- Coronavirus: World Connectivity Can Save Lives
- The Movement of Disease and Data
- More Dashboards Share Localized Details
- Technology’s Potential for Disease Control
- Disease Shapes Decisions
- Toward Global Health Awareness
- Hopkins Around the World
- Undergraduate Admissions
- Office of International Services
- Study Abroad
- Effectiveness of travel bans — readily used during infectious disease outbreaks — mostly unknown
- Medical Tourism
- Big Menu, Discount Prices
- Before You Book a Trip …
- Patient Concerns
- Immediate Impact
Coronavirus: World Connectivity Can Save Lives
The healthcare community has expanded its use of maps to communicate and understand the spread of disease.
- Dashboards pull together data to convey a real-time map-based understanding of spreading disease.
- Authorities from global to local use dashboards and maps to display data at different scales.
- The improved pace of data sharing helps speed awareness and preparedness.
As pandemic fears escalated in late January, Johns Hopkins University published its now-famous coronavirus dashboard—a map-based tool developed to track and fight the spread of the disease now called COVID-19.
Developed by Lauren Gardner and her team from the University’s Center for Systems Science and Engineering, the dashboard went viral almost instantly with hundreds of news articles and shares on social media and hundreds of millions of page views.
While it’s clear the dashboard—with real-time information about the global health emergency—is immensely popular, it takes some analysis to understand why.
The healthcare community has used maps to understand the spread of disease for a long time, most famously in 1854 when Dr. John Snow connected location and illness with his history-making map of a London cholera outbreak.
From disease atlases of the early 20th century to more recent web mapping of Ebola and Zika scares, healthcare professionals have long considered mapping, and more recently geographic information systems (GIS), a critical tool in tracking and combating contagion.
The Movement of Disease and Data
One of the greatest challenges in the war against disease is humanity’s increasing mobility. Today, a person can pick up a virus in one place and share it to any other location on the planet within hours. Among the jet set, there’s the potential to become a super spreader, infecting a large number of people across a large geographic area.
This level of mobility places scientists at a serious disadvantage in slowing potential epidemics. While technology to create vaccines has become incredibly advanced, it still takes months to formulate an effective vaccine for a new virus. In those months, the virus can easily reach every corner of the world.
When disease can travel so quickly, information has to move even faster. The intense response generated by the Johns Hopkins’ dashboard shows how eager people around the world are to track health threats.
The dashboard presents targeted, up-to-date information needed to understand the progress of a disease, and makes it available in a public, easy-to-digest format.
Anyone across the globe with access to the internet can learn, in a few short clicks, a tremendous amount about the novel coronavirus and COVID-19 disease.
The dashboard’s interactive map includes the number of confirmed infections, fatalities, and recoveries, and where they happened. Graphs detail the progress of the virus over time. Viewers can also see the day and time of the most recent data update and review the data sources used to produce the dashboard.
Five authoritative sources selected by Johns Hopkins for the effort include the World Health Organization, the Centers for Disease Control and Prevention, the National Health Commission of the People’s Republic of China, the European Centre for Disease Prevention and Control, and the online medical resource DXY.cn. The Johns Hopkins dashboard provides links to these authoritative sources where viewers can learn more.
Web services allow GIS users to easily ingest and display disparate data inputs without having to host or process the data centrally. This eases data sharing and speeds the aggregation of information for improved understanding.
More Dashboards Share Localized Details
In the short time since the release of the Johns Hopkins dashboard, other organizations have been quick to use GIS technology to address similar needs. The resulting dashboards share some of the same details, customized with additional information to serve specific audiences.
The World Health Organization (WHO) has created a dashboard to track the global spread of COVID-19 cases. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) Johns Hopkins University is tracking the spread of COVID-19 cases in near real time with a map-centric dashboard using ArcGIS Online that pulls relevant data from WHO, U.S. CDC, ECDC China CDC (CCDC), NHC, and Dingxiangyuan. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) The Chinese Center for Disease Control and Prevention tracks the spread of COVID-19 cases across China. Updates come from the National Health Commission and its provincial health organizations. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) The Hong Kong dashboard shows the locations of buildings visited by higher concentrations of confirmed cases and the locations of current quarantines—a detail that can help residents of those areas actively reduce their exposure. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) The International Civil Aviation Organization created an animated dashboard to convey typical air traffic connectivity in different parts of the world compared to current cases. This resource illustrates the potential for quick spread given today’s increased mobility. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) The United Nations World Food Programme created this dashboard of confirmed cases and the total population affected in Italy. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) The Robert Koch Institute created this dashboard to show the number of COVID-19 cases in Germany. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.) JAG Japan Corp created this dashboard to show the number of COVID-19 cases by prefecture in Japan. (Static screenshot as of March 20, 2020. Click the image to go to the live dashboard.)
