Rhythms of Care: Medical Travels beyond the Borders of Bangladesh

Abstract

This article examines the experiences of Bangladeshi patients and their families as they travel transnationally within Asia for medical care. I explain how failures of biomedicine in Bangladesh feed into idealized expectations of care abroad. This medical imaginary is fueled by the hope that more expensive treatment in wealthier countries will result in better care, and it is sustained by the way the medical tourism industry operates and the way Bangladeshi patients and their families make choices and engage in the doing of care abroad. A detailed case study of a Bangladeshi cancer patient’s prolonged care in Singapore illustrates the tensions and ambivalences in the quest for the best treatment. These tensions are exacerbated by the linguistic, monetary, and emotional challenges faced in traveling back and forth between countries. While patients feel at times betrayed by experiences of care that do not meet their expectations, they also feel compelled to carry on. I capture this dynamic in the term rhythms of care, understanding these as the way the medical imaginary shapes care practices that become a scaffolding for hope to be maintained and further travel to be undertaken. I also reflect on how I become part of these rhythms by acting as the family’s interpreter as they navigate health care in Singapore.

• transnational medical travel
• rhythms of care
• cancer
• medical imaginary
• hope
• patient choice

Acknowledgements

I would especially like to thank Catelijne Coopmans for her care, encouragement, and insightful feedback for this article through its many iterations and drafts. She and the other participants in our workshop “Framing Technology and Care in Asian Contexts” helped me to develop the ideas that eventually became this article. Also two anonymous reviewers’ careful feedback was critical in convincing me to push my argument in interesting directions. Marjorie McNamara was a patient sounding board for the times when I was working through ideas. I also want to thank all the Bangladeshi families who openly shared their experiences about medical travel with me. Finally, I am grateful to the Asia Research Institute of the National University of Singapore (NUS) for enabling me to conduct this research during my postdoctoral fellowship and for supporting our workshop both financially and logistically.

Notes

¹ This is a significant cost. In 2015, SGD 20,000 was equivalent to approximately USD 15,121 or BDT 1,177,081 (Bangladeshi taka). According to the World Bank, the average monthly income in Bangladesh in 2016 was approximately USD 117 or BDT 9,138. A middle-class salary is estimated to be USD 416 or BDT 35,166 a month. Therefore, the cost of cancer treatment in Singapore would be more than the yearly income of most middle-class families. See iresearch.worldbank.org/PovcalNet/povOnDemand.aspx and thefinancialexpress.com.bd/views/views/middle-income-population-slowly-running-out-of-puff-1541260569.

² USD 3,024 or BDT 235,416 in 2015.

³ I use pseudonyms for the patients, family members, and doctors in order to protect their identity. I also do not mention the names of the hospitals where Rashida received treatment.

⁴ In 2010, there were an estimated 6 million medical travelers around the world—with a third of these patients traveling to Thailand and India. By 2020, the global medical tourism market is expected to be around USD 100 billion (Inhorn 2015: 12). These numbers are often unreliable because there is no systematic way to count medical travelers or the money they spend. Marketing companies also inflate both numbers, and governments and hospitals do not always make this data public (Chee, Whittaker, and Yeoh 2017).

⁵ Except when referring to the industry, I do not use the term medical tourism, because it evokes the idea that these trips are for pleasure and leisure. I follow scholars who are in favor of using more neutral terms such as international medical travel, transnational medical journeys, or medical migrations (Kangas 2011; Roberts and Scheper-Hughes 2011).

⁶ In Asia, the economic crisis of the 1990s stimulated the development of a medical tourism industry as a way to increase export earnings, which has encouraged the privatization of health care as a means to generate profit. Thailand, Singapore, and India have become hubs of the medical tourism industry.

⁷ Patients travel to this clinic from 140 countries around the world and some patients are from India. In Prasad’s (2015) article he focuses exclusively on non-Indian patients and in particular on the experiences recounted in the blog of an American woman.

