An ongoing Facebook discussion on medical tourism set me thinking about its implications. There are many who argue that more should be done to encourage the growth of Singapore’s medical tourism industry, which reached its peak In 2012. Reasons include regional stature, development of more specialized medical skills (due to a larger pool of patients requiring more complex medical care), benefits to the economy (albeit very small in the great scheme of things), etc. There are also detractors who feel that these benefits are often overstated, and do not outweigh social costs and other negative effects on the healthcare system as a whole (which are hard to accurately measure). I will state upfront that I did benefit from medical tourism during my stint in the private sector.

I can only comment from the angle of infectious diseases (which is often also not factored in when people discuss medical tourism), and there are only downsides here, primarily because – until recently – we have largely failed to take stringent measures to prevent their spread in our hospitals when medical tourists (and returning Singaporean residents who have been treated in hospitals overseas) inadvertently carry infectious organisms into our hospitals.

The New Delhi metallo-beta-lactamase (NDM) – an enzyme that confers resistance to carbapenems in Gram-negative bacteria – was first detected in a diabetic Swedish patient of Indian origin, who had brought Klebsiella pneumoniae carrying this enzyme back to Sweden after staying in a hospital in New Delhi in 2007. It was subsequently described in the U.K. again largely from patients who had resided in Indian or Pakistan hospitals, and has since spread worldwide. There were multiple introductions of NDM-1-carrying bacteria into Singapore since 2010 (here is one such report) – one of the very few occasions where we have documented such incursions of drug-resistant bacteria – largely in medical tourists from the Indian subcontinent. Bacteria carrying this and other carbapenemase enzymes (private hospitals have not been spared) have become entrenched in many of our local hospitals over a short course of 5-6 years.

Now I believe that such drug-resistant bacteria would have been introduced into Singaporean hospitals with or without medical tourism, but the importations would probably have been delayed/spread out and the transmission might not have been so rapid.

Anecdotally, there have also been reports of medical tourists who came for the management of other conditions such as cancer, for example, and were found to have active pulmonary tuberculosis (or worse – multidrug-resistant tuberculosis). It is hard to determine if there has been any spread of TB from these patients, given the long incubation and latent infection period, and the overall impact is likely to be small given that our local TB rates are not low, but nonetheless these represent an unnecessary risk to the healthcare system. It is curious to find slides related to this issue on a University of Washington website, obviously presented by a Singaporean speaker in 2011.

It is possible to make our hospitals less vulnerable to the importation of infectious diseases from medical tourists (or returning travelers), but complete prevention is impossible given the current state of diagnostic tests and hospital design. The nature of our interlinked healthcare system is also such that some nosocomial pathogens will inevitably spread to other hospitals, including those not involved in the care of medical tourists. Infectious diseases (and the costs for preventing them/managing outbreaks) need to be factored into any discussion or policy regarding medical tourism.