In Praise of Lesser Evils
Can Realism Repair Foreign Policy?
For many women—and men—around the world, infertility is a dire burden that comes with intense social stigma and community ostracism. It can lead to marital duress, divorce, and abandonment. No wonder, then, that many infertile couples are willing to undertake extensive reproductive travel to have kids.
In the twenty-first century, infertile women and men who cross national and international borders in pursuit of conception through IVF are often called “reproductive tourists.” It is fair to claim that reproductive tourism is as old as IVF itself. For example, Lesley Brown, the world’s first test-tube mother, would be considered a reproductive tourist by today’s standards. She and her husband John traveled across southern England (from Bristol to Cambridge) to meet the inventors of IVF, Cambridge University professor Robert G. Edwards and his physician partner, Dr. Patrick Steptoe. The world’s first test-tube baby, Louise Brown, was delivered on July 25, 1978, in a distant third location (Oldham Hospital, Lancashire) to avoid media scrutiny and moral condemnation. Within weeks of Louise’s birth, long-term infertile couples were traveling from all over Europe to Bourn Hall, Cambridge, the world’s first IVF clinic, to obtain the new technology of conception.
Since then, political and legal scholars have been at pains to describe the phenomenon, about which there is still relatively little known. The existence of cosmopolitan clinics such as Dubai’s Conceive that attract people from around the world suggests that the scale may be surprising. The largest empirical study to date—sponsored by the European Society for Human Reproduction and Embryology Taskforce on Cross Border Reproductive Care—involved 46 IVF clinics in six destination countries in Europe, including Belgium, the Czech Republic, Denmark, Slovenia, Spain, and Switzerland. Based on the analysis of 1,230 completed patient questionnaires, the study estimated that there was a minimum of 24,000–30,000 cross-border IVF cycles in Europe each year, involving 11,000–14,000 patients. The main reason for travel, according to the patients who responded to the survey, was “unfriendly” legislation in their home countries—such as the prohibition of certain techniques (egg donation, for example) or inaccessibility of the techniques because of patient characteristics (such as age, sexual orientation, or marital status).
Only one attempt has been made to assess the extent of reprotravel on a global level. As part of an international process of data collection for the International Committee Monitoring Assisted Reproductive Technologies, clinics in 11 countries were surveyed about “out going” treatment cycles. The data showed that patients from these countries had undertaken approximately 5,000 cross-border IVF cycles in more than 25 other nations. Collectively, the 15 recipient country clinics that reported data estimated that 7,000 couples traveled from nearly 40 countries to receive IVF. However, without any kind of global registry of IVF clinics or minimal international monitoring of cross-border IVF travel, data will remain incomplete.
For now, the best scholars can do is look to a number of sites that have clearly emerged as reprohubs offering specialized IVF services. The first is Belgium, known for its early 1990s invention of intracytoplasmic sperm injection (ICSI), a variant of IVF designed to overcome male infertility. More generally, Belgium is regarded as one of the most liberal European destinations, with a wide range of assisted reproduction services. Spain has recently cornered the market on egg donation, purportedly because Spanish women are the most altruistic in the world, although the real reason remains unclear.
Not all reprohubs are in Europe. One study from Latin America shows thriving reprotravel sectors in Argentina, Brazil, Chile, and Mexico. Furthermore, Latin America has been at the forefront in the development of two regional IVF clinic registries, which are able to track the movement of patients across the region.
India and Thailand likewise deserve special mention, because the governments of these nations are encouraging the growth of a reprotravel industry. India is perhaps the most widely known global reprohub, with more than 500 registered IVF clinics and many centers specializing in commercial gestational surrogacy. India has become renowned (or notorious, depending on one’s vantage point) as the global hub for transplant and surrogacy tourism, both of which rely on a steady supply of poor Indian surrogate mothers. The Indian government has promoted commercial gestational surrogacy as a new kind of niche market for the country, with profits projected to reach $6 billion in the second decade of the twenty-first century. Thailand, which has marketed itself as the world’s premier medical tourism hub, is also developing a niche in the reproductive market. There, reprotravelers can now access IVF with pre-implantation genetic diagnosis (PGD), which can be used for the purposes of sex selection.
Those who cannot afford to wait in line—for example, women who are aging out of their fertility—may seek services abroad, where immediate access to medical services is virtually guaranteed.In both India and Thailand, reprotravelers can stay in five-star hotels, which may be adjacent to “five-star hospitals” with their own internal IVF units. Morning clinic visits may be followed by afternoon pampering in a resort’s spa, with massages, gourmet food, and villas on the beach. Even with the international travel, the costs are much lower, and the success rates may not be so different from those found at home.
Reproductive medicine has become embedded in a much larger industry of medical tourism, which has ballooned over the past decade. For example, in 2003, approximately 50,000 medical travelers left the United Kingdom, mostly to bypass long waiting lists in the NHS. In 2007, approximately 750,000 Americans—most of them belonging to the group of 46.6 million uninsured people—left the country for medical purposes. By 2010, the total number of medical travelers was estimated to be six million worldwide, with approximately a million heading to India, and another 1.2 million to Thailand. As of 2008, the total worldwide medical tourism market was estimated to be worth $60 billion; by 2020, the figure is expected to reach $100 billion.
