HSS+from+2008

Newlyweds extend their honeymoon in Johannesburg, South Africa, for the day following their safari so that the bride may receive Lasik eye surgery at a lower cost than home. An Israeli grandmother living in the United States, travels to Turkey after visiting relatives in Israel and has a new kidney surgically implanted, unconcerned about its origin she recuperates in a hospital looking upon the Historic Blue Mosque in Istanbul. Until recently, Americans who traveled to India or Mexico for medical procedures did so out of desperation. Today, however, the AARP and other influential organizations discuss "medical tourism" as an acceptable supplement to conventional domestic healthcare resources, and the practice of voluntary international travel for healthcare is on the rise. How did transnational healthcare delivery become a normal, acceptable part of medical treatment, and why has this shift occurred in recent years? Medical tourism (MT) describes the practice of traveling across national boundaries for healthcare, a practice that has recently grown to a multi-billion dollar industry. Proponents praise the globalization of healthcare as leading to universal improvement in the quality of care by redistributing healthcare technology and promoting investment in developing countries while providing cheaper care for tourists. Contrarily, some advocate groups claim this is damaging to local healthcare systems of destinations, and undermine efforts at healthcare reform in the US, as well as being individually dangerous. New Forms of patient care combine with technical intervention to define a group of patients as tourists. At the same time tourists start to need to be concerned about effective ethical care and novel forms of risk. Technical definitions of disease and illness conditions engage in liminal points with sight seeing and recreation culture in new ways. The rise in acceptability of this trend as 'common sense', or naturalization, of the trend presents an avenue to explore the way that social change happens. Examination of the growing and various new practices suggest several focuses and research questions that contribute to our understanding this particular phenomenon and the process of naturalization. Through the study of lived effects we can begin to examine the changing formations of entitlements and common sense as they play out in the case of medical tourism: __ I. Lived effects: __ 1. Practice: Does MT influence the practices and protocols of medicine, & if so, in what way? 2. Economic: How does MT affect domestic healthcare markets in participating nations? 3. Policy and regulatory: What factors determine why certain national governments officially regulate MT while others don’t? __ II. Epistemological attitudes on medical tourism: __ 1 Are there differences in discourse surrounding different forms of MT? 2 What is the relationship between ideas of choice and healthcare discourses on MT? 3 Why do some forms of biomedicine lend themselves to MT better than others? Because of the rapid expansion of MT and the urgency surrounding evaluation of new medical situations, this project represents needed scholarship. Theoretically it offers key insights into the way people experience their health, travel, and new forms of life. In this project, I will conduct a discursive analysis of the patients, industry and its representative texts, as well as a comparative ethnography of the phenomenon as it appears in the US (the single largest source of patients) and selected representative destination sites in the developing world. My research will contribute to three broad areas of scholarship: 1) discussions of transnationalism; 2) academic study of travel and tourism; 3) the construction and transfer of technology and medical knowledge between cultural settings in Science and Technology Studies (STS). This work will position me for continuation as a scholar, and provide needed analysis of MT for policy formation and further study. Studies of medical tourism have focused on the 150,000 or more medical travelers to India and to Singapore annually, while ignoring more than a dozen other countries that are actively promoting MT programs (including Brazil, Costa Rica, Cuba, Mexico, Turkey, Slovenia, Romania, Thailand, Malaysia, and the Philippines). Other instances are ongoing in nations without national programs, such as reproductive tourism between Korea and China, and the organ trade in Moldova. While dollar figures are inexact, the international value is frequently placed at 1 billion US dollars or higher by industry estimates. Others suggest it is as high as 2-3 billion US$ (Demico; Cetron & Davies 2008) and all estimates suggest that it is rapidly expanding. This represents an important change in the way people globally are receiving healthcare. The effect of new formations on preexisting systems and conceptions of healthcare have relevance to treatment of an unprecedented number of patients. Given the potential impact of MT on patients and preexisting healthcare institutions this topic displays special urgency. Drawing on STS and anthropological perspectives on culture I will look at: the diseases and medical conditions for which people travel, the forms of care and service provided and required in each site, the social institutions and actors involved in forming these ideas and practices, as interlocutors about the similarities and incommensurability that exist as variations in practice and experience. Through my analysis of the contemporary discourses and practices of the nascent industry and institutions of MT I will document cross cultural interactions and contribute to several fields. Medical tourism represents an ideal site for observations about conflicts and negotiations that arise, analysis of the way ethical, ontological and epistemic practices vary and constitute different medicines in multiple locations. I focus on patient-provider relations in medical care, expert – lay person relations involving technical knowledge, and inter-national relationships between states. This work will contribute to theoretical discussions on cultural authenticity, knowledge and technology transfer, and conceptions of risk in the study of tourism and