Background

The rise of medical tourism emphasises the privatisation of health care, the growing dependence on technology, uneven access to health resources and the accelerated globalisation of both health care and tourism.1

Medical tourism, defined as ‘travel with the express purpose of obtaining health services abroad’, is not a new phenomenon.2 Such travel dates at least to the 19th century when middle-class individuals in several European countries travelled to spa towns to enhance their health and well-being. For most of the 20th century, medical tourism largely consisted of wealthy citizens of low-resource countries travelling to access high-quality healthcare in more affluent countries. However, in the last 20 years, there has been a growth in individuals travelling from richer, more developed nations to less developed countries. This direction of travel has been driven by the availability of low-cost treatments within specialised niche treatment centres, aided by the increased marketing of such treatments via the internet and facilitated by low-cost travel.3 Adult medical tourists travel most commonly for dental care, cosmetic surgery, elective surgery and fertility treatment.1 ,3–7 Little is known, however, about medical travel by children. The aim of this paper is threefold. First, we report the findings of a systematic search for research on child medical tourism. Second, the paper discusses the potential importance of ‘return health migration’ of children from migrant communities in the UK and other Western European countries as an issue of importance for healthcare providers in their countries of residence who are potentially treating such children before and after treatment abroad. Third, the paper summarises the current gaps in knowledge of the phenomenon of child medical tourism, and offers suggestions for future research.

Children and medical tourism

Anecdotal evidence from professionals in the UK would suggest that child medical travel from the UK is increasing and having an impact on the health of children and on the UK healthcare system, but the issue has not yet been addressed at a local or national level. Internationally, three main forms of child medical travel have been suggested. First, there is sporadic media coverage and commentary on individual cases of parents in high-resource countries taking children outside their country of residence for ‘revolutionary’, experimental or novel treatments not available in their home country, as a form of ‘medical pilgrimage’.8 This is at a variation with the pattern of adult medical travel, and more often in relation to chronic illness, rather than the need for defined surgical interventions. Second, there are commentaries on health migration of children from low-resource countries travelling overseas, travel that is usually funded by humanitarian organisations, to access life-saving treatment in the ‘West’. Kathryn Senior, for example, in a short commentary on child ‘health migration’ in the Lancet, discusses the growth in migration of child cancer patients as a result of wide global inequalities in treatment success in paediatric oncology.9 Senior argues that despite the humanitarian aspects of such movements, it is important to consider the financial implications for the UK and other governments and the pressure such migrations place on paediatric oncologists. Third, there are anecdotal accounts of children from resident migrant and minority ethnic communities being taken ‘home’ for medical tests and treatments to countries familiar to parents or other family members.

To explore what empirical research has been carried out internationally on child medical travel, the authors conducted a literature search as part of an ongoing scoping review of child medical tourism.10 The review question was: “What is known about children who travel outside of their country of residence for health or medical treatment?”

A systematic search was undertaken (January–February 2012) to identify peer reviewed academic literature which discussed children travelling abroad with their parents/carers or guardians for medical or health treatment, including complementary therapies. No date limits were set, and only English language literature was extracted. Key words and phrases were identified and agreed by two individuals. A total of 16 academic databases were searched. In addition, hand searching of two specialist medical travel journals was undertaken. Totally, 4749 titles were retrieved, with 26 relevant titles remaining after removing duplicates and reviewing titles for relevance. Eleven potentially relevant articles remained once abstracts were reviewed in full. Of these 11, only two peer-reviewed papers were relevant to the scoping question.

Both papers are concerned with children travelling for treatment from less developed countries in Asia, Africa, post-Soviet Union countries and Balkan member states, to more developed countries.11 ,12 The primary reason for foreign medical travel is identified as a desire to access a higher standard of care and more effective therapies than those available in home countries, and most cases are reported as organised and financed by humanitarian organisations.

Ben-Sefer et al12 describe paediatric medical tourism in one hospital in Israel, a country which has become an important centre for medical tourism generally. The Dana Children's Hospital in Tel Aviv has a medical tourism department receiving children from many countries including the former Soviet Union, Gaza, Cyprus, Greece and the Balkan countries. Massimo et al11 describes receiving 523 child patients in 2008 at Giannina Galsini Children's Hospital in Genoa, Italy, from Eastern Europe, post-Soviet, African and Arab countries, Latin America and Asia (including China), though it is unclear from the paper whether all these children are medical tourists or children of resident (legal or undocumented) migrant families. Both papers describe and comment on the need for doctors and other health professionals to help families to understand their child's illness and discuss the challenges in providing culturally and linguistically appropriate medical and nursing care.

This systematic literature search demonstrates a paucity of empirical research addressing the issue of child medical travel, and shows that existing work is largely limited to local accounts of doctors’ and nurses’ experiences of treating ‘foreign’ patients. We return below to the issue of the gaps in knowledge and avenues for future research. The next section of this paper explores an aspect of child medical travel of potential relevance to western nations with substantial minority ethnic populations—parents taking children ‘back home’ for medical treatment.