Several of these tools, the one created by Johns Hopkins, include a mobile-optimized version, which makes the dashboards more versatile and accessible to the public on phones or tablets.
Technology’s Potential for Disease Control
In the future, one could imagine dashboards being used to direct citizens of affected areas to the locations of crucial aid and resources.
Dashboard maps could identify hospitals with available beds, clinics offering medical aid along with the current wait times, grocery stores and pharmacies that are open, where to purchase personal protective equipment, and so on.
In heavily impacted cities, this kind of information could critically improve outcomes and save lives.
Another factor affecting epidemics the Novel Coronavirus (COVID-19) situation is the calendar.
During the Ebola and MERS scares of 2014, many people were faced with the prospect of canceling their trips to participate in Hajj, a six-day pilgrimage to Mecca made by more than two million Muslims every year.
Equipped with days-old data and rumors, many faithful made the choice to take the chance and proceed with their pilgrimage, putting themselves at risk of contracting potentially deadly viruses and further spreading disease when they returned home.
Similarly, in the current coronavirus outbreak, Chinese New Year celebrations posed a threat as the themes of togetherness and reunion trigger the largest human migration in the world.
China chose to push back the start of the Lunar New Year holiday to reduce mass gatherings, a public health intervention called social distancing. Travelers worldwide have subsequently been restricted from entering the country.
With access to current information, authorities in Beijing, Macao, and Hong Kong made the difficult decision to cancel many major festivities entirely.
Future disease dashboards could incorporate the locations of scheduled cultural events and celebrations to accurately reflect the associated risk to travelers and enhance public health decision making. By bringing together location and time-sensitive events in relationship to a spreading disease, officials have the potential to reduce exposure and spread.
Disease Shapes Decisions
The arrival of the novel coronavirus (COVID-19 disease), pandemics in the past, has impacted the way people travel, the way people feed themselves, and the economy.
As human mobility spreads the coronavirus at an unprecedented pace, outbreaks bring affected communities to a standstill, and anxiety stretches across the globe.
The public health community is hard at work finding new ways to combat the current threat while the medical community rallies to provide treatments and find cures. The availability of real-time, map-based dashboards have a role to play in informing all of these actions.
This method of communication provides accessible, easily understood information to people around the world eager to protect themselves and their communities.
This tool improves data transparency and helps authorities efficiently and effectively disseminate information to improve awareness about quickly spreading diseases.
Learn more about the use of GIS for health and human services. The Coronavirus Disease (COVID-19) GIS Hub includes a catalog of GIS data to support mapping and analysis, and to increase community preparedness. If you’re looking for ways your GIS department can prepare, here are details to help you respond to COVID-19.
Interest in this outbreak and the value of maps to understand its spread continues to grow.
Toward Global Health Awareness
With growing awareness of the interconnectedness of the health of people, animals, and the environment, a collaborative effort is underway across disciplines to define and monitor One Health.
This eco-medical approach to wellness and conservation promotes a holistic view of health.
Reaching back as far as 400 BC, when Hippocrates wrote his text On Airs, Waters, and Places, this philosophy acknowledges that the wellbeing of humanity is inextricably linked to, and impacted by, the condition of animal life and our natural environment.
The span of One Health includes the effects of pollution, global warming, and zoonoses (viruses that can pass from animals to humans, including Ebola, HIV, COVID-19, and some influenza strains).
Geography is an integral component of this next-level understanding of world health, taking into account the increase of global travel, accelerated deforestation, and human expansion that result in increased opportunities for diseases to spread from person to person, and from wildlife to humanity.
One Health combines the collaborative efforts of medical professionals, veterinarian specialists, and ecologists to address threats facing any one, or any combination, of these three facets of life on our planet.
