Scalpel Safari to New Delhi, or the Perils of Medical Tourism

In the 20th century residents of developing countries traveled to hospitals in the West to receive medical treatment. Today the situation is reversed due to the high cost of care in the U.S., long delays in treatment in parts of Europe, and the growing demand for cosmetic surgery. Reporter Sonia Shah investigates medical tourism in New Delhi and discovers that this new trend has spawned unintended consequences, including debilitating illnesses caused by newly detected antibiotic-resistant bacteria. Subscribers to Le Monde may read the story in its entirety in French here. The following text is from the December English edition.

Medanta Hospital is just 10 minutes from New Delhi international airport, where special immigration counters and prominent signs help medical tourists breeze through arrivals. The new highway to the hospital is lined with the buildings of multinational companies — Ray-Ban, Ericsson, 3M, Toshiba, Deloitte — and epitomises today's Indian economy in which the pro-market reforms of the early 1990s have led to years of 6-8% annual growth.

Through the later 20th century, patients from developing countries came to western hospitals seeking high-tech medical care unavailable at home. That flow has started to reverse. With costs in countries such as the US increasing sharply, and waiting times in Europe getting longer, patients from the West now go to developing countries for cheap, quick medical care no longer accessible at home, in a booming medical tourism industry valued at $60bn worldwide. This year, reports the Deloitte Centre for Health Solutions, over 1.6 million Americans will go on "scalpel safaris" to lower costs and avoid queues.

More than 100,000 will arrive at such places as Medanta Hospital, a new 174,000 square metre facility outside New Delhi, where world-class doctors attend over 1,000 beds and 45 operating theatres, and "international care executives" coordinate treatment, travel and hotel rooms for patients from the Middle East, Asia, Africa and the Americas. Private, for-profit hospitals such as Medanta can now be found across India, because of Indian policymakers' commitment to support "the supply of services to patients of foreign origin", through tax exemptions and other breaks (1).

The stately hospital building is surrounded by extensive gardens. Inside, white marble walls are hung with museum-quality art. Young women usher overseas guests to a dedicated lounge, with deep leather couches and plasma-screen televisions, to await heart surgeries and knee replacements.

Similar procedures cost five times as much in countries like the US. "We can do a heart surgery for less than $5,000," said Medanta's chairman, Dr Naresh Trehan, with as good or better results. It's not just that labour and services are cheaper in India, "what's going on over there [in the West] is actually a lot of wastage. There is inflation everywhere in their overhead costs. The administrators in a hospital [in the US] outnumber doctors." Not so in India, where regulatory oversight of medicine, from prescription drug sales to medical education, is scant at best.

Advocates of medical tourism claim that Indian surgeries should be seen as a boon for ailing western healthcare systems, a kind of medical outsourcing, equivalent to the call centres that have allowed western companies to cut service costs by 40% or more (2). Western insurance companies such as Blue Cross Blue Shield and Aetna seem to agree. Both have quietly added hospitals in India and in the developing world to their lists of covered providers (3).
'We should set our own house in order'

But questions on the ethics of providing sophisticated medical care for foreigners while many ordinary Indians lack access to basic health services go unanswered (4). "We should set our own house in order rather than cater to foreigners," said New Delhi surgeon Samiran Nundy, a prominent critic of the privatisation of healthcare in India. India spends around 1% of its GDP on public health, one of the lowest rates in the world. Fewer than half of India's children are fully immunised, and a million Indians die every year from treatable tuberculosis and preventable diarrhoeas. Medical expenses drive nearly 40 million Indians into poverty every year (5).

Advocates such as Trehan say that treating medical tourists allows his hospital to provide better care for locals. "It's like space travel. People will always say 'there is so much hunger, why are you doing it?' That's not the point" (6). Locals who do make it to Medanta grumble about being treated as second-class citizens. One described being made to wait for over an hour, while international patients were rushed through to their doctors. "International patients get priority," he complained on a website about Medanta. "Domestic patients don't."

Nowhere are the contradictions of the business — and the government's support for it — clearer than in the controversy over the spread of antibiotic-resistant bacteria. New Delhi microbiologist Chand Wattal heads one of the few microbiology labs in hospitals in India. Last year he reported on the spread of a new drug-resistant bacterium in his Delhi hospital, one that could resist not only the usual antibiotics but the most powerful, last-resort antibiotics, given intravenously (7). These super-resistant bacteria have the "NDM-1" (New Delhi metallo-beta-lactamase-1) gene, named after the city in which they appear to have emerged. Only two imperfect drugs are available that can treat NDM-1 infections, and there are few new drugs under development, a situation that Wattal said has clinicians across India "scared".

