities, there!|s about 300,000 abortions take place every year in Thailand. And a recent survey found about 19.5 per thousand births. So, a fairly high percentage of abortions still take place in Thailand.

SIAN PRIOR
Well, Andrea, tell us more about the women that you talked to and worked with in order to do your research. Who were they and where did you find them?

ANDREA WHITTAKER
Well, I!|m a medical anthropologist which means I look at cultures of health and illness, and in this case, I look at reproductive health. So for this research, it builds upon long term ethnographic research, which means that I went to a village in North East Thailand which is near the Lao and Cambodian boarder and lived there for 18 months initially, went back again for another 10 months and in that time got to know women in the village, so these are essentially women who are of peasant background, they grow rice, they may have about four years education, and talked to them about their lives and got to know what they do when situations like this occur. And so then through social networks talked to more women who!|d had abortions, they referred me to more women and more women. So at the end of the day, I did a survey of about 179 women and very indepth case studies with about 20 or so women who had had very recent illegal abortions.

SIAN PRIOR
Andrea, in many Asian countries and having many children is highly valued in the culture and in the society. What are the kinds of reasons that the women you worked with in Thailand are giving you for why they wanted to have abortions?

ANDREA WHITTAKER
The decision to !V to have an abortion, of course, is not a very easy one. And this is particularly in a context where the religious precepts of Buddhism suggest that abortion is !V is a very sinful act, and so, it!|s a very difficult decision for women and they often stressed that in their interviews to me. The primary motivation that women gave me in my interviews in the north east, and this may differ from place to place in Thailand, was essentially poverty and the economic difficulties that another child would bring. Most of the women that I talked to already had existing children. And this may differ in urban areas where it may be more likely that you!|ve got younger unmarried women or women who haven!|t yet had children having abortions. But certainly, in my area the majority of women were married, they had two children already and they!|d essentially completed their family, and really couldn!|t afford a !V another child to !V to raise and educate.

SIAN PRIOR
My guest today in Melbourne University Up Close is Andrea Whittaker, a senior lecturer at Asia Institute here at the University of Melbourne, Australia. Andrea, were these women!|s husbands or partners involved in that decision making generally?

ANDREA WHITTAKER
Well it!|s !V it!|s interesting that in focus groups about that very issue, opinions differed. And not surprisingly, men often said, !!!OOh yes. We !V we!|re deeply involved in all of these decisions. And of course they take our opinion into account.!!L
Whereas women often said, !!!ONo. it!|s just !V it!|s got nothing to do with the men and they!|re not the ones who have to raise and look after the child.!!L
So, it differed depending on who you talked to. So, one of the interesting things from the research was that it very much elicited local people!|s own sense of entitlements, women!|s own sense of what their reproductive rights were. And I was quite surprised at the way in which women often said outright that they didn!|t consult their husbands about the decision.

SIAN PRIOR
What about the health risks? If as you say quite a proportion of these abortions are you know off to the side, are strictly speaking, illegal, does this mean that women are putting themselves at risk of !V of things going wrong?

ANDREA WHITTAKER
Approximately 30% of women who!|d had illegal induced abortions from a very recent survey in the year 2000 - about 30% of women experienced serious complications. So, it depends very much on the techniques used to induce the abortion. They range from like I said trained practitioners, but also to very crude techniques which are just very unsafe and they can lead to things like septicaemia, so blood poisoning, haemorrhaging, death.

SIAN PRIOR
Infertility.

ANDREA WHITTAKER
And long term problems with !V with fertility.

SIAN PRIOR
It must be interesting if not difficult for you to be working in this area and on the one hand looking at the absolute high end of wealthy people accessing the latest gadgets, the latest in medical technology through medical tourism. And then poverty-stricken women in rural Thailand, enduring unsafe abortions through either lack of legal recourse or lack of simple access to appropriate medical facilities.

ANDREA WHITTAKER
Well, one of the things I guess is that I!|m interested in, in very broad terms, about the notion of Stratified Reproduction which is a term used to describe the way in which women have differential !V women and men have differential access to reproduction. One of the things that drives my research is this interest in class issues. How do poor women negotiate their reproductive decisions. And what are the sort of structural constraints that allow them either to have the children that they choose to have or not to have children. Again, in terms of my current research, I!|m interested again on the other side; what do the wealthy do when they want children but can!|t have them, and what are the constraints, or in this case, because of their wealth, what are the opportunities that are available to them which certainly aren!|t available to poorer women.

SIAN PRIOR
Well many thanks Andrea for joining us today !V

ANDREA WHITTAKER
Thank you.

SIAN PRIOR
- telling us all about your research.

ANDREA WHITTAKER
Pleasure.

SIAN PRIOR
I!|m Sian Prior and my guest today has been Andrea Whittaker, Senior lecturer at Asia Institute here at the University of Melbourne, Australia. And relevant links, a full transcript and more information on this episode can be found on our website at upclose.unimelb.edu.au We also invite you to leave your comments or feedback on this or any episode of Up Close, we!|d love to hear from you. Simply click on the Add New Comment Link at the bottom of the episode page.

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute of the University of Melbourne, Australia. This programme was produced by Kelvin Param, Eric Van Bemmel and myself Sian Prior. Audio recording by Craig McArthur and the theme music is performed by Sergio Ercole. Melbourne University Up Close is created by Eric Van Bemmel and Kelvin Param. Until next time, thanks for joining us. Goodbye.

VOICEOVER
You!|ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au, that!|s upclose.u-n-i-m-e-l-b.edu.au. Copyright 2007 University of Melbourne.

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