Can Superbugs Doom Medical Travel?

Domestic providers can gleefully celebrate.  the UK journal Lancet Infectious Diseases on August 11 has raised the alarm of antibiotic resistant bacteria being spread across the world by patients receiving medical treatment in India and Pakistan.  The article specifically voiced concerns about medical travel.  Mainstream media like the WSJ on August 12 have picked up the refrain. 

This has created an uproar in India, with political leaders crying foul and the Indian health establishment downplaying the report.  Ulterior motives and underhanded means have been ascribed to the drug company Wyeth (now part of Pfizer) that sponsored the study, and to western providers who tend to undermine medical travel.  Even a  lead author of this article, India based Kartheyan Kumarasamy who also published an earlier alert in March, said the warnings had been overblown.

"It's all hype and not as bad as it sounds," he said, adding "The conclusion that the bacteria was transmitted from India is hypothetical. Unless we analyze samples from across the globe to trace its origin, we can only speculate."  The LA Times on August 13 quoted US experts who called the threat overblown, and the NY Times on August 11 similarly had them "put it in perspective."

Professor Jagdish Bhagwati and I have conferred after his contact on this with policy makers in India as well as some American protectionists who regularly spar with him on trade issues.  Here are our views on four key aspects of this story:

Is the study exaggerating the dangers, and should the Western medical experts be trusted to give unbiased opinions?  Sadly, it will likely be several months or even years before the validity of the concerns raised by the study are strongly established one way or the other.  We should certainly listen to Western experts but be aware that medical travel is a threat and unwelcome competition for many Western providers.

They do not have a good track record of honest assessment.  Many have exploited patient anxieties over medical travel by playing up, distorting or even inventing risks of substandard care, lack of recourse if anything goes wrong, dying in a strange land, etc. For example, in my June 11, 2009 post I described how the NY times Op-Ed on medical travel by three US doctors was biased and misleading, while seemingly objective.

Another factor that should give their audience pause: Many of these experts are warning, not just against medical travel to India, but against medical travel abroad, period.  In sum, all these views should be carefully weighed against facts, potential conflicts of interest or industry allegiances, and counter-arguments.

Will this affect the flow and growth of medical tourism to India?  Many medical travelers and policy makers may subscribe to "When in doubt, don't."  So some impact on the patient traffic to India seems inevitable, even if fears (after a long time, to the point above) are ultimately found to be misplaced or highly exaggerated.  The world isn't always fair.  But the damage can be considerably mitigated and result in net benefits for Indians if effective and prompt action is taken by the health authorities and hospitals.  This brings us to the next question.

What corrective steps should be taken in India?  Antibiotic overuse and abuse is an endemic problem here, perhaps more so than in the West.  This is largely behind the creation of superbugs.  The current spotlight should jolt the Indian authorities into cleaning house and raising awareness among the general population of providers and patients.  It can become a case of the small medical travel tail wagging the large Indian health care dog, to everyone's benefit.

Indian health authorities can also join Western efforts to encourage and facilitate development of more new drugs to combat gram negative bacteria like the NDM-1 superbug.  Though two existing drugs are presently effective it is vital to have more in the pipeline.  Many experts have also stressed the need for the tracking, collection and transparency of data on outbreaks of drug resistant bacteria in hospitals and the general populace.

Tens of thousands of medical travelers from the West have been treated in India in the past year.  Indian health authorities can coordinate efforts to reach these former patients and offer free testing for pathogens in their home countries.  This will allow treatment and reassure against the risk of spread of superbugs in those countries, while building a database that guides further policy and actions.  This will involve some costs and the home countries are likely to agree to bear part or most of them.  Managed properly, this is certainly money well spent. 

The findings, whatever they are, should be widely shared and made public.  Honesty and transparency is likely the best policy that will build confidence and credibility over the long term.  Even more importantly, it's the right thing to do. 

Tertiary care hospitals popular with medical travelers can take effective steps like: a) Further strengthening or emphasizing infection control practices (though the top ones already have infection and complication rates that are far lower than in the US overall), b) Sharing verifiable statistics and practices with patients and health agencies, and c) Keeping and treating medical travelers separately (and perhaps by country of origin) from the Indian patients.  This isolation could be decried as discrimination or special treatment reserved for more privileged medical travelers if not handled properly.  But it can be truthfully positioned as an infection control measure, and a two way street that also protects Indian patients from pathogens (like MRSA) possibly carried by foreigners.

Should and will this story significantly damp medical travel in general?   Certainly not.  While India is logically a premier medical travel destination because of high quality and low cost of care, it is by no means the only one.  Medical travelers having misgivings about India can look to other destinations like Malaysia, Singapore or even Turkey as alternatives with many good JCI accredited facilities.  They are likely not as cheap as India but still offer enormous cost savings and offsetting advantages of better amenities and visitor friendly infrastructure outside of the hospitals and hotels.

So even in the worst case scenario, while the numbers may change slightly, our overall case for medical travel laid out in my May 13 post remains as strong and compelling as ever.