Hopkins Around the World
Johns Hopkins actively prepares students to be global leaders and citizens, to take part in international learning activities, and—as our founding mission implores—to bring the benefits of discovery to the world.
We have a proud tradition of leadership in education, research, service, and patient care around the globe.
Some examples of our global impact:
- The Johns Hopkins Bloomberg School of Public Health is a leader in public health research, education, and practice with ongoing work in more than 100 countries. The Bloomberg School has led major advances against global public health threats including malaria, polio, road traffic injuries, malnutrition, drowning, gun violence, HIV/AIDS, tobacco, and addiction.
- The Johns Hopkins School of Advanced International Studies has campuses on three continents and has, for more than 70 years, produced great leaders, thinkers, and practitioners of international relations.
- The Johns Hopkins Center for Global Health brings together experts from our top-ranked schools of Public Health, Medicine, and Nursing to address pressing health challenges, including HIV/AIDS, malaria, tuberculosis, and malnutrition.
- The Johns Hopkins Center for Communications Programs uses social and behavior change communication to help solve some of the world’s most pressing health problems, including maternal health issues, malaria, and HIV/AIDS.
- Jhpiego, a nonprofit health organization affiliated with the university, has spent more than 40 years improving the health of women and families in more than 155 developing countries.
- Johns Hopkins Medicine International provides personalized care for patients traveling to Hopkins from outside the U.S. and works closely with affiliates around the world to improve health care globally.
- The Johns Hopkins Alliance for a Healthier World brings together leading experts from a range of disciplines to address global health challenges and advance global health equity.
From offering pioneering medical and nursing training at Peking Union Medical College Hospital in the 1910s; to creating a graduate-level international relations campus in Bologna, Italy, just 10 years after the end of World War II; to conducting ongoing research at hundreds of locations in more than 110 countries, we continue to bring knowledge to the world.
There are more than 450 international students representing 61 countries among our undergraduate population, a testament to our belief in the value of cultivating a community of diverse backgrounds and worldviews. Learn more about application deadlines, financial aid options, and requirements for international applicants.
Office of International Services
OIS assists international students, scholars, and researchers with visas and immigration as well as range of other issues, including housing, transportation, tax preparation, and legal assistance.
Johns Hopkins promotes intellectual discovery through academic exchanges, programs abroad, collaborative research, and cooperative agreements. Our undergraduate students participate in study abroad and international projects in more than 50 countries worldwide, and more than 40 percent of Hopkins undergrads have an international experience prior to graduation.
Effectiveness of travel bans — readily used during infectious disease outbreaks — mostly unknown
Because of the quick and deadly outbreak in late December of a novel coronavirus in Wuhan, China, now known as COVID-19 — infecting tens of thousands and killing hundreds within weeks, while spreading to at least 24 other countries — many governments, including the United States, have banned or significantly restricted travel to and from China.
And while travel bans are frequently used to stop the spread of an emerging infectious disease, a new University of Washington and Johns Hopkins University study of published research found that the effectiveness of travel bans is mostly unknown.
However, said lead author Nicole Errett, a lecturer in the UW Department of Environmental & Occupational Health Sciences in the School of Public Health, that's largely due to the fact that very little research into the effectiveness of travel bans exists.
“Some of the evidence suggests that a travel ban may delay the arrival of an infectious disease in a country by days or weeks.
However, there is very little evidence to suggest that a travel ban eliminates the risk of the disease crossing borders in the long term,” said Errett, co-director of the ColLABorative on Extreme Event Resilience, a research lab focused on addressing real-world issues relevant to community resilience.
The researchers combed through thousands of published articles in an effort to identify those that directly addressed travel bans used to reduce the geographic impact of the Ebola virus, SARS (Severe Acute Respiratory Syndrome), MERS (Middle East Respiratory Syndrome) and the Zika virus. They did not include studies of influenza viruses, for which travel bans have already been shown to be ineffective in the long term.
In the end, the researchers were able to identify just six studies that fit their criteria.
Those six were models or simulations, not data from actual bans after they were implemented, to assess the effectiveness of travel bans in controlling outbreaks.
Consequently, to improve research in this area, the study authors recommend that research questions, partnerships and study protocols be established ahead of the next outbreak so empirical data can be collected and assessed quickly.
