Francesca Tomasi received her B.A. from the University of Chicago and is now a microbiologist.
When you hear the word “tourism,” your mind probably jumps to a trip you’ve taken – perhaps to see cool sights, or learn a little history while taking in a new place. But museums, historic landmarks, and nature aren’t the only things that attract tourists. In fact, there’s an industry out there that’s worth more than many of these more traditional markets.
Medical tourism refers to people traveling to a foreign country in order to obtain medical treatment there. You would expect such travel to flow in one direction: wealthy individuals leaving underdeveloped nations to receive top-notch care in developed countries. Today, however, medical tourism flows in the opposite direction as well. In fact, it’s increasingly more prevalent than the former trend. With the advent of twenty-first century medicine and technology bringing about reasonably affordable technologies, any place with the infrastructure can set up a good healthcare system. And in countries rife with poverty, where something “cheap” per first-world standards is considered expensive, this quality healthcare can come at a fraction of the typical cost in other parts of the world. Recent trends show millions of people traveling from developed nations to third-world countries for less expensive, but just as legitimate, medical care. The majority of traveling cases are surgical; these are individuals looking for kidney transplants or open heart operations whose bills won’t send them spiraling into bankruptcy. For instance, a heart valve in india costs about $15,000; in the us, it usually costs upward of $150,000. Virtually every other type of health care is also available for a medical tourist, from fertility treatment to psychiatric evaluation.
Medical tourism has its justifications beyond financial motivation: patients may find better treatment for their cultural needs in another country. Medical tourism furthermore allows for a bypass of traditionally long waiting lists, as well as sidestep from potentially awkward questions from friends and family (going abroad for cosmetic surgeries is extremely popular).
India has a particularly booming medical tourism market worth over two billion dollars, making it a top medical tourist destination. A more detailed description of the factors contributing to low prices can be found here, but the point is that, in general, the quality of care at these medical tourist hospitals is very high. Hospitals in india, for instance, boast commendably low nosocomial (hospital-acquired) infection rates. This sounds like the ultimate solution to many people’s problems: travel halfway around the world for a significantly more affordable, yet equally legitimate, procedure. Is this endeavor consequence-free?
Not exactly. “low infection rates” does not mean “no infections.” Sterile operating rooms are never 100% bacteria-free. Rigorous procedures certainly minimize the population of potentially pathogenic microbes, and should always precede any medical procedure. However, the fact remains that microbes are ubiquitous: they’re on our skin, in our bodies, and even on surfaces previously wiped down with betadine. Therefore, especially if you are an inpatient with a weakened immune system due to medications, illness, or recent surgery, it is not uncommon to pick up a strain or two from the environment. Medical tourists leave their homes and arrive at their destination having unknowingly served as a hitchhiking medium for their native microbes. Likewise, medical tourists who pick up organisms in a hospital carry these microbes back home. Just like that, two different places that were initially naïve to a world of bacteria are now colonized with new strains, including good bugs and bad bugs. In another scenario, you’re a medical tourist who decided to do some sight seeing before going to the hospital. Based on what you might have come into contact with – plants, animals, or even a frequently used taxi cab – some foreign microbes may have settled on your body and temporarily, albeit harmlessly, colonized you. This is usually never a big deal; when you go back home your resident microbes revert back to your environment (alternatively, if you stay abroad for a long time, your microbial makeup may slightly shift – check out this paper on microbiome shifts that occur simply from someone moving in with you!). Colonization by novel microbes in itself is not a problem. It happens all the time. But the moment a surgeon cuts you open, some of these microbes may make their way into the incision; if your immune system cannot fight them off, an infection ensues.
India has very different types of prevalent microbes in the environment than, say, the united states – whereas most us-borne hospital infections are gram-positive bacteria (such as mrsa), the bacteria prevalent in indian hospitals tend to be gram-negative (such as e. Coli, salmonella, and pseudomonas). Both types can be devastating if left untreated, but gram-negative bacteria on average tend to be less vulnerable to disinfectants and general antibiotics. The reason is physiological: gram-negative bacteria are encased in tougher outer membranes than gram-positive ones, so it’s a lot harder for substances to penetrate and destroy them. Regardless, if your body is used to fighting gram-positive bacteria but one day it is challenged with a gram-negative species, it’s going to have a hard time warding off the infection. The same goes the other way around, with someone being exposed to a gram-positive bacterium like mrsa (especially with a weakened immune system).
In addition to a different type of dominant microbe population, bacteria in india have significantly higher drug resistance rates: in a country where infection is so widespread and the doctor to patient ratio is extremely low, antibiotics are a common household item. Most of the time, these drugs are not prescribed by a doctor, and they are therefore not nearly as controlled as they should be (india’s huge population is another contributor to a lack of antibiotic stewardship). Antibiotic misuse and overuse are the agents responsible for the global rise in drug resistant bacteria. Therefore, it should come as no surprise that india has one of the world’s highest rates of antibiotic resistance. So if you’re a medical tourist and pick up an infection, odds are the infection you picked up is more serious because of its drug resistant nature.
A few months ago, Infective Perspective published an article titled “the journey of a gene,” which traces the story of a little dna sequence capable of wreaking some serious havoc: New Delhi Metallo-Beta-Lactamase 1, or NDM-1. In 2010, scientists analyzed bacterial infections in a new delhi hospital and found that almost one fourth of them were resistant even to the hospital’s last-resort intravenous antibiotics, the carbapenems. NDM-1 encodes an enzyme that inactivates carbapenems and other beta-lactam antibiotics that target cell wall synthesis, an essential process for bacterial viability. The gene easily spreads via horizontal gene transfer to other bacterial species; to date, NDM-1 has spread to over 35 countries. While it is still uncertain exactly where NDM-1 first appeared, its rapid spread and contribution to the antibiotic resistance can partially be attributed to the widespread travel of medical tourists and the melting pot of microbes created in tourist hospitals. While all hospitals serve as a breeding ground for bacteria, tourist hospitals are especially powerful because they draw in thousands of people every year from nearly every part of the world. Such unparalleled diversity could be catastrophic in a building with immunocompromised patients, or with people cut open on an operating table. And of course, the drug resistant form of a bacterial species will replace its drug-susceptible counterpart the moment a patient is given antibiotics.
Medical tourists alone are certainly not entirely to blame for global drug resistance. And it goes without saying that no single country is to blame for “breeding” bad bugs – every pocket of the world has its unique microbial makeup, and every bacterial population has traits that may emerge in different situations. The simple act of travel for any reason, whether across town or across the globe, serves as a vector for microbial migration and the mixing of potentially destructive genes. Furthermore, we live in a bacterial world: bacteria are everywhere, in and around us. Most of them are good – our microbiomes are like an essential organ to us, and we owe most of earth’s functioning ecosystems to the hard work of our single-celled friends. The bad bacteria, however, are bound to get the most publicity because of their serious implications on human health, and it’s therefore important to understand the different mechanisms that help spread infections and drug resistance. One of the most important is travel.
Medical tourism has helped millions of people. An unfortunate consequence of healthcare trade however is bacterial trade, the intermingling of microbes that otherwise would never come into contact with each other. In a hospital, where patients are particularly susceptible to colonization by new bacteria and infection, this is bad news. These microbes are perfectly capable of exchanging genes with each other, and they evolve differently in new environmental conditions. As a result, patients can pick up completely new, drug-resistant bacteria and get sick. Furthermore, if they were only colonized, they could unknowingly bring them back home and help propagate the microbes with everyone they touch. When you hear about a hospital-acquired infection in one part of the world, it’s really only a matter of time before hospitals in other countries come across it.