Andrea Whittaker

Pleasure and pain: Medical travel in Asia

Abstract The trade in health services for foreign patients, often termed ‘medical tourism’ or medical travel, is a growing industry being aggressively marketed across Asia. This paper explores the industry development in four countries: Thailand, India, Malaysia, and Singapore, providing a preliminary review of the political economy of the industry, marketing strategies, and linkages. As yet, there has been neither academic work considering the implications of this trade for public health, nor studies on the medical travellers themselves and their experiences. The final part of this paper contemplates some of the implications for public health in the region, and the ethical issues this globalized trade presents.

“Cycling Overseas”: Care, Commodification, and Stratification in Cross-Border Reproductive Travel

Cross-border reproductive travel involves the movement of patients to undertake assisted reproductive treatment through technologies, such as in vitro fertilization and associated procedures otherwise denied to them due to cost, access, or regulatory restrictions. Based on fieldwork in Thailand, the United States, and the Czech Republic, we explore the commodification of reproductive bodies within this trade and the reduction of the nurturing affective labor of reproduction to exchange value. Second, we examine the intensification and globalization of the stratification of reproduction. These inequalities are illustrated though discussion of the trade in poor womens bodies for surrogacy and ova donation. Even reproductive body parts, ova, sperm, and embryos are stratified—marketed according to place of origin, the characteristics of their donors, and gender.

Patients without borders: understanding medical travel.

The rapidly growing medical travel industry has implications for the health sytems of both sending and receiving countries. This article outlines the political economy of the industry and the potential opportunities and disadvantages it poses for access, equity, and the right to health. Although the trade carries economic benefits for countries receiving foreign medical patients, it comes at a cost to the provision of public health, through distortions in the health workforce and the development of two-tiered health systems. Inequalities and failures in the health systems of sending countries largely drive the need to travel for care.

Challenges of medical travel to global regulation: A case study of reproductive travel in Asia

This article explores the challenges medical travel poses for the development and implementation of health regulation in Asia. Cross-border reproductive travel in Asia is used to exemplify some of the ethical, legal and regulatory complexities such travel poses. A number of countries in the region lack regulatory frameworks regarding controversial procedures such as preimplantation genetic diagnosis for sex selection, commercial donor and surrogacy procedures to ensure protections for donors and surrogates or children born of such procedures. The particular challenge of reproductive travel arises when people travel for services because they wish to undertake a treatment requiring the embodied services or biological materials of other people in ways that are not legal or considered unethical in their home country. The final part of the article examines prospects for a global response towards the regulation of such trade. Such a response will require cooperation across sectors, international government organizations, state, and non-state actors to deal with the transnational interdependence it involves and to protect the rights of vulnerable groups. The challenge is to determine the mechanisms for regulating the trade, as well as the basis upon which global regulation is undertaken. Problématique du voyage médical au regard de la réglementation internationale: Etude de cas sur le tourisme reproductif en Asie Le présent article explore les défis posés par le voyage médical en termes d’élaboration et d’application de la réglementation de la santé en Asie. L’exemple du tourisme reproductif transfrontalier dans cette région est utilisé pour illustrer la complexité que ce type de voyage revêt sur le plan éthique, légal et réglementaire. Dans un certain nombre de pays asiatiques, des procédures controversées telles que le diagnostic génétique préimplantatoire pour la sélection du sexe, la vente d’organes et la maternité de substitution ne sont régies par aucun cadre juridique garantissant la protection non seulement des donneurs et des mères porteuses, mais aussi des enfants nés de ce type de procédure. Le défi propre au tourisme reproductif se pose lorsque le voyage est motivé par la recherche d’un traitement nécessitant l’utilisation du corps ou de matériel biologique d’autrui à des fins qui seraient illégales ou considérées comme non éthiques dans le pays d’origine. La dernière partie de l’article examine les options à envisager pour trouver une réponse visant une réglementation de ce commerce à l’échelle internationale. Une telle réponse nécessitera une coopération entre les différents secteurs, les organisations gouvernementales internationales, les Etats et des acteurs non étatiques pour gérer l’interdépendance transnationale qu’elle implique et protéger les droits des populations vulnérables. Le défi consiste à déterminer quels mécanismes permettront de réglementer ce commerce et sur quelles bases la réglementation internationale reposera. Retos del viaje de carácter médico para la regulación global: Un caso práctico de viaje reproductivo en Asia Este artículo examina los retos que el viaje de carácter médico plantea para el desarrollo y la implementación de reglamentos de salud en Asia. El viaje reproductivo transfronterizo en Asia se utiliza para ejemplificar algunas de las complejidades regulatorias, legales y éticas que tal viaje plantea. Varios países de la región carecen de marcos regulatorios en cuanto a procedimientos controvertidos tales como el diagnóstico genético de pre-implantación para la selección del sexo, el donante comercial y los procedimientos de vientres de alquiler, para asegurar la protección de los donantes y madres de alquiler o para los niños nacidos por de esos procedimientos. El particular cambio del viaje reproductivo surge cuando las personas viajan porque desean someterse a un tratamiento que requiere de servicios incorporados o materiales biológicos de otras personas y que se consiguen de manera ilegal, o se considera inmoral en sus países natales. La parte final de este artículo examina las expectativas de obtener una respuesta global hacia la regulación de tal mercado. Tal respuesta requerirá la cooperación a través de los sectores, organizaciones gubernamentales internacionales, actores estatales y no estatales para así tratar la interdependencia transnacional que implica y para proteger los derechos de los grupos vulnerables. El reto consiste en determinar los mecanismos que regulan el mercado así como las bases sobre las cuales se lleva a cabo la regulación global.