transnationalism as well as Science and Technology Studies. Discussion of Medical Tourism in popular media and political rhetoric, including President Bush’s 2007 State of the Union, have suggested that consumer choice and industry transparency are the natural neoliberal remedy for contemporary crises in healthcare access. But this discourse begs the question of how choice and individual responsibility have taken their “natural” place in our understanding of the world (Foucault 1976; Harvey 2005). This call has been paralleled in the popular promotion of MT as a new option and a site of greater individual agency in choosing healthcare options (Bookman & Bookman 2007). This is in direct response to an ongoing crisis in medical coverage dating to the 1960s (Illich 1976). The most recent national census figures show approximately 15% of the US population is without any sort of health insurance, and this includes more than 30% of those living below the poverty line. Preliminary research on health care and broader culture in the US (Starr 1987), the history and development of the American healthcare industry suggests that despite framing the crisis as new there is a long history of antagonism around healthcare (Starr 1987). In the long process by which common sense has changed, we can see how conceptions of healthcare have shifted from 'entitlement' and 'local' to an idiom of personal individual responsibility. Following this trend since the 1970's (Lyotard 1984; Illich 1976; Harrington and Estes 2008) we can see that idea of healthcare delivery as being individually managed has progressively increased, and today seems 'natural.' The recent literature on MT focuses on specific sites, such as India (Pruthi 2006), and often attempt to overview this widespread phenomenon as it appears in a single country. Academic focus has been on business growth and impact with little work on aspects of experience, or medical practice itself; a notable exception to this lack of breadth are a few works considering MT an outgrowth of colonialism (Bookman and Bookman 2007). Limited access to patient narratives and the zooming in on one as opposed to multiple sites renders those accounts limited at best (Carrera & Bridges 2006), while a plethora of popular media articles and books, most notably Schult (2006) have received significant press attention. The popular milieu often provide one or a collection of successful patient narratives, but do not suggest any challenges or critiques and mostly function as how-to consumer guides (Hancock 2007). The traditional subjects of STS have been Euro/American and a growing number of scholars call for STS to diversify. Studies of medical practice are at the forefront of this new direction in STS (Anderson 2002; Harding 2006). This project will contribute to this emerging focus, and my training in political economy and the anthropology of health and medicine will enable me to contribute to both theoretical and policy discussions surrounding MT. As development issues have become an area of considerable interest to STS scholars work has appeared. However, critiques of development have frequently focused on the lack of sensitivity to local cultural contexts while implementing Western technologies. Often, these studies have been overly focused on the transfer of artifacts and systems with technological knowledge embedded in them. STS theory on expertise and knowledge construction will add interpretive depth to Tourism studies theory. MT exists between multiple cultures and biomedical/technoscience knowledge(s) and practice(s), and is characterized by the transfer from, and flow between, nations. These variations are embodied or emplaced in the people, texts and institutions that constitute the system of MT, and it suggests that current brief definitions of MT are inadequate. This work introduces the idea of differential power relations between the visitor and the locals as a central theme in the field. Smith (1977) drew attention to the new relationships formed when participants in tourism travel move from one cultural location into another. It is neccesary to look at the relationship between changing common sense about healthcare delivery and the growing perception of uniformity of medical practice across contexts.This parallels discussion of western medical culture, as popularly represented and considered homogenous, being viewed in STS as a set of related systems; interrelated “epistemic cultures” (Knorr-Cetina 1999) which contain different conceptions and frameworks that contribute to the construction of localized variation. One aspect of the MT industry in need of examination is the extent to which it is actually independent from or affecting local identity. Lynn Stephen’s (2005) work on the reproduction of “sameness” as part of the framing process in social movements potentially leading to essentiallization can be connected to Smith’s concern about responses to contact and power difference in exchange, as tourists demand the same experience they were implicitly promised before arrival. At the same time, as these systems interact they demand boundary work (Epstein 1996) as participants construct their credibility in relation to differing socio-cultural contexts. In tourism studies McCannell (1976), describes the transfer, and notional portability of artifacts as a key characteristic of modernity and the formation of the notion of tourism, as fundamentally based in power relations, and in response the demand for the local to match the expectation of the visiting tourist, he suggests that the roles and terms of tourism became natural, as opposed to starting off that way. Investigation of new transnational forms of life serves to expand the discussion of social and theoretical shifts, as key phenomenon are no longer centered in local sites, but rather between sites. I use the framework of transnationalism to emphasize that MT is anchored in and simultaneously transcends the boundaries of one or more nation-states. This de-centering is key to ongoing methodological discussion of the scientific study of what Rabinow (2008) terms anthropology of contemporary phenomena. This dislocation of phenomena from a single location has in its turn been part of a