Title: HSS4331
1HSS4331 Introduction to International Health
Theory
- Nov 24, 2008 Medical (Reproductive) Tourism
2Upcoming Events
- Wednesday Nov 26, 630pm, UC Terminus Hunger
Banquet featuring Prof Paul Haslem. 5 in
advance (from International House) or 6 at the
door - Thursday Nov 27, 6pm, UC Terminus - Student
Refugee Program Awareness Night free of charge
and there will be pizza. - Monday Nov 24, 5-7pm, RGN Amph A, Dr Jane
Philpott on Canadians engaging in global health
All are eligible for your summaries
3Today.
- Were going to talk a little bit about some of
the work I currently do - Some of it is coordination with Assisted Human
Reproduction Canada (AHRC) - But nothing I say or present today should
necessarily be considered the position of AHRC
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5In General.
1. The act of (typically Western) medical
professionals doing abroad to do good work, but
in reality functioning as gawking tourists 2.
The act of (typically Westerners) going abroad
(to typically developing countries) to seek
medical care.
6The First Type
- The act of (typically Western) medical
professionals doing abroad to do good work, but
in reality functioning as gawking tourists - The danger of every international health project
- Whom does it really benefit?
- cowboy global medicine
- Sustainable?
7The Second Type
- The act of (typically Westerners) going abroad
(to typically developing countries) to seek
medical care. - Growing in popularity
- Often tied to other tourist activities
- Negative downstream consequences may not be
immediately obvious
EXAMPPLE Reproductive medical tourism
8Terminology
- Infertility
- One year of unprotected sex without conceiving a
child - Includes both sterile and subfertile people
- Sterile
- Will never conceive without medical assistance
- Subfertile
- May still conceive without medical assistance
9Infertility
- About 15 of couples will be defined as
infertile - But this only accounts for those who actually
seek services likely an underestimate - -1990 estimate gt1 billion women worldwide are
affected by infertility - -only covers those of reproductive age who have
been diagnoses - On the increase in Western nations
10Why Is Infertility On The Rise?
- People waiting till later in life to have kids
- Obesity and diabetes are on the rise
- Environmental contaminants may be affecting
hormone levels
11Terminology
- Assisted Human Reproduction (AHR)
- Anything involving helping infertile people
become fertile - Assisted Reproductive Technologies (ART)
- Technologies related to AHR
- Some define it only as technologies involving
embryo formation outside the body
12IUI
- Intra-uterine insemination
- Artificial presentation of sperm into the vaginal
canal - turkey baster method
13IVF
- In Vitro Fertilization
- Creation of embryo in a dish, and returning it to
the womb - test tube babies
- Considered the vanguard ART technology
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15ICSI
- Intra cytoplasmic sperm injection
- Done in conjunction with IVF
- Grab a sperm and force it into an egg
- Used when sperm just cant get the job done by
themselves
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18Gamete Donation
- Sperm donation
- Relatively simple
- Donors are usually friends or family
- Anonymous donors are rare and in demand
- Egg donation
- Very invasive
- Expensive procedure
- Hard to find donors
19Surrogacy
- A surrogate mother is a woman who agrees to
gestate and give birth to a baby for someone else - Scenarios
- Surrogate receives sperm via IUI and uses her own
egg - Surrogate donates egg, embryo created via IVF
(with or without ICSI) - Another egg is used, embryo created via IVF (with
or without ICSI)
20Statistics
- Canada
- about 6500 IVF embryo transfers per year
- USA
- About 120,000 IVF procedures per year
- UK
- About 35,000 IVF procedures per year
- Europe
- About 300,000 IVF procedures per year
21Costs
- One attempt at IVF costs 8000-16000
- ICSI costs extra
- Donated sperm costs 200-600 (from US centre)
- Donated egg costs 500-20000 (from US source)
- Surrogate services cost 50,000 or more
22The Law
- 1993 Royal Commission on New Reproductive
Technologies - 2004 Assisted Human Reproduction Act
- 2006 Assisted Human Reproduction Canada
- 2009 rules spelled out in the Act begin to be
enforced
23Canadas Act
- Human cloning prohibited
- Sex selection prohibited
- In vitro gene alteration prohibited
- Transplanting non-human gametes or embryos into a
human is prohibited - Transplanting human gametes/embryos into a
non-human for the purposes of creating a human - Create chimeras/hybrids
24Canadas Act
- No payment for surrogacy
- No paid brokerage for surrogacy
- No payment for gametes
- No paid brokerage for gametes
- etc
25The Law
- Laws in different countries vary dramatically
- In the US, it varies from state to state
- In Australia, only one state has clear
regulations - In UK, rules are well defined and monitored
- In Israel, its the wild wild west
- Etc.
26So.
- Lets say youre an infertile couple in Canada
who wish to - Select sex of your baby
- Pay for a surrogate mother
- Pay for a sperm or egg donor
- Pay less for a baby
What do you do?
