IMPAKTER ESSAY: Vaccination, Medical Tourism, and the Expansion of Global Bioethics
In 2003, the Concorde stopped ferrying international passengers across the Atlantic Ocean at supersonic speeds, while metaphorically demonstrating how much smaller the world has become. But international travel at prices more affordable than the Concorde demanded remains popular, despite the imposition of heightened security measures since the terrorist attacks in the US on September 11, 2001 and oil price rises in the subsequent decade that have only tailed off during the last two years without corresponding declines in air fare. Other modern technologies have also certainly stepped or stampeded into the breach to cement the notion of ease of interaction among a globally burgeoning population. In our increasingly globalized or more navigable world, people across the planet can now instantaneously, wirelessly connect via webcams, Facebook, Twitter, Instagram, and texting, as well as older but just as rapid methods like e-mail.
The speed and sheer quantity of modern communications do not guarantee quality, but the technological advances that they represent have rendered today’s population of human beings much more connected and interdependent. Indeed, the modern uses of financial markets—and abuses stemming from their deregulation—have engendered a global, not local, economic crisis that provides ample evidence of convoluted connections worldwide.
Despite the greater mobility among what has expanded to a global population of over 7 billion increasingly interconnected people, and the gradual declines of some cultures and languages corresponding with industrialization and modernization, there remain vast differences among global cultures and significant disparities in wealth, health and access to adequate health care, as well as means to affordable travel and various other metrics within and across countries.
Slightly pre-dating these changes, though largely concurrent, the modern field of bioethics emerged, in the late 1960s and early 1970s, establishing principlism as the predominant method and autonomy, non-maleficence, beneficence, and justice as the guiding principles.(1-3)
While a useful framework, particularly in the clinical setting from which it was derived, several authors have questioned its applicability on a global scale.(1-4) Indeed, accounting for cultural distinctiveness and variation is thought by some to be an integral approach to global bioethics that the principlist approach does not adequately address.(1-3, 5)
When we consider the backdrop of an increasingly interrelated and mobile global population, the issues related to vaccination and medical tourism loom as especially instructive. If we accept the critics’ arguments that a broader understanding of global bioethics must include culture, including pertinent variations in perspectives, do the categories of vaccines and medical tourism simply present additional problems regarding the regnant normative bioethical framework or point us in a direction toward progress?
What should global bioethics look like?
In the photo: Immunizations against measles are being administered in Uttar Pradesh, India. Photo credit: Flickr/CDC Global (cc 2.0)
Vaccination: India, Nigeria, Cameroon, and Pakistan
It is well known that millions of lives have been saved through the discovery, development, and use of vaccines. And yet their use remains somewhat controversial. In the US, a small but vocal faction has scared up enough opposition based on fears of a link between various childhood vaccinations and autism that several studies have been conducted to debunk such beliefs.(6)
Clearly, then, an effective means of delivering the message about vaccines is necessary. But various populations can and do have legitimate reasons to distrust their own governments or interlopers with an agenda that may not match local perceptions of the most exigent needs or even exacerbate rampant fears or rumors. So, while the goal of the World Health Organization (WHO) of globally eradicating polio is, of course, laudable, such a massive undertaking must include not just employing local personnel but learning about local attitudes and cultural beliefs that may help or hinder such a lofty aim.
In Southern India in 2003, efforts to stymie a new outbreak of polio were largely successful but met with some resistance because rumors in a small Muslim community had circulated about the Indian government distributing different vaccines to Muslim boys to render them infertile.(7) The vaccination program was also met with healthy doses of skepticism in terms of its overall mission. That is, several people, including doctors, villagers, and even those participating in the door-to-door inoculation campaign—all witnesses to a greater prevalence of malaria, tuberculosis, and cholera—wondered why international funding was available for a polio vaccine program when there was an apparently greater need for clean water, improved nutrition, irrigation systems, and functioning septic systems, which would help prevent polio and other diseases.
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Similar concerns were expressed a couple of years later in Nigeria. Only the local community in Zaria, the town in Northern Nigeria targeted by a consortium of international health agencies and associated donors, went further in its criticism. Besides questioning the benefits of a polio vaccination program when primary health care clinics could be better serviced, they questioned the top-down governmental imposition of the program under the auspices of outside or foreign aid organizations.(8) In addition, some Zaria residents viewed routine immunization of apparently healthy infants and children as dangerous. Renne also identified the long-standing political issues plaguing Nigeria that help explain widespread distrust of the government.
Consistent with the case in India is the perspective among significant swaths of the population that such programs represent a misappropriation of resources at the expense of more pressing needs.