Drug-resistant bacteria are a global problem, with bugs such as MRSA (methicillin-resistant staphylococcus aureus) plaguing western hospitals. But medical tourism, poverty and government policy in India make the spread of NDM-1 worrying. The first NDM-1 infection was spotted in 2008 in a Swedish patient who had recently been hospitalised in India. In 2009 the UK national health service issued a warning that patients in the UK who had been hospitalised in India and Pakistan had NDM-1 infections. In 2010 three cases of NDM-1 infection were discovered in the US. All three patients had received medical treatment in India (8). Since then, NDM-1 infections have been discovered in 35 countries, in many cases tied to medical tourism to India. There is also evidence that NDM-1 bacteria have started to spread more widely, infecting people with no history of travel to South Asia.
Prime conditions for NDM-1

But NDM-1 bacteria are propagating most lushly in India. The NDM-1 gene circulates in a family of bacteria called "Gram-negative" (after the Gram test used to identify them) whose unique cell envelopes make them both more toxic and harder to treat than "Gram-positive" bacteria. Many Gram-negative bacteria colonise the human gut and thrive in places with poor sanitation, where gut bacteria can pass from host to host through food and water contaminated with faecal matter. Basic sanitation remains rudimentary in many places in India. Only 65% of Delhi's sewage is adequately treated and 20% of the population live in overcrowded slums highly exposed to contaminated water and food (9). Uncollected trash and teeming crowds abound just outside Medanta's gates. Hawkers sell freshly squeezed fruit juice and vegetables from carts and, in a dusty lot next to the hospital, men sit on overturned buckets, eating rice and curry. A narrow stream emerges from near the hospital gates; its weedy banks are lined with trash. In a nearby slum, barefoot children play in narrow alleyways lined by open gutters carrying waste water and excrement.

In April 2011 researchers found NDM-1 bacteria in samples of Delhi's drinking water and in puddles around the city. University of Cardiff microbiologist Tim Walsh suspects that between 100 million and 200 million Indians now carry NDM-1 bacteria in their guts. NDM-1 bacteria flourish at tropical temperatures, so the warm weather and floods of the monsoon season expose even more people.

Better healthcare for the poor, improved hospital hygiene and more judicious use of antibiotics could help contain NDM-1. But the politics of national pride may make such measures impossible. Indian medical authorities and politicians have both denied the public health relevance of NDM-1, and accused scientists working on the issue of a "conspiracy to hurt Indian medical tourism", as The Indian Express put it. After initial reports on the bacteria appeared, Indian government authorities sent threatening letters to Indian researchers who had collaborated with British scientists on NDM-1 studies, according to the UK's Channel 4 News (10). Walsh, who led many of the studies, said that his Indian collaborators were pressured to disavow their research and he became persona non grata in India: "I'm the devil incarnate and eat babies for breakfast according to the Indian government. It's a witch hunt."

The Indian government first complained that the bacteria gene was named after their capital city. Then, as the controversy grew, it convened an advisory committee on antibiotic resistance, and floated an ambitious proposal to ban the sale of antibiotics without a physician's prescription, and restrict the use of last-resort intravenous antibiotics to tertiary hospitals. But after pharmacists went on strike in August 2011, the proposal was withdrawn (11). "The committee was a knee-jerk response," said Ramanan Laxminarayan, of the Public Health Foundation of India. Wattal, Laxminarayan and others agree that the proposed restrictions would have affected a wide range of drugs besides antibiotics, and would have impeded access to life-saving antibiotics for the rural poor. In fact, the policy had little chance of being enforced: health policy is implemented at state level in India, not federal level.

(1) Amit Sengupta and Samiran Nundy, "The private health sector in India", British Medical Journal, London, no 331, 17 November 2005.

(2) "Back office to the world", The Economist, London, 3 May 2001.

(3) Bernhart and Roseanne White Geisel, "Few US employers book passage on the ship of medical tourism; estimates vary widely on savings achieved by surgery performed abroad", Business Insurance, 10 March 2008.

(4) Ramanan Laxminarayan and Nirmal K Ganguly, "India's vaccine deficit: why more than half of Indian children are not fully immunized, and what can — and should — be done", Health Affairs (Project Hope), no 6, Bethesda (US), 8 June 2011.

(5) Yarlini Balarajan et al, "Health care and equity in India", The Lancet, London, 5 February 2011.

(6) Amelia Gentleman, "Lines drawn in India over Medical Tourism", International Herald Tribune, 3 December 2005.

(7) ProMED Digest, vol 2011, no 467, Brookline (US), 6 October 2011.

(8) "Detection of enterobacteriaceae isolates carrying metallo-beta-lactamase — United States, 2010", Centers for Disease Control and Prevention, Atlanta, 25 June 2010.

(9) See Maggie Black, "The world's dirty big secret", Le Monde diplomatique, English edition, January 2010.

(10) Tom Clarke, "Drug Resistant Superbug Threatens UK Hospitals", Channel 4 News, 28 October 2010.

(11) Alice Easton, "Regulating Over-the-Counter Antibiotic Sales: What will 'Schedule HX' Mean for India?", The Center for Disease Dynamics, Economics, & Policy, Washington, DC, 2 August 2011.