Passion for Equity in Health Care Fuels Recent Grad to Study Medical Tourism in Costa Rica
In the course of her studies, Courtney Lee, alumna of the Health and Behavioral Sciences (HBSC) PhD program, observed a perplexing contradiction. "I came across this article about medical tourism [patients traveling abroad for health care] to Costa Rica, and it was this incredibly uncritical piece that took an attitude about how great it was that Costa Rica was promoting this industry. From my knowledge of global health, I knew Costa Rica had a really successful stand-out, socialized health care system, and so I got to thinking how strange it was that medical tourism—which is very Westernized and based on an American model of health care—was being promoted in Costa Rica. So I started reading more about it, and the more I read, the more it seemed to me to be one of those really baffling contradictions, and I wanted to know more about how it functioned."
Now, a few short years later, if you want to ask anyone in the world how this contradiction plays out in Costa Rica, Courtney Lee may be one of the people best qualified to answer. Between 2009 and 2012, she conducted extensive research on the issue of medical tourism and how it affects public health systems in destination countries. She then spent a year undertaking ethnographic research in Costa Rica, interviewing more than fifty Costa Ricans—from doctors and nurses to academics and medical tourism facilitators—about the social, ethical, and ideological implications of a growing private medical tourism industry on the existing socialized health care system. She synthesized this research into her dissertation and completed her PhD in HBSC in May 2012. Her dissertation work discovered a complicated interplay between the successful socialized medical system that serves most Costa Ricans and the system of private medicine that caters to medical tourists and is largely inaccessible to locals.
Medical tourism is a rapidly growing industry that sends North Americans, Europeans, and others with enough financial resources to poorer nations to receive medical treatments (often cosmetic or elective) at a fraction of the cost they would pay back home. It is an economic force sweeping through Latin America. On average, medical tourists spend six times as much as non-medical tourists when they visit a country. However, as Lee discovered, the profits from medical procedures rarely make it back into the public health system that serves local populations. Instead the majority of profits remain with organizations in the U.S. and other "home countries" that facilitate the medical tourists' stay.
Knowing the strength of the existing health care system in Costa Rica, Lee was interested in whether the country received any economic benefits from medical tourism. Costa Ricans already enjoy a socialized care system generally considered among the best in the world. For example, in the World Health Organization's rankings of health systems in 2009, the U.S. spent 16.2% of its GDP on health care and was ranked 37th, while Costa Rica spent 10.5% of its GDP on health care and was ranked 36th. Socialized medicine in Costa Rica was organized in 1941 when the Caja Costarricense de Seguro Social (CCSS) was established—a system for wage earners that gradually expanded to cover the entire population over the next 50 years. Lee says, "The Costa Rican system is really good, and I think in this country we have preconceived notions about 'socialized medicine' and what that means, and really the reason that medical tourism is flourishing in Costa Rica is because of their very successful, long standing socialized system. I think that's something that surprises people, and I do like to let people know that Costa Rica has a really good health infrastructure, a really strong workforce, great facilities, and they do a wonderful job of taking care of their people."
"Ironically, it is the successes of the Costa Rican socialized health system that allows for medical tourism to exist there in the first place," writes Lee in a chapter for the book Medical Tourism: Risks and Controversies in the Exploding Industry of Global Medicine (Leigh Turner and Jill Hodges, eds. Westport: Praeger Publishing). She also writes, "There is very little scholarly research on the effects of medical tourism or local perceptions of medical tourism in destination countries." Her dissertation project, which was funded by a National Science Foundation Doctoral Dissertation Improvement Grant, the Wenner-Gren Foundation, and the Health and Behavioral Sciences Department, has begun to change that situation. Lee discovered that the issues were far more complicated than she first imagined.
"Ninety five percent on all Costa Ricans exclusively use the public health care system, and they see a private health care system as something completely separate. And that's dangerous, I think, because it means they aren't recognizing when the private sector is detracting from public health care." Lee is careful to credit medical tourism as having certain benefits for the Costa Rican economy, but she worries about the unseen side effects discovered through her research and interviews: "With an increase in medical tourism, a lot of physicians are opting to work in the private sector because they make more money there working with American medical tourists. There are no regulations stating that they have to choose between the public and the private sector, so what many physicians do is receive their education and training and build their experience in the public sector and then at a certain point in their career they leave for the private sector." This "brain-drain" effect from public to private medicine has been growing in the wake of medical tourism. Lee's research uncovers a direct economic impact as well: "Now for procedures that are considered profitable for hospitals, like expensive diagnostic tests or preventive care, Costa Ricans will sometimes go to the private sector to get served more quickly, if they can afford it, but once they are diagnosed, and especially if it is a serious illness, they will go back to the public sector to be treated. So the public sector becomes responsible for expensive, long-term procedures, while the private sector profits. It's a drain on the public system that's very real and happening more and more."
Lee writes in her dissertation that, despite these challenges, the Costa Rican system has remained strong. "The focus has remained on solidarity, equity, and universal access. Costa Ricans have fiercely defended the CCSS from privatization, calling it a ‘Robin Hood system' in which subsidizing the poor is part of citizens' social responsibility. The health care system and CCSS play a prominent role in national ideology within Costa Rica and are routinely cited as a source of pride and as a 'pillar' of the nation." She sees the challenges facing the public system as something that more research, better public awareness, and a focus on international regulation can help mitigate.
Lee became interested in the subject of medical tourism early in her studies at CU Denver—in fact, before she formally began her PhD work, she took a Qualitative Methods class from Prof. Steve Koester, who would eventually become the chair of her dissertation committee. As an assignment for that class, Lee wrote a mock grant proposal on the topic that would one day become her dissertation. Lee started the PhD program in 2006, after completing an MA in Anthropology at CU Boulder, and says one of the major draws to the CU Denver program was its focus on issues relevant to public health and the "What are you going to do about it now?" attitude toward applying social research within the HBSC program. She says, "Throughout the program, I really got to know the professors and was afforded every opportunity. I was able to teach classes, to be a research assistant, and I branched out from there to work on research at the CU Medical School and for Colorado Health Outcomes. By the time I finished the program, I felt like I was really well positioned in my job search in applied research and social sciences."
Lee now works for The Colorado Trust, a grant-making foundation with the mission of achieving access to healthcare for all Coloradans. With her job as evaluation and learning officer, she says, "I take the 'higher level' knowledge that I have from my academic training, and all the theoretical foundations of social sciences that I have, and translate that into something that can be applied to really help people. I like the challenge of trying to connect those two levels, because I think sometimes in an academic setting we talk a lot about things but don't really know enough about what's going on ‘on-the-ground' to apply those things." In the future, Lee looks forward to focusing on issues facing Colorado‘s most disadvantaged and at-risk populations and using critical thinking skills to evaluate our health systems here at home. "I think it's important to always take a critical perspective and ask whether the systems in place are really the best, and how things can be better, to really achieve access to health for underserved and marginalized populations," she says.