Previously, in Cameroon in 1990, rumors that a vaccine program intended to reduce neonatal tetanus was actually a drive to sterilize young women thwarted the well-intentioned campaign.(9) There were numerous governmental, social, and public policy factors converging in this case, as well as a prior history of a French colonial attempt to control gonorrhea adversely affecting fertility that contributed to such beliefs. In addition, the fact that the vaccination program was free despite the recent implementation of a fee-for-service schedule in public health centers provoked suspicion, actually fanning the flames of the rumor.
Aid workers embark on vaccine programs with the best of intentions: to improve the public health, to prevent disease from spreading locally, and to prevent disease from crossing borders. But these cases demonstrate the inadequacy of the Western bioethical approach founded on principlism by revealing that historical and socio-cultural contexts must be accounted for and that external organizations, even if they employ local workers, must strive not to act paternalistically by ignoring the perspectives of the people to whom they intend to lend assistance.
In 2011, it was a fake vaccination program which sparked reasonable cynicism that doomed several people in Pakistan. Specifically, the fraudulent hepatitis B vaccination drive run in Abbottabad by the U.S. Central Intelligence Agency with a Pakistani doctor as a cover to find information on and ferret out Osama Bin Laden—and in which international non-governmental organizations were manipulated—led to widespread anger in many Pakistan villages directed at health workers trying to conduct legitimate polio vaccinations. Polio has been nearly eliminated from the world, but remains extremely endemic in Pakistan.(10)
All of these cases buttress the need for cultural sensitivity and understanding of the social, political, and historical contexts of the countries in which foreign, often Western, aid workers find themselves. Such a dynamic might be best summed up by Pearce’s statement that “cultural conflicts and transformations occurring when technologies fashioned in accordance with the values and structures of one type of society are transported to another possessing different assumptions, ideals, and constraints.”(11) Aid workers embark on vaccine programs with the best of intentions: to improve the public health, to prevent disease from spreading locally, and to prevent disease from crossing borders. But these cases demonstrate the inadequacy of the Western bioethical approach founded on principlism by revealing that historical and socio-cultural contexts must be accounted for and that external organizations, even if they employ local workers, must strive not to act paternalistically by ignoring the perspectives of the people to whom they intend to lend assistance.
Photo credit: European CEO
Questionable uses of resources, particularly at the expense of local populations, come into play in the realm of medical tourism as well. It is considered one of the primary disadvantages of this emerging phenomenon, which itself may be a perfect example of the manifestations of the global changes that have made the world seem much smaller. As Whittaker and colleagues suggest, travel for medical purposes has resulted from a “changing demographic profile of aging populations in high- and middle-income countries seeking health care, the ease of international travel and global communication, the retreat of neoliberal states from the provision of public services, and the increasing portability of health insurance.”(12) The services cover cradle to grave needs insofar as popular specialties include fertility, various diseases, elective procedures (including dermatology and plastic surgery), and euthanasia.
Medical tourism offers a complex set of circumstances as nations can both gain and lose income; that is, they can send and receive patients, practitioners, and products, and hospitals can be foreign owned. This interplay creates an intricate web of advantages and disadvantages experienced by the host country.
Benefits include the generation of foreign exchange, jobs, and tax revenues as well as a diverse range of specialists for the whole population.
Disadvantages include a “brain drain” that occurs when skilled medical practitioners are lured from the public to the private sector, or even to another country, and the development of a two-tiered health system in which advanced hospitals cater to wealthy patients and poorly equipped public hospitals treat the rest of the population.(12) More affluent traveling patients may then benefit from medical resources that would have otherwise been directed to local poor patients, particularly in low-income countries.
Indeed, this is the ethical crux of the issue—medical tourism can limit the access, availability, and quality of health care for native, especially poor, populations, thus yielding a flagrant lack of equity in the distribution of health care and potentially compromising public health.
A particularly stark example of poverty and inequity impinging on the health system is the case of the widespread sale of healthy kidneys by the destitute in India, with evidence of associated decline in health and failure to achieve long-term economic benefit by the seller.(13) Egregiously, donors felt that they were poorly informed of the likely results. In line with the criticisms of this practice, this phenomenon is a patent example of desperate people taking desperate steps rather than exercising autonomy.(13) This case highlights not only global interconnectedness, when travelers receive the donated kidney, but exploitation of the global poor, and the commodification of the body, which is more likely in lower-income nations with fewer regulations.
