Gareth+-+Memo+-14+-+Emerging+Narratives

MEMO 15- Core Categories

1- “GOOD MEDICINE”

While I am tempted to say the definition of medical tourism is itself a Core Category (Strauss and Corbin 1990) I think that in order to do the story development that they suggest, of linking the multiple stories under the umbrella of a central unifier, I will return to the idea of “good medicine” I mentioned in class. The many ideas that I find coming together in my research can better be linked in that core concept that uses medical tourism instead as a context, rather than guiding concept. While medical tourism is still in the process of coalescing, I think the argument over it overlaps into two central discourses that both participate in framing good medicine. These subsidiary concepts/categories, that of the “universality of biomedicine” or simply “biomedicine” and the linked ideas of “access” and “choice”, are parts of the way that people understand good medicine and by extension how they justify or understand its creation in medical tourism.

2- “TRAVEL”

Continuing to try to avoid the core category of medical tourism, I’m going to suggest that the ongoing academic discussion about space/place and the reconceptualization of political, cultural and economic boundaries could be another core category. This would be either in the guise of the concept of “foreign” or “place” or I might prefer to focus on the notion of “travel” as the central one. This concept, what it means to different characters in the story to travel (an act), be a traveler or by extension a host (identity), what it means for participants and observers to see healthcare as a subject of travel or a field in which travel is appropriate. This avenue considers the use of the word “tourism” and the ideas of good medicine, access, and choice become subsidiary categories of analysis.

MEMO 14- EMERGING NARRATIVE Emerging narrative supported by the "good medicine" core category: The definition of good medicine as constructed by patients often relies on the idea that medicine, which I refer to here as biomedicine, is universal. That is to say that in order to understand medicine as good whether in the US or while receiving care in foreign countries it is important that the patient feel it is the same medicine that others receive. The exception is the frequent contextualizing of good medicine that is universal in terms of knowledge, but in which style of application varies, such that foreign medicine which they see as the same medicine or medical knowledge, is provided in a different and better style. At the same time, I see the idea of medicine and its universality as more contested in the participation of professionals. For professionals there is a need to appeal to patients, and they have a political motivation in defining their national context as equivalent both for their professional standing and probably out of forms of nationalism. This universalizing impulse is balanced by the fact that in order to compete with other national sites of care, or other local sites, they must offer something distinct. The performance of good medicine and balance of its universality and heterogeneous contingency is therefore central to the public performance of participants in medical tourism. This performative notion of medicine is also combined with a participation in the field of knowledge creation and innovation, which in turn offer both specific advantages in demonstrating mastery of good medicine that is universal, but offers a way to distinguish the locally contingent within the acceptable parameters of these negotiations. I look specifically at the construction of something like joint replacement surgery, as opposed to joint resurfacing surgery. While Indian Orthopedic Surgery was primarily responsible for the development of resurfacing techniques and it was initially seen as bad medicine the shift in perceived legitimacy of their medical system, and the formation of patient demand for the surgery over the last few years have pushed it into the category of good medicine. This was an unusual pattern of knowledge transfer from a marginalized/developing nation, to the US and Western Europe.

Secondly the ideas of Access and Choice which are intrinsically linked in Healthcare, have had growing popular discussion, and serve centrally in the discussion of legitimacy of medical tourism, but also of healthcare reform and quality in general. For some the idea of good medicine requires strong knowledge, technological innovation, and for others these require supplement or are secondary to access and appropriate application. For patients “choice” is often seen in an expanded access to care because of decreased price, but in doing so they accept that the healthcare policy/knowledge/practice assemblage in the US is as it should be. By using the pricing and choice argument in normalizing their travel, and legitimating their access through a new channel, they often incidentally justify structuring healthcare as a commodity market business, even while criticizing the social organization of the national institution of health as unfair. These arguments connect back to the idea of “good medicine” by frequently talking about the importance of choice and self-direction in good medicine as lacking here, and that the price is secondary to the inability to function within the strict authority structure. This levers their particular choice away from one of inability or ability to afford care, to a choice between good and bad medicine.

OTHER NARRATIVES:

Examining the rapid shift in the discursive position of “Medical tourism” (MT) in the US media over the last two years… MT has gone from a marginal practice with public association of risk (almost desperation in face of healthcare “crisis”), through a process of naturalization and reframing in terms of “transparency” and “choice” to a common-sense result of neoliberal and globalization processes, this has recently concretized into a push to promote it by health care insurance companies, and in some cases to make it a mandated practice for approval of some procedures. The variability of the form of experience and practices of those currently labeled as participants in medical tourism suggests a dramatic limitation to that conception. The term derives from popular media representations that originally referred to voluntary cosmetic surgeries, and fails to adequately describe the variable types and forms of health care delivery that involve transnational process and travel. Though the term is limited, its popular use has lead to its adoption by academics and potentially due to the limitations contained in the term, the little academic work available so far centrally focuses on that aspect that most closely extends medical tourism into new practices. In order to avoid this I am currently considering my work to not focus on “medical tourism” (MT) but rather on the broader panoply of Transnational Healthcare, or more specifically Transnational Healthcare Delivery (THD). The large body of work that has described global networks, even specifically around technoscience has suggested that the networks interact, the nature of THD as opposed to MT is very general, and a goal of reframing it in this manner is to be able to ask how other networks are interactive or competing. One aspect of this has taken the form of boundary work around what may be called MT; distinctions exist around the blanket differentiation of ‘bleeding edge’ bio-sciences that are therapeutic (gene therapy, molecular medicine, clinical drug trials, experimental treatments), as well as marginal practices such as cryogenics. Similarly, the recent discussion of clinical care around reproductive technologies and maternal surrogacy (especially in India) has bounced back and forth between framing as MT and as reproductive travel or tourism, but has been increasingly not defined as part of MT.

The apparent novelty of MT & THD belies its historical origins. Health travel for many reasons has been practiced since ancient times, but largely it has been initiated due to geographic and culturally specificity of locations, rather than the current perception that medical protocols and technology are uniform across context. To exemplify this practice I look to work such as Mitman, on the travel in the 19th to early 20th Century US context to escape hay fever, this travel was predicated on the sense that location mattered. As the railroad and urbanization infrastructure allowed increases of this travel it also brought plants and reconstructed the original space, ending the practice as the qualities of the locations converged. The discussion of the assimilation or mutual reconfiguration of sites has been discussed in largely in terms of the Nation/State in transnational theory (i.e. Appadurai’s concept of “[-]scapes”), and in light of economic forces in globalization theory (Harvey’s description of neoliberalism; Ritzer – Mcdonaldization; ) while landscape and material context are mostly absent in the literature outside of the work of some geographers.

Theoretical work on cultural interference/homogenization and authenticity within globalization seems important, and the nature of MT/THD as bodily embodied practice, connected to highly variable local/traditional knowledge, and economic incentivization/modernization/development, offers a good site. Because these issues all connect to the local, I think that comparative analysis will be useful in sxploding the details. So I am thinking of looking at the Philippines and India to represent interesting sites for comparison, India is the exemplar today but started out aspiring to be Singapore and in turn The Philippine president and explicitly launched their National MT Initiative citing Indian Successes. These countries are hugely different economies, and populations yet models of industry development travel between them. If time/money allows I also think that the distinction between broader tourism travel culture would be interesting and it would be particularly interesting to add a comparison to Thailand.Thailand represents a linked system with sex tourism supporting medical tourism as gender reassignment (i.e. sex change) surgeries are funded by the participation of seekers in the sex trade as “lady-boys”… This is not tourism, as the surgery seekers remain in residence over long periods and if they return home fundamentally different people…