“Travel bans are one of several legal options that governments have drawn on to mitigate a pandemic,” said co-author Lainie Rutkow, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health. “As coronavirus spreads, our study raises the importance of understanding the effectiveness of legal and policy responses intended to protect and promote the public's health.”
“When assessing the need for, and validity of, a travel ban, given the limited evidence, it's important to ask if it is the least restrictive measure that still protects the public's health, and even if it is, we should be asking that question repeatedly, and often,” said co-author Lauren Sauer, an assistant professor of emergency medicine at Johns Hopkins University's School of Medicine and director of operations with the university's Office of Critical Event Preparedness and Response.
Consequently, the authors write, additional research is “urgently needed” to inform policy decisions, especially in light of the tremendous social, economic and political impacts of their implementation.
Materials provided by University of Washington. Original written by Jake Ellison. Note: Content may be edited for style and length.
David Dupray, a 60-year-old uninsured coffee shop owner from Bar Harbor, Maine, had been having left leg pain on ambulation for four years. His cardiologist recommended stent placement for left iliac artery stenosis. The estimated bill: approximately $35,000.
Unable to afford the procedure, Dupray began searching the Web for affordable medical care overseas. His physician suggested Thailand.
Within days, Dupray had an appointment with a cardiologist halfway around the world—at Bumrungrad Hospital in Bangkok, Thailand.
Dupray spent two days in the hotel- hospital, had three stents placed in his leg arteries, and completed a cardiac stress test. The total bill: $18,000.
“I will never go to a hospital in the U.S.,” says Dupray, who represents a growing number of Americans searching for affordable healthcare in the global marketplace.
With rising U.S. healthcare costs and millions of Americans uninsured or underinsured, more American patients are seeking affordable, high-quality medical care abroad—known as “medical tourism.
” In 2007, an estimated 750,000 Americans traveled abroad for medical care; the number is expected to increase to 6 million by the end of this year.1 On the flip side, only a little more than 400,000 nonresidents visited the U.S. in 2008 for the latest medical care.
1 Globally, the medical tourism industry is estimated to grow into a $21 billion-a-year industry by 2012, with much of the growth expected from Western patients traveling overseas for affordable care.2
“As hospitalists, we have been seeing increasing numbers of patients going overseas for urgent and elective procedures, as it is a general perception the medical treatment overseas is less expensive,” says Joseph Ming Wah Li, MD, SFHM, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston and SHM president-elect.
Physicians in U.S. hospitals encounter potential medical tourists all the time. Some are uninsured or underinsured. Some have insurance carriers that limit or exclude coverage for certain procedures and treatments.
Even those with insurance sometimes struggle to pay deductibles, copays, and their costs after insurance has paid its part. Others are uncomfortable with the language barriers and cultural differences of U.S.
hospitals and physicians.
Medical tourism also lures patients who are citizens of countries (e.g. Canada, the United Kingdom) that offer universal healthcare, Dr. Li says.3 For example, more expatriates from India and Malaysia are traveling to their native countries for medical care, as they receive affordable and quicker medical care while visiting family.
Hospitalists routinely care for patients requiring essential cardiac or orthopedic surgeries—conditions that are common in the medical tourism trade. With medical tourism growing in scope and popularity, it is essential that hospitalists are prepared to discuss with their patients the pros and cons of traveling for medical care. Hospitalists should be able to:
- Identify patients who might benefit from medical tourism;
- Know where and how to look for an accredited overseas facility; and
- Explain to patients the potential travel risks and complications, including insurance coverage and legal restrictions in destination countries.
A basic understanding of the industry and the issues can help guide your patients through medical decisions and help you care for those who have returned from a medical trip.
Big Menu, Discount Prices
Medical tourism offers a wide range of medical services performed in hospitals on nearly every continent, with a wide range of costs for certain procedures (Table 1, p. 26). Most surgeries cost 50% to 90% less than the average cost of the same surgery at a U.S. hospital.
Many in the medical tourism industry say these types of savings have brought once-unaffordable surgery within the reach of most Americans, regardless of insurance status. For example, cardiac bypass surgery on average costs $144,000 in the U.S.; it costs about $8,500 in India.