Cross-border reproductive travel is another example of medical tourism in which exploitation, in this case of poor women for surrogacy or ova donation, is an integral element of the enterprise.(14)
Getting Away from It All: Medical Tourism in Pursuit of Euthanasia
Physician-assisted suicide and euthanasia are controversial, hotly debated topics in the medical, legal, and bioethical realms. Such practices are illegal in many countries and most states within the US (except, OR, WA, CA, and VT; physician-assisted suicide is legal under a court ruling in MT and is under consideration or legal review in a handful of other states).(15) At least in this case, direct exploitation of a native, especially low-income, population is not the prevailing issue. But it can still translate to the transfer of medical resources from native citizens, in the form of practitioners and infrastructure that might be otherwise directed.
Switzerland is the capital of medical tourism for this purpose and would appear to cater to wealthier clients, while these services are offered inexpensively in Mexico.(16) If a country, especially when in close proximity to or surrounded by others, is the only provider of such services, the potential for revenue generation could be significant and could thus serve as an incentive to its medical sector, even if the law permitting euthanasia is enacted for ostensibly humanitarian purposes.
The poor around the globe, by comparison to most people who have the resources to pay for such a final destination, are more likely to financially struggle through their lives, to be exposed to infectious disease, and they have a higher probability of not dying in comfort. Medical tourism for the purposes of dying with dignity, from the perspective of the poor, might appear to be unfathomable at some level but also another stark example of the advantages of affluence.
In the photo: Paul Wolpe, bioethics professor at Emory University, gives a TedX talk. Photo credit: Flickr/TedxPeachtreeTeam (CC2.0)
Broadening the Scope of Global Bioethics Beyond Cultural Consideration
It is clear from these international examples of vaccination programs and medical tourism that a global bioethics must incorporate the sociocultural context, not to mention the historical, political, and economic contexts, in which it is to be applied. Of course, examples abound and Turner’s discussion of the vast disparity between the way most Americans and Canadians are prepared to hear bad medical news and the attitudes, conceptualization, and vernacular of the Navajo people in Northeastern Arizona about such issues concisely illustrates the point of divergent perspectives on matters related to health and the inadequacy of the prevailing normative framework of bioethics.(2)
It isn’t only a wider range of voices and contexts to account for that would benefit and enrich global bioethics. The global economic crisis is showing no real tangible signs of abating. In fact, a so-called “double dip” in what has been called the “Great Recession” may be underway.(17) All but the most intransigent, politically motivated of folks are beginning to link the spate of extreme weather events and string of heat records being broken to the effects of global climate change. Our planet faces daunting challenges related to the reverberating effects of these human-generated or –influenced phenomena. Continued reliance on nuclear energy coupled with the effects of earthquakes and a resultant tsunami threatens the food and water supply chain in Japan and in countries to which they export. As for how sea creatures fare as a result of that chain of disasters—and how it ultimately affects the food chain in regions far from Japan—remains to be seen. But five years on, the area is not safe for human habitation.
Such catastrophes bring into relief one of the tragic ironies besetting the human plight: on the one hand, there is a growing movement to shun plastic water bottles due to their pervasive environmental pollution and to fight corporate profits and efforts to further privatize water, access to which is considered by many to be a universal human right; on the other hand, with the number of environmental catastrophes proliferating in recent years threatening water supplies and food chains (e.g., the BP oil gusher in the Gulf of Mexico in 2010 and the Fukushima nuclear meltdown in Japan in 2011), bottled water might soon actually be safer than filtered tap water. Although, by and large, tap water in most municipalities in the US, at least, has been considered as safe if not safer than bottled water and, of course, free, with the Flint River a notable and tragic exception.
Such events can clearly exert far-reaching ramifications on various aspects of human health, not to mention forcing migration of climate refugees from the loss of low-lying island nations in the near future. In 2011, the world witnessed a mass exodus into Kenya of Somalis fleeing protracted drought and political instability. Starving Somali children at that time were being vaccinated for polio and measles in an ambitious campaign by WHO that targeted 215,000 children under the age of five years.(18) Economic reforms have led to the gutting of China’s free health care system.(19)
A normative bioethical framework should be able to accommodate the many voices and cultures affected by such far-reaching events, taking into account the ethical variations among cultural groups,(3) and of course within them, as well as the dynamics of power in multiple kinds of relationships among individuals and within and across cultures.
In other words, in addition to taking the cultural context into account when applying, and perhaps expanding, normative bioethical principles in increasingly pluralistic settings, a global bioethics must also consider global contexts or the implications of trends, issues, or movements with global impact.