process of normalization and change in thinking about the common sense of the experience of time and space that has been observed and criticized (Lyotard 1984; Ong 1999; Harvey 1989). While transnationalism has been studied in information technology and manufacturing (Harrison 1992), little comparable work has been done on medicine. MT offers a vantage point where theories of risk (Beck 1992) and experience of time (Lyotard 1984) are embodied in individual access to medical care. While Western biomedicine has never been fully local, the shift in practices and discourse that have recently reframed surgery as part of recreational tourism represent a distinct shift from historical health travel such as travel to Hay fever resorts in the US (Mitman 2007) in the historical literature of tourism, or travel for relaxation of the nerves (Furlough 1998) in sociological literatures. This disciplinary conversation connects to a broad literature on post-modernity (Harvey 1989), or late-modernity (Giddens 1991), representing an ongoing effort to understand new forms of life activities. Recent discussions of the way these changes effect different institutions, such as citizenship (Ong 1999), cultural imaginaries (Appadurai 1996), and economic structures (Harvey 2005) have proved fertile and should be added to the discussion of tourism. This larger literature on transnationalism contains little work on science and medicine and the work on new systems such as the international organ trade (Lock 2006) or MT would provide insights from into how these systems are involved. Medical tourism as a new form of healthcare provides new insights into the extension of scale that is characteristic of late-modernity (Tsing 2000). Tourism studies has looked at these changes and responded in a theoretical shift away from neat divisions of visitors and locals, to a more complex interplay of global networks and the “mobile nature of the whole touristic venture” (Nash 2005). This has been part of a controversy over the very nature of local authenticity focused on deterritorialization (Sheller and Urry 2004) regarding the development of new systems and discussion of basic changes in the nature of societies and institutions in the contemporary world. The study of tourism in sociology (Smith 1977;McCannell 1973; Pearce 1982) and anthropology (Graeburn 1989; Stronza 2001) has been characterized by their focus on descriptions of the tourist as a product of leisure, and accounts often focus on the roles, performances and positions of the actors as opposed to the negotiation or interaction between them (Cohen 1984). This has been productive, and could be usefully combined with the recent literature focusing on transnationalism which stresses that forms and experiences in interaction are distinct from their isolated antecedents.  I would describe this shift, after Clarke et al. (2003) the “biomedicalization” of tourism; thus, describing shifts in the US as producing new identities, and reflecting the expansion of technoscientific knowledge into areas where it had not previously been, both true of MT in regards to traditional definitions of tourism. The flexibility of identity presents a potential problem as one can see medical tourism as a reform movement, or an extension of preexisting hegemonic business practices in neoliberalism (extended from Harvey 2005). Depending on whether, as Marc Edelman (2005) points out, the benefits are part of a projected false identity or “shell” which use a claim of popular support to gain false credibility. This conception of a false understanding, and negotiation of identity (of states and individuals) parallels the conception of “culturally intimate” knowledge as opposed to open public knowledge (Herzfeld 2005) and suggests one danger of the acceptance of cultural phenomena as natural in the contemporary setting.
 * HASS Fellowship Proposal Gareth Edel, Dept STS, RPI **
 * //__ Medical Tourism: __//** ** Nascent Practices In An Emergent Industry, **
 * Determining Effects On Healthcare Institutions. **
 * __ Overview __**
 * __ Broad Significance and Intellectual Merit __**
 * __ Literature Review __**


 * __ REFERENCES __**
 * 1) Abram, S.; Waldren, J. and Macleod, D. V. L.. 1997. __Tourists and Tourism: Identifying with people and places__. Oxford and New York, Berg Press.
 * 2) Anderson, W. (2002). "Postcolonial technoscience." __Social Studies of Science__ 32(5/6): 643-58.
 * 3) Appadurai, A. (1996). __Modernity at large: The cultural dimensions of globalization.__ Minneapolis, University of Minnesota Press.
 * 4) Beck, Ulrich. 1992. __Risk Society: Towards a New Modernity__ (Published in association with Theory, Culture & Society). Sage, London.
 * 5) Bookman, Milica; Bookman, Karla. 2007. __Medical Tourism in Developing Countries__. Palgrave Macmillan
 * 6) Bowie, Katherine. 2005. “The State and the Right wing: The village Scout movement in Thailand”. Pp46-65 . In __Social Movements : An anthropological Reader__. June Nash(Editor). Oxford, UK; Blackwell
 * 7) Carrera, Percivil M. ; Bridges, John. 2006. “ Globalization and healthcare: understanding health and medical tourism”. //Expert// __review of Pharmacoeconomics and Outcomes research__. Vol 6, #4, Pp 447-454.
 * 8) Clarke, A; Shim, J; Mamo, L; Fosket, J R; Fishman, J. 2003. __American Sociological Review__ Vol 68, No 2. pp 161-194.
 * 9) Cohen, E. 1984. “The Sociology of tourism: approaches, issues and findings”__Annual Review of Sociology__ Vol 10, pp 373-392.
 * 10) DeMicco, Fredrick J.; Cetron, Marvin J. and Davies, Owen. (2008) __Hospitality 2010: The Future of Hospitality and Travel__//.// Prentice Hall Publishing.
 * 11) Drori, G. S. (1993). "The Relationship between Science, Technology and the Economy in Lesser Developed Countries." __Social Studies of Science__ **23**(1): 201-15
 * 12) Edelman, Marc. 2005. “When Networks Don’t Work ; the rise and fall of civil society in Central America.”pp.29 – 45. In __Social Movements : An anthropological Reader__. June Nash(Editor). Oxford, UK; Blackwell
 * 13) Epstein, Steve. 1996. __Impure Science__. Univ. Cal Press
 * 14) Escobar, A. (1995). Encountering __Development: The Making and Unmaking of the Third World__. Princeton, Princeton University Press.