⁸ Although I use the word care in this article, anthropological work has shown that the English word care does not translate simply into other languages or cultural contexts (see Van Hollen 2018; Aulino 2016). The Bengali word jotno, meaning earnest or careful attention, is the closest to the English word care. For example, jotno is used to describe the care of a mother for a child or taking care of oneself. Another word for care in Bengali is sheba. Sheba means serving, worshipping, or waiting on and can have a religious connotation, especially in a Hindu sense, when it can mean the service or worship of god. Chikitsha (healing or medical treatment) paired with sheba implies a caring kind of medical treatment or serving another person through healing. Chikithsa sheba, shastho (health) sheba or even the English word treatment are the most common ways to refer to medical care.

⁹ There are also many practitioners of traditional medicine and religious-based healing throughout the country, especially in rural areas.

¹⁰ The average GDP spending on health care for “least developed countries” is 4.31 percent. High-income countries spend an average of 12.53 percent of their GDP on health care. Some examples are Japan (10.93 percent), Canada (10.53 percent), the UK (9.76 percent), and the US (17.07 percent). India spends a comparable low amount of 3.66 percent. Other low-income countries like Nepal spend 6.29 percent and Indonesia spends 3.12 percent. These numbers are from a 2016 World Bank report. See data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS.

¹¹ The nursing profession in Bangladesh is not very professionalized and nurses are stigmatized because of the work and do not receive good pay. These problems have contributed to the shortage of nurses in Bangladesh. In Singapore the nursing profession is more professionalized and better paid. See Amrith 2017 for an in-depth study of Filipino nurses in Singapore.

¹² Patients express this lack by saying there is no good treatment (bhalo treatment/chikitsha nai).

¹³ With a population of over 160 million in the space of 56,977 square miles, Bangladesh has one of the highest population densities in the world.

¹⁴ An estimated five hundred Bangladeshi patients cross the border to India every day (Datta 2010).

¹⁵ The medical tourism industry is growing in Asia, but surprisingly not in Singapore. From 2005 to 2009, the Singapore government supported medical tourism through a now defunct program called Singapore Medicine, which attempted to establish Singapore as the region’s leading medical hub. Singapore had $832 million in revenue from medical tourism in 2013, a 25 percent decline from 2012 (Huang 2015). Some private hospitals in Singapore want more government support because of the declining numbers of international patients (Estioco 2016).

¹⁶ Malaysian hospitals, where private medical treatment is offered at less than half the Singapore price, have recently started targeting Bangladeshi patients and have even partnered with Malaysian Airlines to give them a 30-percent discount on airfare to Malaysia (Palma 2016).

¹⁷ This neighborhood caters to thousands of Bangladeshi migrant workers as well as Singaporeans of Indian descent. Many Bangladeshi patients prefer to stay in this area because there are cheap hotels and restaurants that serve Bangladeshi cuisine.

¹⁸ VIP stands for very important person. This is a common English term used in Bangladesh to refer to elite, powerful, and rich people in the country.

¹⁹ Patients interpret the act of disclosure about illness details differently depending on the cultural context. For example, in South India it can be seen as a symbol of care to withhold or disclose information about cancer treatment to a patient depending on the situation and patient preference (Van Hollen 2017). In Singapore, doctors balance their duty to be truthful and transparent to patients with a sensitivity to the cultural preference for collective decision making by the family (Tan and Chin 2011).

²⁰ SGD 200 was USD 138 or BDT 10,922 in 2017. SGD 300 was USD 208 or BDT 16,383 in 2017.

²¹ SGD 1,000 was USD 692 or BDT 54,612 in 2017.

²² SGD 600 was USD 415 or BDT 32,767 in 2017.

²³ SGD 15,000 was USD 10,379 or BDT 819,174 in 2017.

²⁴ SGD 4,000 was USD 3,460 or BDT 218,446 in 2017.

²⁵ SGD 20,000 was USD 13,839 or BDT 1,092,232 in 2017.

Additional information

Notes on contributors

Karen M. McNamara

Karen M. McNamara is currently a Fulbright-Nehru scholar affiliated with the Christian Medical College in Vellore, India. Previously she was a postdoctoral fellow in the Science, Technology, and Society Research Cluster at the Asia Research Institute of the National University of Singapore. Her research is broadly concerned with pharmaceuticals and traditional medicine in Bangladesh, neoliberal governance and care, and disparities in access to health care. She is currently conducting research on Bangladeshi medical travel within Asia.