This afternoon the Petrie-Flom Center co-hosted a panel discussion (with the HLS Library and the Harvard Global Health Institute) of Glenn Cohen‘s new edited volume out from Oxford University Press, The Globalization of Health Care: Legal and Ethical Issues. Panelists were Professor Cohen, Sue Goldie, and Neel Shah; Einer Elhauge served as moderator. This isn’t quite *live* blogging because the event just finished, but here were some of the highlights:
- Professor Cohen began by describing the book and its contents, noting the theme that health care is becoming global – just like everything else. The book is broken up into five sections:
- Medical Tourism: This is the phenomenon of patients traveling abroad for the primary purpose of getting care, in order to save on costs or to access procedures and technologies that are not available in their home country. The number of medical tourists is high (for example in 2010, nearly a million Californian’s traveled to Mexico for care), as are the profits (it’s been estimated that India’s revenues from medical tourism are around $2.2B annually). This section of the book addresses a variety of related issues, including lessons about accreditation and safety for medical tourists, insurance coverage and encouragement for services abroad (and travel costs), media coverage of medical tourism, distributional justice issues in terms of diverting access to care for local patients, and legal questions related to tourism for services that may be illegal in a patient’s home country.
- Brain Drain: This section of the book addresses medical worker migration, which is a significant issue both for countries who lose the doctors they train and for countries who rely heavily on foreign doctors to provide services. Chapters here focus on best practices for ethical recruitment of medical personnel, the types of limits home countries can place on their trainees and where they practice, and the role of international bodies like the World Health Organization.
- Globalization of R&D: A substantial portion of clinical trials are run in developing countries, but spending is not proportional to the types of diseases that cause the greatest global burden. This section asks questions like: “should access to clinical trials be conceptualized as part of the global right to health?” and “if research subjects are injured by malfeasance abroad, can they rely on the Alien Tort Statute for protection?” Chapters here also address sharing of resources for global R&D, e.g., Indonesian flu strains; data exclusivity and patenting issues that influence access to essential medicines; and approaches to antibiotic resistance.
- Telemedicine: This section of the book addresses various aspects of telemedicine, including everything from remote consultation to highly technical cybersurgery. Chapters here also address health information technology, as well as the problems that can arise when locally regulated practitioners seek to provide care across borders.
- Equity and Justice: The book closes with a discussion of some of the broader philosophical issues associated with globalized health care, including questions related to provincialism v. globalism, social determinants of health, and most fundamentally, what kind of right is the global human right to health care?
- Next, Neel Shah picked up the conversation from the perspective of a practicing physician in a globalized world, sending out and receiving medical tourists. Dr. Shah explained that he had been taught in medical school that health care in the US is local, but that appears to be changing. During his residency at three major Boston medical centers, Dr. Shah saw four types of medical tourists: (1) those seeking more affordable care elsewhere; (2) those seeking expediency, or access to care without the wait they might face in their home country; (3) those seeking access to care that isn’t available in their home country; and (4) those seeking rights associated with care, such as citizenship for those born in the US. He explained that empirical data regarding volume of medical tourism is poor, which makes it difficult to get reliable estimates of outcomes and safety. He also noted that we need to worry not only about poorer patients and the risks they face, but also about wealthy tourists who may succumb to problematic advertising. Dr. Shah noted that the ACA may not weaken incentives to go abroad for care through its efforts to expand access, and in fact may have the opposite effect as people with high deductible plans seek ways to stretch their dollars. Finally, he asked whether health insurers might start to provide coverage for the risk of injury should a patient experience a problem with a foreign physician that they were referred to by the insurer.
- Finally, Sue Goldie, discussed the Harvard Global Health Institute and its mission to create a paradigm shift in terms of how we think about health globally. Dr. Goldie noted four key features related to this paradigm shift:
- The world is becoming more interdependent: There is a set of global risks and opportunities we all face, all of which have health dimensions and implications. But the risks tend to affect the worst off, while the opportunities are exploited by the best off. How can we equalize benefits and burdens?
- Population dynamics: As the elderly population grows, people migrate to urban areas, and fertility rates decline, what impact will there be on global health?
- Changing patterns of care: Now that everything moves across borders, we see an escalation of risk factors for chronic disease in lower income countries that still face a high burden of infectious disease. How can we deal with this double-burden problem?
- Health is no longer the exclusive purview of the health sector: We have long recognized the social determinants of health, but are now also realizing that health is an important aspect of foreign policy, global security, innovation policy, and human rights. Health is everyone’s business.
Dr. Goldie noted that each of these elements is addressed in the book, and called for the development of global health leaders, global leaders that value health, and an educated citizenry coming together to work in the interdisciplinary “white space” that needs to be explored to make real progress in global health issues. She noted that the book didn’t offer pat solutions, but rather calls for continual engagement.
During the Q&A with the audience, the group discussed the theory of comparative advantage, the possibility that encouraging medical tourism will result in improved care in home countries, efficiency gains and distributive justice related to medical tourism, issues related to transparency with regard to cost and quality, the impact of the trend toward universal coverage, insurance pressures, and the idea of “reverse innovation,” or learning from systems that do things well but cheaply.
Video from the event will be available soon – we’ll post an updated link shortly.