 * 15) Fortun, Kim & Fortun, Michael. 2005. “Scientific Imaginaries and Ethical Plateaus in Contemporary U.S. Toxicology” in, __American Anthropologist__, Vol. 107, No. 1, pp. 43-54
 * 16) Foucault, Michel. 1969. __Archaeology of knowledge__, New York, New York; Pantheon Books.
 * 17) Fujimura, Joan. 2003. “Future Imaginaries: Genome Scientists as Sociocultural Entrepreneurs”. in __Genetic Nature/Culture: Anthropology and Science Beyond the Two-Culture Divide__, pp. 176- 199, edited by Alan Goodman, Deborah Heath, and Susan Lindee. University of California Press
 * 18) Furlough, E. 1998. “Making Mass Vacations: Tourism and consumer culture in France, 1930s to 1970s” __Comparative studies in Soc and Hist.__ Vol 40, No 2, pp 247-286.
 * 19) Graburn. N. 1989. “Tourism: The sacred Journey” pp21-36 in Smith, (ed) __Hosts and Guests: The Anthropology of tourism__ Philadelphia; University of Penn Press.
 * 20) Gupta, A. (1998). __Postcolonial developments: Agriculture in the making of modern India__. Durham, NC; London, Duke University Press.
 * 21) Guston, D. (1999). "Stabilizing the Boundary between US Politics and Science: The Role of the Office of Technology Transfer as a Boundary Organization" __Social Studies of Science__ 29:1:87-111.
 * 22) Hancock, David. (2007) __The Complete Medical Tourist: Your Guide to Inexpensive and safe cosmetic and medical surgery__.Chapel Hill, NC: John Blake press.
 * 23) Harding, S. G. (2006__). Science and social inequality: feminist and postcolobial issues__. Urbana, University of Illinois Press.
 * 24) Harrington, Charlene; and Estes, Carroll. 2008 __Health Policy: Crisis and reform in the US health care delivery system__. Sudbury, Mass., Jones and Bartlett Pub.
 * 25) Harrison, David (Ed.) 1992. __Tourism and the Less Developd Countries__. Belhaven, NY.
 * 26) Harvey, David. 2005. __A Brief History of Neoliberalism__; Oxford, Oxford University Press
 * 27) Harvey, David.1989; __The Condition of Postmodernity: An Enquiry into the Origins of Cultural__; Blackwell Press, London
 * 28) Herzfeld, Michael. 2005. __Cultural Intimacy:Social Poetics in the nation state__. NY, NY Routledge.
 * 29) Illich, Ivan. 1976__. Medical Nemesis__. Pantheon Books
 * 30) Kearney, M. (1995). "The local and the global: The anthropology of globalization and transnationalism." __Annual Review of Anthropology__ 24: 547-565
 * 31) Knorr-Cetina, K. (1999). __Epistemic cultures: How the sciences make knowledge__. Cambridge, Harvard University Press.Cambridge Mass.
 * 32) Latour, Bruno (1987): __Science in action__. Cambridge, Massachusetts: Harvard University Press.
 * 33) Lee, Kelley. (2004). __Globalization and Health: An Introduction__ .New York, NY: Palgrave Macmillan.
 * 34) Locke, Margaret.(2001) Twice Dead: Organ Transplants and the Reinvention of Death. California: University of California Press.
 * 35) Lyotard, Jean-Francois. (1984) __The Postmodern Condition: A Report on Knowledge (Theory and History of Literature, Volume 10)__ Minnesota: University of Minnesota Press.
 * 36) Marcus, G. E. (1995). "Ethnography in/of the world system: The emergence of multi-sited ethnography." __Annual Review of Anthropology__ 24: 95-117.
 * 37) Marcus, G. E. and M. J. Fischer (1986). __Anthropology as cultural critique: An experimental moment in the human sciences.__ Chicago, University of Chicago Press.
 * 38) McCannell, D. 1973. “Staged Authenticity: Arrangments and social space in tourist settings” __Am journal of Sociology__. Vol 79 No 3, pp 589-603.
 * 39) McCannell, D. 1976. __the Tourist__. New York, Schocken Books
 * 40) McIntyre-Mills, Janet J. 2000. __Global citizenship and social movements : creating transcultural webs of meaning for the new millennium__. Routledge
 * 41) Mitman, Gregg. 2007. __Breathing Space: How allergies shape our lives and landscape__. New Haven, Connecticut ; Yale Univ Press.
 * 42) Nash, June. 2004__. Social Movements: An Anthropological Reader__. Wiley-Blackwell
 * 43) Ong, A . 1999. __Flexible Citizenship: The cultural logics of transnationality__. Duke University Press, Durham NC
 * 44) Pearce, P. 1982. __The social psychology of tourist behavior__. New York, Pergammon.
 * 45) Pruthi, Raj. 2006. __Medical Tourism In India__. Arise Publishers
 * 46) Schult, Jeff. (2006) __Beauty From Afar: A medical tourist’s guide to affordable and quality cosmetic care outside the US.__ New York, NY: Stewart, Tabori & Chang.
