Summary Background Gram-negative Enterobacteriaceae with resistance to carbapenem conferred by New Delhi metallo-β-lactamase 1 (NDM-1) are potentially a major global health problem. We investigated the prevalence of NDM-1, in multidrug-resistant Enterobacteriaceae in India, Pakistan, and the UK. Methods Enterobacteriaceae isolates were studied from two major centres in India—Chennai (south India), Haryana (north India)—and those referred to the UK's national reference laboratory. Antibiotic susceptibilities were assessed, and the presence of the carbapenem resistance gene bla NDM-1 was established by PCR. Isolates were typed by pulsed-field gel electrophoresis of XbaI-restricted genomic DNA. Plasmids were analysed by S1 nuclease digestion and PCR typing. Case data for UK patients were reviewed for evidence of travel and recent admission to hospitals in India or Pakistan. Findings We identified 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan. NDM-1 was mostly found among Escherichia coli (36) and Klebsiella pneumoniae (111), which were highly resistant to all antibiotics except to tigecycline and colistin. K pneumoniae isolates from Haryana were clonal but NDM-1 producers from the UK and Chennai were clonally diverse. Most isolates carried the NDM-1 gene on plasmids: those from UK and Chennai were readily transferable whereas those from Haryana were not conjugative. Many of the UK NDM-1 positive patients had travelled to India or Pakistan within the past year, or had links with these countries. Interpretation The potential of NDM-1 to be a worldwide public health problem is great, and co-ordinated international surveillance is needed. Funding European Union, Wellcome Trust, and Wyeth.

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Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

Contemporary medical tourism: Conceptualisation, culture and commodification

Relatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.

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Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making

Medical tourism: assessing the evidence on treatment abroad.

India, Indonesia, Malaysia, the Philippines, Singapore, Thailand and many other countries market themselves as major destinations for ‘medical tourism’. Health-related travel, once promoted by individual medical facilities such as Bumrungrad International Hospital and Bangkok International Hospital, is now driven by government agencies, public–private partnerships, private hospital associations, airlines, hotel chains, investors and private equity funds, and medical brokerages. ‘Medical tourists’ include patients trying to avoid treatment delays and obtain timely access to health care. Medical travellers also include uninsured Americans and other individuals unable to afford health care in their home settings. Destination nations regard medical tourism as a resource for economic development. However, attracting patients to countries such as India and Thailand could increase regional economic inequalities and undermine health equity. International medical travel might also have unintended, undesired outcomes for patients seeking affordable health care. With globalization, increasing numbers of patients are leaving their home communities in search of orthopaedic surgery, ophthalmologic care, dental surgery, cardiac surgery and other medical interventions. Reductions in health benefits offered by states and employers will likely increase the number of individuals looking for affordable medical care in a global market of privatized, commercial health care delivery.

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'First world health care at third world prices': globalization, bioethics and medical tourism.

Faced with long waiting lists, the high cost of elective treatment and fewer barriers to travel, the idea of availing healthcare in another country is gaining greater appeal to many. The objective of this review is to perform a literature review of health and medical tourism, to define health and medical tourism based on the medical literature and to estimate the size of trade in healthcare. The Medline database was used for our literature review. In our initial search for 'health tourism' and 'medical tourism' we found a paucity of formal literature as well as conceptual ambiguity in the literature. Subsequently, we reviewed the literature on 'tourism' in general and in the context of healthcare. On the basis of 149 papers, we then sought to conceptualize health tourism and medical tourism. Based on our definitions, we likewise sought to estimate market capacity internationally. We defined health tourism as "the organized travel outside one's local environment for the maintenance, enhancement or restoration of an individual's wellbeing in mind and body". A subset of this is medical tourism, which is "the organized travel outside one's natural healthcare jurisdiction for the enhancement or restoration of the individual's health through medical intervention". At the international level, health tourism is an industry sustained by 617 million individuals with an annual growth of 3.9% annually and worth US$513 billion. In conclusion, this paper underscored the issue of a severely limited formal literature that is compounded by conceptual ambiguity facing health and medical tourism scholarship. In clarifying the concepts and standardizing definitions, and providing evidence with regard to the scale of trade in healthcare, we hope to assist in furthering fundamental research tasks, including the further development of reliable and comparable data, the push and pull factors for engaging in health and medical tourism, and the impact of health tourism but, more so, medical tourism on local healthcare systems.

Globalization and healthcare: understanding health and medical tourism

Since the early 1990s, medical tourism, whereby individuals choose to travel across national borders or overseas to receive treatments, has been increasingly recognized in the United States and Asia. This article highlights the emergence of medical tourism in the European context. It examines the drivers for such developments and situates medical tourism within the broader context of health globalization and forms of patient mobility in the European Union. In outlining the developments of medical tourism in Europe, the authors distinguish between two types of medical tourist: the citizen and the consumer. The discussion explores the need for greater empirical research on medical tourism in Europe and argues that such research will contribute toward knowledge of patient mobility and the broader theorization of medical tourism. The authors make suggestions about the content of this research agenda, including understanding the development of medical tourist markets, the nature of choice, equity implications, the role of brokers and intermediaries, and general issues for health management.

A European perspective on medical tourism: the need for a knowledge base.

Purpose – A key driver in the medical tourism phenomenon is the platform provided by the internet for gaining access to healthcare information and advertising. Given the pivotal role of web‐based resources, there are important questions about their role and function including: the availability and types of information provided; information provenance and reliability; and privacy protection. This paper aims to address these questions.Design/methodology/approach – The paper provides the first systematic review of medical tourism sites, interrogating them for the range and quality of advice on seeking care.Findings – A typology of sites (industry, media, professional, and consumer sites) was identified and quantitative and qualitative assessment tools were used to explore the content of information and materials.Originality/value – In light of this review, the paper comments on the nature of medical tourism information available and the extent to which information asymmetry – rife in the market for healthcar...

Systematic review of web sites for prospective medical tourists

Issues of empowerment have recently gained much attention in many countries. In this article, the history, application, and implications of empowerment are examined as it relates to health and health care. Special attention is focused on the different models of patient empowerment presented in the literature. The discussion of patient empowerment is facilitated by a conceptual model focusing on the antecedents, barriers, and outcomes relating to both patients and providers. This model is centered on four central processes of patient empowerment: information sharing, doctor-patient communication, shared decision making, and patient self-care. We conclude with a discussion of recent health-care system/financing reforms aimed at facilitating patient empowerment.

Percivil Carrera

Papers

Medical tourism: assessing the evidence on treatment abroad.

Globalization and healthcare: understanding health and medical tourism

A European perspective on medical tourism: the need for a knowledge base.

Systematic review of web sites for prospective medical tourists

Patient empowerment in health care