In addition to the need to attend to the moral worlds of patients and their families, as Turner calls for,(2) across the globe, bioethics can and should be applied to a whole host of other intimately linked issues that can and do impact health throughout the world. The billion-dollar food industry, for example, that wields so much power in the multicultural US society, and far beyond, has contributed mightily to an obesity epidemic in this country that has been recently “exported” to other nations in the form of the Western diet, which is heavy on processed foods, as large-scale agribusiness has widely supplanted subsistence and sustainable farming across the globe.
A global bioethics would not only weigh in on the merits of what recently passed for debate in the US on health care reform (read: health insurance reform, as it turned out to be in the form of the Affordable Care Act), but introduce comparisons to the systems in other developed as well as less developed countries. The issues that an evolving global bioethics should address would also include politics and its causative or ameliorative roles in the vast array of issues pertaining to health and the germane moral dimensions of our actions and inactions in sundry inextricably linked global developments and crises.
EDITOR’S NOTE: THE OPINIONS EXPRESSED HERE BY IMPAKTER.COM COLUMNISTS ARE THEIR OWN, NOT THOSE OF IMPAKTER.COM.
- Hellsten SK. Global Bioethics: Utopia or Reality? Developing World Bioethics, 2008;8(2):70-81.
- Turner L. Bioethics in a Multicultural World: Medicine and Morality in Pluralistic Settings. Health Care Analysis, 2003;11(2):99-117.
- Muller JH. Anthropology, Bioethics, and Medicine: A Provocative Trilogy. Medical Anthropology Quarterly, 1994;8(4):448-67.
- Takala T. What is wrong with global bioethics? On the limitations of the four principles approach. Cambridge Quarterly of Healthcare Ethics, 2001;10:72-7.
- Marshall P, Koenig B. Accounting for Culture in a Globalized Bioethics. Journal of Law, Medicine & Ethics, 2004;32:252-66.
- Maryland Family Network website: http://mfn.convio.net/site/News2?page=NewsArticle&id=5207&autologin=true. Accessed 8/6/11.
- Gawande A. The Mop-Up: Eradicating Polio from the Planet, One Child at a Time. The New Yorker, January 12, 2004.
- Renne E. Perspectives on Polio and Immunization in Northern Nigeria. Social Science & Medicine, 2006;63:1857-69.
- Feldman-Savelsberg P, Ndonko FT, Schmidt-Ehry B. Sterilizing Vaccines or the Politics of the Womb: Retrospective Study of a Rumor in Cameroon. Medical Anthropology Quarterly, 2000;14(2):159-79.
- Lazare S. Pakistan: CIA’s Fake Vaccination Ploy to Hunt Bin Laden Sparked Polio Epidemic. Common Dreams, May 9, 2014 (http://www.commondreams.org/news/2014/05/09/pakistan-cias-fake-vaccination-ploy-hunt-bin-laden-sparked-polio-epidemic).
- Pearce TO. Women’s Reproductive Practices and Biomedicine: Cultural Conflicts and Transformations in Nigeria. In Conceiving the New World Order: The Global Politics of Reproduction. Ginsburg F, Rapp R, eds. Berkeley: University of California Press. 1995, pp. 195-208.
- Whittaker A, Manderson L, Cartwright C. Patients without Borders: Understanding Medical Travel. Medical Anthropology, 2010;29(4):336-43.
- Goyal M, Mehta RL, Schneiderman LJ, Sehgal AR. Economic and Health Consequences of Selling a Kidney in Inda. JAMA, 2002;288(13):1589-93.
- Whittaker A, Speier A. “Cycling Overseas”: Care, Commodification, and Stratification in Cross-Border Reproductive Travel. Medical Anthropology, 2010;29(4):363-83.
- Li V. California Becomes 5th State to Legalize Assisted Suicide. ABA Journal, October 5, 2015 (http://www.abajournal.com/news/article/california_becomes_fifth_state_to_legalize_assisted_suicide).
- Health-Insurance.org website: http://www.health-insurance.org/assisted-suicide-travel. Accessed 8/7/11.
- Reich R. The Republicans’ Double Dip, and What Must Be Done. The Huffington Post, August 5, 2011 (http://www.huffingtonpost.com/robert-reich/post_2262_b_919217.html).
- International Rescue Committee website: http://www.rescue-uk.org/about-irc-uk/media-centre/news/article/date/2011/08/vaccination-campaign-reaches-vulnerable-refugee-children-in-kenya/. Accessed 8/3/11.
- Pomfret J, Nelson D. The Body Hunters: An Isolated Region’s Genetic Mother Lode. The Washington Post, Dec. 20, 2000.