 * 47) Sheller, Mimi and Urry, John (eds) 2004. __Toursim Mobilities: Places to play, places in play__. London and New York; Routledge
 * 48) Smith, M. P. and L. Guarnizo, Eds. (1998). __Transnationalism from below__. New Brunswick, N.J., Transaction Publishers.
 * 49) Smith, Valene L. (ed) 1977. __Hosts and Guests: The Anthropology of tourism__ Philadelphia; University of Penn Press.
 * 50) Stephen, Lynn. 2005. “Gender, Citizenship, and the Politics of Identity.” 66-77. In __Social Movements : An anthropological Reader__. June Nash(Editor). Oxford, UK; Blackwell
 * 51) Starr, Paul. 1984. __The Social Transformation of American Medicine: The Rise of a Soverign Profession and The making of a vast Industry__. Basic Books.
 * 52) Strauss, A. and J. M. Corbin (1990). __Basics of Qualitative Research: Grounded Theory Techniques and Procedures.__ Newbury Park, Sage.
 * 53) Stronza, Amanda. 2001.”Anthropology of tourism: Forging new ground for ecotourism and other alternatives.” Pp.261-283. __Annual Review of Anthropology__. Vol 30
 * 54) U.S. Census Bureau; 2006, __Current Population Reports__; P60-231, and Table HI01-102 Health Insurance Data: 2005. http://www.census.gov/hhes/www/hlthins/hlthin05.html

__**LONGER VERSION**__

Newlyweds extend their honeymoon in Johannesburg, South Africa, for the day following their safari so that the bride may receive Lasik eye surgery at a lower cost than home. An Israeli grandmother living in the United States, travels to Turkey after visiting relatives in Israel and has a new kidney surgically implanted, unconcerned about its origin she recuperates in a hospital looking upon the Historic Blue Mosque in Istanbul. Medical tourism (MT) describes the practice of traveling across national boundaries for healthcare, a practice that has recently grown to a multi-billion dollar industry. Proponents praise the globalization of healthcare as leading to universal improvement in the quality of care by redistributing healthcare technology and promoting investment in developing countries while providing cheaper care for tourists. Contrarily, some advocate groups claim this is damaging to local healthcare systems of destinations, and undermine efforts at healthcare reform in the US, as well as being individually dangerous. New Forms of patient care combine with technical intervention to define a group of patients as tourists. At the same time tourists start to need to be concerned about effective ethical care and novel forms of risk. Technical definitions of disease and illness conditions engage in liminal points with sight seeing and recreation culture in new ways. The growth and variety of these new practices suggest several focuses and research questions that I will answer: __ I. Epistemological attitudes on medical tourism: __ 1 Are there differences in discourse surrounding different forms of MT? 2 What is the relationship between ideas of choice and healthcare discourses on MT? 3 Why do some forms of biomedicine lend themselves to MT better than others? __ II. Lived effects: __ 1. Practice: Does MT influence the practices and protocols of medicine, & if so, in what way? 2. Economic: How does MT affect domestic healthcare markets in participating nations? 3. Policy and regulatory: What factors determine why certain national governments officially regulate MT while others don’t? Because of the rapid expansion of MT and the urgency surrounding evaluation of new medical situations, this project represents needed scholarship. Theoretically it offers key insights into the way people experience their health, travel, and new forms of life. In this project, I will conduct a discursive analysis of the patients, industry and its representative texts, as well as a comparative ethnography of the phenomenon as it appears in the US (the single largest source of patients) and selected representative destination sites in the developing world. My research will contribute to three broad areas of scholarship: 1) discussions of transnationalism; 2) academic study of travel and tourism; 3) the construction and transfer of technology and medical knowledge between cultural settings in Science and Technology Studies (STS). This work will position me for continuation as a scholar, and provide needed analysis of MT for policy formation and further study. Studies of medical tourism have focused on the 150,000 or more medical travelers to India and to Singapore annually, while ignoring more than a dozen other countries that are actively promoting MT programs (including Brazil, Costa Rica, Cuba, Mexico, Turkey, Slovenia, Romania, Thailand, Malaysia, and the Philippines). Other instances are ongoing in nations without national programs, such as reproductive tourism between Korea and China, and the organ trade in Moldova. While dollar figures are inexact, the international value is frequently placed at 1 billion US dollars or higher by industry estimates. Others suggest it is as high as 2-3 billion US$ (Demico; Cetron & Davies 2008) and all estimates suggest that it is rapidly expanding. This represents an important change in the way people globally are receiving healthcare. The effect of new formations on preexisting systems and conceptions of healthcare have relevance to treatment of an unprecedented number of patients. Given the potential impact of MT on patients and preexisting healthcare institutions this topic displays special urgency. Drawing on STS and anthropological perspectives on culture I will look at: the diseases and medical conditions for which people travel, the forms of care and service provided and required in each site, the social institutions and actors involved in forming these ideas and practices, as interlocutors about the similarities and incommensurability that exist as variations in practice and experience. Through my analysis of the contemporary discourses and practices of the nascent industry and institutions of MT I will document cross cultural interactions and contribute to several fields. Medical tourism represents an ideal site for observations about conflicts and negotiations that arise, analysis of the way ethical, ontological and epistemic practices vary and constitute different medicines in multiple locations. I focus on patient-provider relations in medical care, expert – lay person relations involving technical knowledge, and inter-national