The first driver has been the privatization of health care. Vigorously endorsed by the World Bank since 1993, privatization has reduced states’ commitment to health care, leaving many people uninsured or underinsured, with little if any access to health-care services. Those who have been pushed out of home-country care may travel abroad to seek more affordable, accessible services elsewhere. The second reason is uneven access in public health-care systems. Many Western European nations, as well as Canada and Australia, subsidize health care for their citizens. However, elective procedures such as IVF may be rationed or unavailable on a regular basis. Those who cannot afford to wait in line—for example, women who are aging out of their fertility—may seek services abroad, where immediate access to medical services is virtually guaranteed.
The third reason is that certain procedures may be unavailable or illegal in some countries. For example, IVF, gamete donation, and gestational surrogacy are restricted in many countries. So are other medical procedures, such as stem-cell therapy, which is still considered experimental in the treatment of conditions such as Parkinson’s disease or spinal-cord injuries. Patients suffering from these afflictions may head to India or China, though, which have become global hubs for stem-cell therapy. Fourth, biomedical technology has rapidly diffused, making medical care more uniform and more available in a greater number of global locations. Whereas the thought of traveling to India or China for medical treatment might have seemed preposterous to a previous generation of Western patients, twenty-first-century biomedicalization has ensured higher standards of medical care and technical excellence in many of the countries now developing medical tourism industries. Finally, globalization itself—the general movement of technology, people, finance, media, and ideas—has made the thought of medical travel seem more reasonable to larger numbers of people.
This new medical tourism is often characterized as “reverse traffic.” That is, in an earlier day, medical care involved the travel of wealthy elites from resource-poor countries to the medically developed countries of the West. However, in the contemporary era, the reverse is now true: Westerners are heading to developing countries, where medical care has improved and can be purchased at bargain-basement prices. Take India, for example, the poster child for the new reverse traffic, second only to Thailand in the number of medical travelers it attracts each year. Indian hospitals treated 450,000 foreign patients in 2007, when the country’s medical tourism market was estimated to be worth $310 million. By 2012, that market had increased almost sevenfold to $2 billion, with an estimated annual growth rate of 30 percent. India has established an Indian Medical Travel Association to secure the country’s position as the world’s leading global health-care destination. Since 2006 the government has issued special M (for “medical”) visas, as well as MX visas for accompanying spouses. And since 2009 the Indian Ministry of Tourism has worked to promote the accreditation of Indian hospitals through the Joint Commission International, an international accrediting organization, as well as India’s National Accreditation Board for Hospitals. Able to boast of its accredited hospitals and English-speaking physicians (who have often trained in the United Kingdom or the United States), India delivers medicine at a fraction of what it would cost in the United States—for example, $10,000 versus $200,000 for heart valve replacement surgery, and $30,000 versus $100,000 for commercial gestational surrogacy.
However, medical tourism in India has come at some cost to the local population. New Delhi is now estimated to spend nearly $50 billion on the private health-care sector, including on medical tourism, but only $10 billion on public health-care expenditures overall. Since neoliberal economic reforms began in the early 1990s, the Indian public health-care system has sustained severe cuts, as have other forms of social-sector spending. As the health activist Amrita Sengupta has noted, “the dominance of the private sector not only denies access for poorer sectors of society but also skews the balance toward urban, tertiary-level health services with profitability overriding equity and rationality.” Indeed, India’s public-health statistics are appalling. For example, only 17.3 percent of Indian women have had any contact with a health worker, and rates of maternal mortality remain extraordinarily high. In other words, neoliberal reforms in India have led to a two-tiered health-care system: a failed public health sector for the poor, and a private sector with “world-class facilities built to cater to the elite—both Indian and foreign.”
In the world of IVF, India’s self-promotion as a global medical tourism hub for foreign and Indian elites, including well-to-do Indians returning from the diaspora, has had some interesting and paradoxical side effects. For example, infertile Indian couples, especially in the middle class, may feel effectively barred from, or forced out of, the local IVF sector. As a result, hundreds if not thousands of infertile Indians fly to the nearby Emirates each year seeking assisted reproduction services. Furthermore, local Emiratis—who are often stereotyped as the kind of global elites who would travel to places like India to exploit the organs and wombs of the poor—may, in fact, be loath to do so. Emiratis, who are Sunni Muslims, are usually very concerned about following religious mandates that disallow any form of third-party reproductive assistance.
The forms and locales of IVF vary around the world, though the desires of those who seek its benefits do not. These couples cannot find safe, affordable, legal, and effective IVF services in their home countries, and their stories offer a window into the world of infertility—a world that is replete with pain, fear, danger, frustration, and financial burden. These hardships dispel any notion that traveling for IVF treatment is reproductive tourism. The magnitude of reprotravel reflects the failure of countries to meet their citizens’ reproductive needs, which suggests the necessity of creating new forms of activism that advocate for developing alternate pathways to parenthood, reducing preventable forms of infertility, supporting the infertile, and making safe and low-cost IVF available worldwide.
This essay is adapted from Cosmopolitan Conceptions. Published by Duke University Press, 2015.
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