Return medical travel and therapeutic homelands

In the UK, there is anecdotal evidence suggesting that some members of established, settled minority ethnic communities and also ‘new migrants’ engage in ‘return medical travel’ to their countries of origin or countries of family origin, and that this may involve accessing medical tests and treatments for their children. Given the growth in minority ethnic populations and increases in temporary migration across several European countries, this could present particular challenges for patients and healthcare providers in some regions, and have an impact on national healthcare systems. There is a concern that new migrants, such as those from countries in Eastern Europe and the former Soviet Union, or members of more settled groups, such as British South Asian communities, are spending time and money taking their children abroad to explore diagnoses or investigations rather than relying on the National Health Service (NHS), and that healthcare professionals are having to follow-up children who may have had treatment outside NHS guidelines. This may result in inappropriate investigations or treatment for children and an economic impact on the NHS.

Our review could not identify any relevant empirical work on this issue internationally. There is, however, a small body of work which specifically addresses the phenomenon of adult migrants returning to their country of origin for healthcare, and it is worth briefly exploring some of this work as it may offer insights into parental decision making about children's healthcare.

Bergmark et al13 discuss the phenomenon of Mexican immigrants to the USA (living far from the border) who travel back to Mexico for healthcare. The main reasons for ‘medical returns’ included: unsuccessful treatment in the USA; difficulty of accessing care in the USA, and a preference for Mexican care.14 As the authors argue, this travel occurs in a context where Latino immigrants face many barriers in accessing care in the USA, including several which are familiar from studies of UK migrant and some minority ethnic communities: lack of information; difficulties making appointments; cost; lack of insurance; cultural incompetency; language and long waiting times. This study also highlights the practice of combining visits home for family reasons as well as medical care.

A study of Korean migrants to New Zealand also documents adult return travel for health treatment.15 Korean migrants are a relatively young and skilled group who do not exhibit problematic health at a population level. However, perceived differences in types of healthcare practices and relations between healthcare providers and patients between host and home countries also seem to play a role in health decision making. In Korea, healthcare is firmly in the private sector; patients are active consumers making unconstrained choices about providers, and have direct access to specialists, with no waiting lists. This contrasts with the New Zealand system of general practice, which is more similar to the UK model. Migrant patients, therefore, may have expectations or preferences derived from their ‘homeland’ experiences. Moreover, there are differences in consulting and communication styles between cultural systems which also affect patients’ perceptions of care, expectations and preferences. Such considerations may also be implicated in decision making regarding children's health.

These authors also discuss the significance of affect and in particular the attachments to, and nostalgia for, particular places, and the role of emotions in health decision making. In migrant communities, certain geographical places are constructed as ‘therapeutic landscapes’ and regarded as promoting health and well-being (not unlike the phenomenon of the Victorian ‘spa town’), as places where patients feel familiar and comfortable, and where they have ‘trust’ in doctors.16 ,17

Thus, social scientists studying cross-border medical travel generally have argued that this arises from economic, legal, social, religious or technological perceived constraints at ‘home’ and/or the sense of having reached a therapeutic impasse.7 ,18 ,19 In some communities, there may also be a cultural preference for particular styles of care provision.

While such work currently reflects studies of adult patients, it is not unreasonable to suggest that such cultural, moral and psychological reasons for travelling for treatment are also at play when adults make decisions about their children's health. In the UK context, this may be particularly relevant for those children with family origins in the Indian subcontinent, since social research suggests strong economic, social and cultural links are maintained between diasporic South Asian communities and ‘home’ countries, with relatively frequent visits and other exchanges.20 ,21 There is also frequent return travel by Eastern European migrants. Such connections may influence daily life choices, including those relating to child healthcare.

Future directions for research on child health travel

As the discussion above indicates, there is a significant knowledge gap internationally regarding the motivations, experiences and outcomes of children receiving treatment outside their home country and the impact on the healthcare systems of the countries of residence, or indeed the destination countries.

In the UK context, there is little published work which explores the phenomenon of the children of settled migrant communities returning to countries of family origin to access medical treatment and, thus, we know little about the potential impact of this on children's health or the costs (or benefits) to the NHS. In addition, little is known about the children of the substantial numbers of ‘new migrants’, such as those from Eastern Europe and the former Soviet Union returning home for medical treatment.

There are several important issues which require further investigation. First, we need to have a clearer understanding of the populations of children who are travelling abroad for treatment (ethnicity, socioeconomic background, migration status), where they are travelling to, and for what investigations and treatment. Second, qualitative research could explore what motivates parents to take children abroad, how parents make decisions and assess the risks and benefits of these journeys, and how they experience treatment outside the UK. Third, it is necessary to collect information on the clinical outcomes of child medical travel and the impact of this on healthcare systems and health professionals in countries of residence. Finally, there is considerable scope for bioethical and legal scholars to address the complex ethical, legal and human rights issues which surround this phenomenon.