relationships between states. This work will contribute to theoretical discussions on cultural authenticity, knowledge and technology transfer, and conceptions of risk in the study of tourism and transnationalism as well as Science and Technology Studies. Discussion of Medical Tourism in popular media and political rhetoric, including President Bush’s 2007 State of the Union, have suggested that consumer choice and industry transparency are the natural neoliberal remedy for contemporary crises in healthcare access. This call has been paralleled in the popular promotion of MT as a new option and a site of greater individual agency in choosing healthcare options (Bookman & Bookman 2007). This is in direct response to an ongoing crisis in medical coverage dating to the 1960s (Illich 1976). The most recent national census figures show approximately 15% of the US population is without any sort of health insurance, and this includes more than 30% of those living below the poverty line. Preliminary research on health care and broader culture in the US (Starr 1987), the history and development of the American healthcare industry suggests that despite framing the crisis as new there is a long history of antagonism around healthcare (Starr 1987). The recent literature on MT focuses on specific sites, such as India (Pruthi 2006), and often attempt to overview this widespread phenomenon as it appears in a single country. Academic focus has been on business growth and impact with little work on aspects of experience, or medical practice itself; a notable exception to this lack of breadth are a few works considering MT an outgrowth of colonialism (Bookman and Bookman 2007). Limited access to patient narratives and the zooming in on one as opposed to multiple sites renders those accounts limited at best (Carrera & Bridges 2006), while a plethora of popular media articles and books, most notably Schult (2006) have received significant press attention. The popular milieu often provide one or a collection of successful patient narratives, but do not suggest any challenges or critiques and mostly function as how-to consumer guides (Hancock 2007). The traditional subjects of STS have been Euro/American and a growing number of scholars call for STS to diversify. Studies of medical practice are at the forefront of this new direction in STS (Anderson 2002; Harding 2006). This project will contribute to this emerging focus, and my training in political economy and the anthropology of health and medicine will enable me to contribute to both theoretical and policy discussions surrounding MT. As development issues have become an area of considerable interest to STS scholars work has appeared (Drori 1993; Guston 1999). However, critiques of development have frequently focused on the lack of sensitivity to local cultural contexts while implementing Western technologies (Escobar 1995; Gupta 1998). Often, these studies have been overly focused on the transfer of artifacts and systems with technological knowledge embedded in them. STS theory on expertise and knowledge construction will add interpretive depth to Tourism studies theory. MT exists between multiple cultures and biomedical/technoscience knowledge(s) and practice(s), and is characterized by the transfer from, and flow between, nations. These variations are embodied or emplaced in the people, texts and institutions that constitute the system of MT, and it suggests that current brief definitions of MT are inadequate. This work introduces the idea of differential power relations between the visitor and the locals as a central theme in the field. Smith (1977) drew attention to the new relationships formed when participants in tourism travel move from one cultural location into another. This parallels discussion of western medical culture, as popularly represented and considered homogenous, being viewed in STS as a set of related systems; interrelated “epistemic cultures” (Knorr-Cetina 1999) which contain different conceptions and frameworks that contribute to the construction of localized variation. One aspect of the MT industry in need of examination is the extent to which it is actually independent from or affecting local identity. Lynn Stephen’s (2005) work on the reproduction of “sameness” as part of the framing process in social movements potentially leading to essentiallization can be connected to Smith’s concern about responses to contact and power difference in exchange, as tourists demand the same experience they were implicitly promised before arrival. At the same time, as these systems interact they demand boundary work (Epstein 1996) as participants construct their credibility in relation to differing socio-cultural contexts (Latour 1987). In tourism studies McCannell (1976), describes the transfer, and notional portability of artifacts as a key characteristic of modernity and the formation of the notion of tourism, as fundamentally based in power relations, and in response the demand for the local to match the expectation of the visiting tourist.  Investigation of new transnational forms of life serves to expand the discussion of social and theoretical shifts, as key phenomenon are no longer centered in local sites, but rather between sites. I use the framework of transnationalism to emphasize that MT is anchored in and simultaneously transcends the boundaries of one or more nation-states (Kearney 1995). This de-centering is key to ongoing methodological discussion of the scientific study of what Rabinow (2008) terms anthropology of contemporary phenomena. While transnationalism has been studied in information technology and manufacturing (Harrison 1992), little comparable work has been done on medicine. MT offers a vantage point where theories of risk (Beck 1992) and experience of time (Lyotard 1984) are embodied in individual access to medical care. While Western biomedicine has never been fully local, the shift in practices and discourse that have recently reframed surgery as part of recreational tourism represent a distinct shift from historical health travel such as travel to Hay fever resorts in the US (Mitman 2007) in the historical literature of tourism, or travel for relaxation of the nerves (Furlough 1998) in sociological literatures. This disciplinary conversation connects to a broad literature on post-modernity (Harvey 1989), or