Global Technologies and Transnational Reproduction in Thailand

Globalisation has spawned new relations between capital and labour, bodies and the state, and belonging and extraterritoriality: entailing complex movements of people, information, technologies, capital and commodities. Hypermobility and the ease of crossing national boundaries have led to a rethinking of the ties between people and place and the politics of place-making and individual, group, national and transnational identities (Kearney, 1995, p. 553, p. 558). Although in the past marriage to an overseas partner would mean that someone would rarely return to their homeland again, today’s global communication networks, affordable transportation, and dual citizenships mean that transnational families are able to maintain significant contact with two or more countries. An increasing number of people now organise their economic, social and family relationships within networks across national boundaries (Smith, 2005; Levitt, 2001). Transnational migrants simultaneously are anchored in and transcend one or more nation-states. They cut across the boundaries of the nation-state and are inclined to identify themselves in hybrid ways as members of global networks spanning national boundaries, living between the local and global (Brah, 1996; Ang, 2001). Such transnational lives have implications for the ways in which gender relations are practised, consumed and represented (Pessar and Mahler, 2003, p. 834) and reproductive lives and family structures are negotiated. This article describes the use of globalised technologies such as assisted reproductive technologies (hereafter, ARTs) by transnational migrant couples. Specifically, it examines ‘‘transnational reproduction’’ – travel back to Thailand by Thai expatriates to undertake assisted reproductive technologies. In this research I explore how global technomedicine, in the form of assisted reproductive technologies, intersects with mobility and transnationality and allows new possibilities for

Eliciting qualitative information about induced abortion: lessons from Northeast Thailand.

Obtaining reliable information about induced abortion is notoriously difficult, especially where abortion is illegal. This article describes methods used in a study of illegal induced abortion among village women in Northeast Thailand. A variety of methods were used to gather in-depth qualitative data on abortion experiences including a randomized interview survey on reproductive health, in-depth interviews with women who had experienced an induced abortion in the last two years, and the use of vignettes in focus group discussions with men and women. The survey provided a broad overview of the extent of the experience of abortion. In-depth interviews through social networks proved more successful for obtaining reliable accounts of abortions and suggest that survey results were underestimates. Focus groups discussed the situational ethics involved in abortion decisions. Within an appropriate context and study design, it is possible to obtain highly sensitive information while respecting the privacy of informants.

Factors impacting HIV testing: a review – perspectives from Australia, Canada, and the UK

With the current global focus on strengthening HIV prevention through greater testing and treatment uptake, it is increasingly salient to identify and address barriers to testing. A review of the published, peer-reviewed literature and national reports from Australia, Canada, and the UK (2003–2013) on barriers to HIV testing was conducted to provide new information relevant to Australia and to complement earlier reviews from Canada and the UK. A systematic database search using keywords and a set of inclusion criteria yielded 36 studies (Australia = 13; Canada = 6; and the UK = 17). In addition 17 unpublished reports were included in the review. Our study uses a novel, comprehensive framework to describe barriers to HIV testing, and thus contributes to moving beyond the traditional patient–provider–system categorization. Within that framework, barriers are categorized as either intrapersonal (reported in 15 studies), interpersonal (21), or extrapersonal (16) and conceptualized within wider sociocultural and structural contexts. Peoples abilities and motivations to test (intrapersonal factors) are influenced by a host of interconnected factors spanning relationship (interpersonal) and broader socioeconomic, political and cultural (extrapersonal) factors. We suggest that the relative effects of interventions targeting barriers to HIV testing at the intrapersonal and interpersonal levels are limited by the extent to which the social determinants of health are addressed. The framework may also lend itself to thinking about the enabling factors for HIV testing, and future research may investigate the application of that framework for strategizing the most effective response. Future studies should also capture the lived experiences of barriers to HIV testing experienced by patients, especially in populations which are hard to reach based on social and geographic distance. Context-specific studies to evaluate the feasibility and effectiveness of various interventions proposed in the literature to address barriers to HIV testing are needed.

Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom

ABSTRACT International focus on reducing onward HIV transmission emphasizes the need for routine HIV testing and early uptake of antiretroviral treatment (ART). Strategic targets have been set for 2020 to achieve the goal of 90% of people infected with HIV diagnosed, 90% of identified cases on treatment, and 90% of persons on treatment virally suppressed (90–90–90). It is vital to understand the complexity of factors influencing a persons treatment decisions over time and the context which may enable better adherence. In this paper we present findings from the review of published and gray literature (2003–2013) on the documented factors associated with treatment initiation and adherence in the general adult population of Australia, Canada, and the UK. A framework developed by Begley, McLaws, Ross, and Gold [2008. Cognitive and behavioural correlates of non-adherence to HIV anti-retroviral therapy: Theoretical and practical insight for clinical psychology and health psychology. Clinical Psychologist, 12(1), 9–17] in Australia was adapted to summarize the findings. A systematic database search using keywords and a set of inclusion criteria yielded 17 studies (Australia = 6; Canada = 8; UK = 3). In addition 11 reports were included in the review. We found that a persons abilities and motivations (intrapersonal factors, reported in 7 studies) to start and continue ART are influenced by a host of interconnected factors spanning relationship (interpersonal, 3 studies) and broader structural (extrapersonal, 15 studies) factors that are situated within social determinants of health. People therefore evaluate various costs and benefits of starting and staying on treatment, in which biomedical concerns play an important yet often subsidiary role. In this review the economic barriers to care were found to be significant and under-reported, highlighting the persistent health inequities in terms of access to services. Our understanding of the context around peoples use of ART remains poor. Qualitative social research within HIV-positive communities is urgently needed to capture peoples lived experiences and may address some of this deficit in understanding.

Living together in Australia: Qualitative insights into a complex phenomenon

Abstract This paper mines data from in-depth interviews on family formation with 115 women, men and couples of family-forming age in eastern Australia to examine aspects of the complex phenomenon of living together unmarried. Sixty-five percent of interviews yielded evidence of one or more such relationships entered over approximately a 20-year period. Informants had rarely made considered ‘decisions’ to cohabit. Moving in had rather ‘just happened’, often after couples were ‘sort of’ living together anyway through regularly staying over with one another. What tended to be transitions rather than datable events were widely perceived to be ‘natural progressions’, and motives for them were typically more pragmatic than emotional. The notion of cohabitation as trial marriage did not resonate widely among cohabiters, but did appear to have aided increasing parental acceptance of the lifestyle. Non-cohabiters mostly cited religious beliefs, a desire not to offend parents or a view that by marrying directly they had shown greater commitment as reasons for not having lived together. Youthful entry to cohabiting relationships seems frequently to presage their dissolution as ‘growing up’ relationships in a climate that increasingly eschews serious family formation until some years later in life. Transitions to marriage, which remains a highly symbolic act of commitment despite being seen in some quarters as irrelevant, have a variety of triggers. Prominent among them are decisions to have children (notwithstanding widespread childbearing within cohabiting unions) and the age-old prerogative of a male to propose marriage as the mood takes him.

Exploring women's perspectives of access to care during pregnancy and childbirth: A qualitative study from rural Papua New Guinea

OBJECTIVES to explore womens perceptions and experiences of pregnancy and childbirth in a rural community in PNG. DESIGN a qualitative, descriptive study comprising focus group discussions (FGDs) and in depth interviews. SETTING this study took place in a rural community in Eastern Highlands Province, PNG. PARTICIPANTS 51 women participated in seven focus group discussions. In depth interviews were undertaken with 21 women, including women recruited at the antenatal clinic, women purposively selected in the community and three key informants in the community. FINDINGS the majority of women mentioned the benefits of receiving antenatal care at the health facility and the importance of a supervised, facility birth. Women faced numerous challenges with regards to accessing these services, including geographical, financial and language barriers. Cultural and customary beliefs surrounding childbirth and lack of decision making powers also impacted on whether women had a supervised birth. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE distance, terrain and transport as well as decision making processes and customary beliefs influenced whether a woman did or did not reach a health facility to give birth. While the wider issue of availability and location of health services and health system strengthening is addressed shorter term, community based interventions could be of benefit. These interventions should include safe motherhood and birth preparedness messages disseminated to women, men and key family and community members.