27You Go Abroad
- Example
- In Virginia Mason medical centre in Seattle, 33
of patients are Canadian, most seeking to buy
donor eggs - In India, reproductive tourism is a 450
million industry
-gt Reproductive Tourism
28South Asia
- Currently, parts of the USA are the most popular
destinations for reproductive tourists - But India is fast becoming an important
destination
29India
- Surrogate mother in India costs lt5000
- Plethora of doctors, all English-speaking
- Case study
- A British couple in 2006 spent 60,000 pounds on
IVF in the UK without success, so they went to
India and paid 3,300 for a surrogate mother
30So, Whats The Problem?
- From an international health/development point of
view, what are the issues?
31The Issues
- Protection for couples travelling abroad
- Protection for women selling services in poor
countries
32The Issues
- Couples are bypassing the laws of their own
countries should they be prosecuted? - Informed consent how informed are these women?
- Choice. In many places, how can we guarantee
that women are not being forced to participate?
33More Issues
- India is popular also because of its familial
laws - In UK, a surrogate mother can change her mind and
claim the baby as her own any time within the
first 2 years of life - In India, the surrogate loses all rights to the
baby at the point of delivery
34More Issues
- Is remuneration fair? Should surrogates be paid
global market rates? - Social stigma of carrying the child of a man who
is not your husband - Loss of control of ones body, as client and
doctor have a vested interest in the surrogates
nutrition and activities
35Even More Issues
- Must protect vulnerable infertile Westerners from
being fleeced by dishonest doctors and surrogates - In instances of extreme poverty, is there really
such a thing as choice for a surrogate? - Compare to instances of choice for an
impoverished woman who chooses prostitution
36Even More Issues!
- What kind of health follow-up are surrogates
given? - Are they given post natal care, especially after
the baby has been given up? - What reproductive effects do surrogates suffer
from? - Giving birth is dangerous
- Potential for surrogate to become infertile
37Legal Issues
- A child born to a surrogate mother in India what
are the legal steps to get it into the country of
the client? - Formal adoption procedures?
- Can a surrogate mother in India benefit from
parental laws of the clients country? - Does she have the 2 year leeway in the UK?
38Cross Border Reproductive Care
- Why is this the preferred terminology?
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41What Needs to Be Done?
42Summary of the Ethical Issues
- Misdirection of financial resources those who
seek services abroad deny their resources (i.e.,
outgoing funds) to their home community - Misdirection of medical resources those who
provide services to tourists are denying their
services to their home community - Implications of insufficiency the act of
seeking services abroad implies that services are
insufficient, in quantity, type, timing or
affordability, in the home community - Criminality if service seeking abroad is done
to avoid laws at home, should the international
community consider this criminal behavior? Is the
provision of services therefore the abetting of
such criminal behavior? - Quality control if the health and welfare of
tourists is a concern, how do we control for
the quality and validity of medical services
provided outside of ones administrative
jurisdiction? - Robustness of informed consent are tourists
provided with adequate and accurate
representation of actual risks and probable
success rates? Brokers may misrepresent facts.
The above may apply to all types of medical
tourism
43- The following issues are particularly relevant to
the seeking of surrogate services in the
developing world - Robustness of informed consent this issue, as
it pertains to the surrogate, is quite separate
from that pertaining to the tourist. Social
downstream impacts must also be communicated (eg,
is a conservative society ready for a woman to
carry baby for two gay men will husband respond
well to wife carrying the baby of another man
specific religions eg, Muslim- concerns) - Custody rights rights vary from country to
country. To what extent is the industry
affecting the drafting of custody rights
legislation? - Cultural appropriateness see (a) economic
attraction of the industry may bring it to
societies presently unprepared for some of the
implications, eg gay parents, single mothers,
carrying a child that is not your husbands - Quality of care surrogates physical health is
maintained, but only to the extent that it
benefits her pregnancy. What of social and
mental health? What of her removal from
care-giving milieu of her own community? If
clinic provides her diet, does she still cook for
her family?
44- Limits of care While the surrogates medical
health is of prime importance during pregnancy,
does this care end upon birth of the child? Is
there an investment in post-partum care? To what
extent does economics affect this trend? (Eg, a
regular surrogate should be maintained in good
health due to her ability to perform again.) - Remuneration one reason tourists seek service
is reduced cost abroad. But while remuneration
for the surrogate is likely above what she would
otherwise earn, it is likely below global market
rates. - Abortion selective reduction is a common
occurrence in ART. Is surrogate aware and
culturally responsive to this likelihood? - Medical advocacy clinician responds to needs of
the tourist. Is it a conflict of interest to
also be care-giver to the surrogate?
45What We Are Doing
- Step 1 bring together ART regulatory bodies
from key nations - Step 2 agree that these are issues worth
considering - Step 3 Collect data!
- Step 4 to be determined
46Achievable Goal
- Establishment of international body to
- Monitor extent of reproductive tourism
- Set forth international guidelines for
appropriate ART/AHR care - Monitor quality control for doctors offering
services to international clients - Monitor rights abuses of local women offering
their reproductive tissue and services