The reasons the costs are so much less at overseas hospitals, as compared with U.S. costs, are many:
- Lower wages for providers;
- Less expensive medical devices and pharmaceutical products;
- Less involvement by third-party payors; and
- Lower malpractice premiums.4
For example, the annual liability insurance premium for a surgeon in India is $4,000; the average cost of a New York City surgeon’s liability insurance premium is $100,000.5
Brazil, Costa Rica, and Mexico are attractive destinations for cosmetic and dental surgeries; Singapore, Malaysia, Thailand, and India have emerged as hubs for cardiac and orthopedic surgeries (Table 1, above).6
The growth in medical tourism led the Joint Commission in 1999 to launch Joint Commission International (JCI), which ensures that offshore hospitals provide the highest-quality care to international patients (see “Ultra-Affordable Prices and No Decline in Quality of Care,” p. 28). JCI has accredited 120 overseas hospitals that meet these standards.
“Overseas hospitals are always keen in partnering with U.S. hospitals,” Dr. Li says.
Collaborations, such as Johns Hopkins International Medical Center’s partnership with International Medical Clinic Singapore, and Partners Harvard Medical International’s affiliation with Wockhardt Hospitals in Mumbai, India, have helped facilitate the accreditation process and alleviate U.S. patient concerns.
Overseas hospitals not only offer greatly discounted rates than insurer-negotiated U.S. prices, but many of the international hospitals also report quality scores equal to or better than the average U.S. hospital’s.7
Before You Book a Trip …
How do patients find overseas facilities? It’s as easy as a click of the mouse.
“Our survey shows 75 percent of patients located offshore hospitals through the Internet,” says Renee-Marie Stephano, president of the Medical Tourism Association, a nonprofit group based in West Palm Beach, Fla.
, that was established in 2007 to promote education, transparency, and communication in the medical tourism community. Patients use overseas hospital websites, international medical coordinators, and medical tourism companies, such as PlanetHospital.com and MedRetreat.
com, to find facilities and providers, and to coordinate medical travel.
“Medical tourism is currently unregulated,” Stephano says. “One of our goals is to certify medical tourism facilitators to create the best standard of practice.”
In 2007, the American Medical Association (AMA) published medical tourism guidelines to help healthcare entities engaged in overseas medical care.8 (Download a PDF of the guidelines at www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf.) The AMA suggests that:
- Medical care outside the U.S. should be voluntary, and patients should be informed of their legal rights and recourses before agreeing to travel outside the U.S.;
- Before traveling, local follow-up care should be arranged to ensure continuity of care;
- Patients should have access to physician licensing, facility accreditation, and outcomes data for both;
- Medical record transfers should follow HIPAA guidelines; and
- Patients should be informed of the potential risks of combining surgical procedures with long flights and vacation activities.
I think the service and quality of care provided at our hospital compares favorably with the very best American hospitals.
—Kenneth Mays, senior director, marketing and business development, Bumrungrad Hospital, Bangkok, Thailand
Hospitalists are highly focused on a patient’s quality of care; the same can be said of some overseas hospitals that attract large numbers of medical tourists.
“I think the service and quality of care provided at our hospital compares favorably with the very best American hospitals,” says Kenneth Mays, senior director of hospital marketing and business development at Bumrungrad Hospital in Bangkok.
That might be so, but the growth of medical tourism also raises concerns stateside. With sleek websites making it easy for U.S. patients to schedule procedure vacations from their kitchen tables, many U.S.
physician and watchdog groups worry about patient safety, privacy, liability, and continuity of care. Although most international hospitals and physicians provide outcomes data, rarely do the benchmarks compare directly with U.S.
hospital quality and safety data.
“Quality comparisons are difficult, even within U.S. hospitals, as hospitals use different methodologies to collect data,” says Stephano. “Patients have to rely on JCI accreditation, surgeon experience, volume, and outcomes to decide.”
Recent studies echo the Medical Tourism Association’s claim: Increased cardiac surgery volume at Apollo Hospitals—an 8,500-bed healthcare system with 50 locations throughout India—and Narayana Hospital in Bommasandra, India, has lowered costs, with similar, or even lower, mortality rates compared with the average U.S. hospital.7,9 Other challenges getting medical records exist even within U.S. hospitals, so emerging platforms Google Health and Microsoft Vault, where medical records can be uploaded at the touch of a button, “will benefit patients and providers,” Dr. Li says.