late-modernity (Giddens 1991), representing an ongoing effort to understand new forms of life activities. Recent discussions of the way these changes effect different institutions, such as citizenship (Ong 1999), cultural imaginaries (Appadurai 1996), and economic structures (Harvey 2005) have proved fertile and should be added to the discussion of tourism. This larger literature on transnationalism contains little work on science and medicine and the work on new systems such as the international organ trade (Lock 2006) or MT would provide insights from into how these systems are involved. Medical tourism as a new form of healthcare provides new insights into the extension of scale that is characteristic of late-modernity (Tsing 2000). Tourism studies has looked at these changes and responded in a theoretical shift away from neat divisions of visitors and locals, to a more complex interplay of global networks and the “mobile nature of the whole touristic venture” (Nash 2005). This has been part of a controversy over the very nature of local authenticity focused on deterritorialization (Sheller and Urry 2004) regarding the development of new systems and discussion of basic changes in the nature of societies and institutions in the contemporary world. The study of tourism in sociology (Smith 1977;McCannell 1973; Pearce 1982) and anthropology (Graeburn 1989; Stronza 2001) has been characterized by their focus on descriptions of the tourist as a product of leisure, and accounts often focus on the roles, performances and positions of the actors as opposed to the negotiation or interaction between them (Cohen 1984). This has been productive, and could be usefully combined with the recent literature focusing on transnationalism which stresses that forms and experiences in interaction are distinct from their isolated antecedents.  I would describe this shift, after Clarke et al. (2003) the “biomedicalization” of tourism; thus, describing shifts in the US as producing new identities, and reflecting the expansion of technoscientific knowledge into areas where it had not previously been, both true of MT in regards to traditional definitions of tourism. The flexibility of identity presents a potential problem as one can see medical tourism as a reform movement, or an extension of preexisting hegemonic business practices in neoliberalism (extended from Harvey 2005). Depending on whether, as Marc Edelman (2005) points out, the benefits are part of a projected false identity or “shell” which use a claim of popular support to gain false credibility. In this section I describe the components of this study, and outline my research schedule. I begin by providing justifications for my chosen methodologies. The primary method chosen for this work is an ethnographic study combining interviews and participant observation. Ethnography’s ability to interpret and translate the emic experience of cultures has generally been localized, and in order to approach a transnational phenomenon I focus on the framework discussed by Marcus and Fischer (1986). This framework considers the potential of ethnographic methods to situate and understand local phenomena in broader contexts of power that render them. It represents the recent anthropological focus on conducting multi-sited research projects (Marcus 1995). I will be implementing the multi-sited structure and analysis maintaining the rigorous observation of the grounded theory approach (Strauss and Corbin 1990). This approach seeks to identify important vocabularies, themes, uncertainties and examples. The interviewing will be organized to directly correlate with the primary aims of this study. In keeping with a grounded theory approach, my interview guide will continue to evolve as this study progresses. I foresee interviews staggered between field site observations over the course of 12 months. At each stage, interviews and observations will be used to refine and verify further sites of study and potential target individuals and groups for interview. The ability of an ethnographic interview and observation to represent the experiences of participants from different standpoints will be supplemented with discursive analysis. Through the Foucauldian concept of discourse (Foucault 1969), attention is drawn to the power of social institutions that remain invisible to participants, and remain difficult to study based on the emic perspective. It is intended to serve here as a compliment to the outsiders gaze in ethnography. In discourse the social institution is embodied in individuals and found recorded in texts and conceptions that define meaning and experience. This is expanded in Dorothy Smith’s approach to institutional ethnography (2005) which offers methodological insight into power and the relation of local instances of discourse in replicating the “ruling relations” that exist outside a local situation. I link this discursive analysis to the ethnographic endeavor through the anthropological literature on Imaginaries, or notional constructions as central to culture in meaning construction (Fujimura 2003; Fortun & Fortun 2005). Throughout the research period I will be harvesting regulatory, media, and industry documentation that will contribute to the textual and discursive analysis. Stage I - __Review of Primary and Secondary Literature and Development of Interview Instrument__ Careful review of all relevant academic literature on MT continues, while also gathering related topical and theoretical materials from STS, Tourism Studies, Medical Anthropology, and Industry Studies. In this stage I will begin to form a list of international field sites, and I will make contact with informants and collaborators to arrange interviews and access. Initial stages of ethnography will begin in the US. Preliminary emails and letters have been prepared and will be sent to former patients, advocates and business figures involved in MT requesting interviews. Gathering and coding of popular press and media content available on MT will continue. Discourse sites in the MT industry will be contacted and texts will be requested where available (e.g. literature from travel agencies). A key site of conversation around MT is its digital presence, and preliminary analysis of websites will include but will not be limited to: patient and advocate blogs, insurance company sites, and