The Medical Tourism Association envisions U.S.-based physicians offering follow-up care to medical tourism patients. “Currently, we encourage patients to follow up with their primary-care physician,” Stephano says.
Dr. Li says malpractice is always a concern when traveling overseas; however, he also notes the legal system in the U.S. is strong enough “to handle any medical malpractice.
” That said, a patient who experiences a poor medical outcome as the result of overseas treatment might seek legal remedies, but the reality is that malpractice laws are either nonexistent or not well implemented in some destination countries.
That makes malpractice claims on overseas procedures a dicey proposition.
“Patients receiving overseas treatment need to realize that they are agreeing to the jurisdiction of the destination country,” Stephano says. Other risks associated with extended travel include exposure to regional infectious diseases and poor infrastructure in the destination country, which could undermine the benefits of medical travel.
Cost-saving benefits have led some U.S. insurance companies to begin integrating overseas medical coverage.
For example, Blue Cross Blue Shield of South Carolina offers incentives for patients willing to obtain medical care overseas at JCI-approved hospitals.
BCBS then waives deductibles and copays, and several other insurers have launched similar pilot programs.10 “We will see more of these changes,” Stephano says, “to cut costs and remain competitive.”
In 2008, U.S. healthcare spending was $2.3 trillion.11 A 2005 Institute of Medicine report suggests that 30% to 40% of current U.S. healthcare expenditure is wasted.12 U.S.
lawmakers, employers, hospitals, and consumers are scrambling to find ways to reduce healthcare costs and improve efficiency. Medical tourism seems to benefit a select few Americans, only lowering U.S.
healthcare spending by 1% to 2%.12
Medical tourism revenue generated in destination countries currently is limited to the private sector, but that might change soon. Government funding for healthcare initiatives in such countries as India, Brazil, and Thailand is declining. Some entrepreneurial physicians and hospitals are looking to medical tourism to fill the funding gap.
Medical tourism ly will continue to grow; so too will the legal, quality, and insurance protections for patients. Efficient resource utilization might help reduce U.S. healthcare costs, and improved distribution of destination-country resources might help improve infrastructure and access to better healthcare for their own citizens.
With their leadership skills and expertise, hospitalists can play a major role in reducing healthcare costs.
However, what actual reforms healthcare legislation brings to medical tourism remain to be seen. TH
Dr. Thakkar is a hospitalist and assistant professor in the division of hospital medicine at Johns Hopkins University School of Medicine in Baltimore.
- Medical tourism: Consumers in search of value. Deloitte Consulting LLP website. Available at: www.deloitte.com/dtt/cda/doc/content/us%5Fchs%5FMedicalTourismStudy(1).pdf. Accessed Sept. 13, 2010.
- Pafford B. The third wave—medical tourism in the 21st century. South Med J. 2009;102(8):810-813.
- Kher U. Outsourcing your heart. Available at: http://proquest.umi.com/pqdweb?did=1041533291&Fmt=7&clientId=5241&RQT=309&VName=PQD. Accessed Sept. 13, 2010.
- Forgione DA, Smith PC. Medical tourism and its impact on the US health care system. J Health Care Finance. 2007;34(1):27-35.
- Lancaster J. Surgeries, side trips for “medical tourists.” The Washington Post website. Available at: www.washingtonpost.com/wp-dyn/articles/A497432004Oct20.html. Accessed Sept. 13, 2010.
- Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: Globaliz-ation of the healthcare marketplace. MedGenMed. 2007;9(4):33.
- Milstein A, Smith M. Will the surgical world become flat? Health Aff (Millwood). 2007;26(1):137-141.
- New AMA guidelines on medical tourism. AMA website. Available at: www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf. Accessed March 26, 2010.
- Anand G. The Henry Ford of heart surgery. Wall Street Journal website. Available at: online.wsj.com/article/SB12587589288795811.html.
- Einhorn B. Outsourcing the patients. Business Week website. Available at: www.businessweek.com/magazine/content/08_12/b40760367 77780.htm. Accessed Sept. 13, 2010.
- . Hartman M, Martin A, Nuccio O, Catlin A, et al. Health spending growth at a historic low in 2008. Health Aff (Millwood). 2010;29(1): 147-155.
- Milstein A, Smith M. America’s new refugees—seeking affordable surgery offshore. N Engl J Med. 2006;355(16):1637-1640.