specifically MT related companies (e.g. Medjourney, Medretreat, Medicalnomad). A preliminary review shows that aside from websites, the largest source of information for patients of MT is coverage of medical tourism in major news outlets and these will continue to be monitored. Stage II - __Ethnographic Fieldwork and Interviews__ I will conduct approximately 60 semi-structured ethnographic interviews, approximately two to three hours in length. My primary interviewees will be patients and professionals involved in, or formerly involved in, the MT industry in the United States and other sites. I will also seek to interview members of their immediate families; local healthcare seekers who are not medical tourists, healthcare reform activists, and policy and regulatory professionals, so that I can better represent the full experience and reality of the MT phenomena. I provide a rough timeline for this project in one of the following sections. Stage III – __Data Analysis and Writing Period __ Expanded data analysis of textual/documentary evidence and analysis of interviews will be through coding and the use of AtlasTi, a qualitative data-analysis software package based on grounded theory (Strauss and Corbin 1990). After coding data may, as needed, be entered into SPSS statistical software to do quantitative analysis of correlations on the basis of factors designated in initial research in Part I. Follow up interviews based on incomplete data will be scheduled, and interview participants from previous stages will be asked to respond to initial conclusions, and verify transcripts of past interviews and observation. 1  ||  Summer '08 || Continue literature review and discursive analysis || Begin work on dissertation proposal ||^  || Prepare for Comprehensive Exams ||^  || Present paper of initial Discursive analysis at 4S conference. ||^  || Fall '08 || Confirm dissertation committee || Continue preparing dissertation proposal ||^  || Apply for further support in the form of NSF dissertation improvement grant ||^  || Begin ten pilot interviews ||^  || Sit for Comprehensive Exams. ||^  || As needed meet with dissertation committee to refine project & present preliminary findings. ||^  || Continue to develop a list of sites, and make contact with key informants. ||^  || Spring '09 || Finalize and Defend Dissertation Proposal. || Continue Literary Review and Discursive analysis. ||^  || Revise interview questions based on pilot interviews, and proceed to primary series of domestic U.S. interviews. ||^  || Summer '09 || Publish paper detailing results from first round of research || Continue work on discursive analysis of interviews, media sources and texts. ||^  || 2   ||  Fall '09 || Finalize Interview instrument and make travel arrangements for research in Philippines  || Present paper at 4S conference in Japan. ||^  || Begin field work and interviews in Philippines. ||^  || Spring '10 || Update plans finding new interview subjects, and new collaborators through snowball effect. || Return to US, and begin data analysis. ||^  || Final series of US interviews responding to data from Fall ||^   || Summer '10 || Submit articles based on initial analysis for conferences and publication, Revise chapter outlines, and finish literature review || 3  ||  Fall '10 || Dissertation Writing || Spring '11 || Dissertation Revision || Dissertation Defense ||^  || I am uniquely qualified to proceed on the study of MT described above; I have been immersed in key theories of globalization and modernity, as well as feminist and critical social theory that provide insight into the formation of institutions. I have experience in unstructured and structured interviewing from work with the New York City based life history project. I have completed coursework in social theory, rhetoric, and policy studies; as well as having methodological experience from seminars in advanced research methods (Spring ‘07), historiographic and ethnographic research methods (Fall ‘06), and Discourse Analysis (Spring ’07). Beyond coursework, my prior work experience in medical advertising, working at a specialty production company, and working with public case workers who arranged and managed healthcare options for their clients, has provide valuable insight into the American Healthcare world. I have traveled extensively in the US and abroad, and have language skills in French and Spanish. Due to the recent formation and expansions of MT, the work will also offer data and analytic insight useful for healthcare regulation. It is my expectation that researching medical tourism will allow me to increase the quality of public policy debate surrounding these practices, as well as publicly provide improved information for decision making about healthcare choices. Professionally, the work will position me to contribute to ongoing academic discussions regarding: transnational scholarship, healthcare systems, medical institutions, and to continue to improve the new methodological focus in framing multi-sited phenomena. My commitment is to advance theoretical expertise in both globalization and medical studies in STS. Tangibly this research will result in publications in major journals in the fields of STS (e.g. __Social Studies of Science, and Science, Technology & Human Values__, __Configurations__), Medical Anthropology (e.g. __Medical Anthropology Quarterly__, __Medical Anthropology__), Industry and organizational studies (e.g. __Industry and Innovation__), Development (e.g. __Perspectives on Global Development and Technology)__. It will be relevant to scholars in STS, medical anthropology, globalization, healthcare studies and political science. **__ REFERENCES __**
 * HASS Fellowship Proposal Gareth Edel, Dept STS, RPI **
 * //__ Medical Tourism: __//** ** Nascent Practices In An Emergent Industry, **
 * Determining Effects On Healthcare Institutions. **
 * __ Overview __**
 * __ Broad Significance and Intellectual Merit  __**
 * __ Literature Review __**
 * __ 3. Research methodology and plan of work __**
 * Ethnography **
 * Discourse Analysis **
 * Stages of Research **
 * Plan of work/Timeline **
 * Fellowship Year ** ||
 * Time frame ** ||
 * Description ** ||
 * Description ** ||
 * __ Qualifications and Background Information on the Researcher __**
 * __ Future Plans __**
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