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Bodies Across Borders is an insightful anthology examining the multiple geographies of cross-border health care mobility encouraged by advances in transport, information technology, and biotechnologies (cryopreservation, immunosuppressive drugs, DNA sequencing), as well as by variegated national regulations and uneven regional development (between the Global South and the Global North, rural and urban areas). By mapping out the spatial dynamics of the circulation of patients, health professionals, and bodily materials across international borders, the volume attempts to disentangle the complex social, political, ethical, and legal implications of contemporary medical transnational migration.
Inspired by a workshop organized by the editors (all members at the time of the Health, Place and Society research group of the School of Geography, Queen Mary University in London) in Geneva in 2010, the volume examines the trade of human organs and tissues, medical tourism, and medical migration from a variety of disciplinary fields, including the geography of health, medical sociology, bioethics, and law. The volume’s principal aim is to document the differentiated impacts of transnational medical mobility for sending and receiving countries’ health care systems, donors/sellers of biomaterials, patients seeking care abroad, and migrating health professionals. It also intends to expose challenges for the effective regulation of these cross-borders (and thus translegal) movements and to discuss potential tools of transnational governance.
Though the volume focuses more on the phenomenon of medical tourism than on medical migration or the trade of human biomaterials, the editors’ willingness to look at these cross-border health movements from a transversal perspective positively contrasts with the way they are generally considered in isolation—both in areas of academic interest and in policy responses. The book convincingly exposes how flows of people and body parts are not discrete phenomena but closely intertwined, occurring at a variety of overlapping spatial scales. In this regard, it resembles another recently published interdisciplinary volume on transnationalism and health, New Cannibal Markets: Globalization and Commodification of the Human Body, edited by Rainhorn and El Boudamoussi (2015). However, unlike New Cannibal Markets, which focuses on the growing inequalities between low-income and high-income countries and within societies upon which the commodification of human body parts stands, Bodies Across Borders draws acute attention to changing, culturally situated conceptions of ethnicity, class/status, gender, citizenship, family obligations, religious morality, illness, and aging and examines these conceptions in relation to the broader themes of neoliberal globalization and transnational migration. The volume offers several nuanced investigations of how the shifting dynamics that shape the social identities of donors, medical tourists, and migrating health professionals produce new forms of individual accountability and different processes of marginalization. In so doing, the book succeeds at providing a finer-grained account of the sociocultural complexities involved in the provision and consumption of transnational medical care.
The volume is organized in four sections each considering a particular trend in the transnational mobility of body parts, patients, and health care professionals. Section I, “Corporeal Circulations,” explores the global trade in bodily derivatives as biomedical tools and transactable commodities through three case studies: the cross-border circulation of biobanked materials, the international marketization of US sperm, and the selling of kidneys by poor male Filipinos. Some of the most important theoretical contributions of the book appear in this section, most notably in Sallie Yea and Bronwyn Parry’s respective chapters, both of which focus on processes of marginalization based on culturally located representations of masculinity.
Parry’s article analyses how the hierarchizing of the genetic “worth” of prospective semen donors enables the successful marketization of US banked sperm within the international market. She shows how, beyond the assessment of the morphological quality of the sperm (not surprisingly through highly masculinist criteria), the marketed “product” is also valued and qualified by US banks websites through a discursive rematerialization of the donors’ social identities—a process that draws on normative ideas regarding donors’ masculine performance and social class. Comparing the ranking of donors on a scale based on their biosocial adequacy to former techniques of selective cattle breeding, Parry critically situates these practices as part of a “new eugenicist agenda of propagating the fit at the expense of those deemed less worthy of reproduction” (69). By drawing attention to these new forms of biosocial discrimination, she convincingly exposes the potentially pernicious political consequences of the ethos of consumer choice supported by commodified health care.
Yea, for her part, contributes significantly to recent discussions on marginal/subaltern masculinities by geographers through an in-depth qualitative analysis of the experience of Filipino young men living in a Manila slum who have sold their kidneys on the illicit global organ trade market. Critical of totalizing constructions of these men as “unwilling victims” in discourses of exploitation (generalized both in the media and in academia) and attentive to the sociocultural relationships shaping local understandings of the body and its commodification, she shows how the exploitation of these men on the global market is closely tied to a culturally specific ideal of the “successful man” as the breadwinner of the family. In conditions of high poverty which make it difficult for these men to perform their familial obligations, organ provision, she argues, allows them to negotiate their self-representation as “sacrificial heroes” for the sake of their family’s security, and hence to recover their sense of masculinity and individual agency. However, because of the absence of follow-up healthcare, Yea shows how these men’s health and capacity to work (and subsequently livelihood) were often diminished after selling their kidneys, leading paradoxically to “a further dilution of their sense of masculinity” (47).
Section II, “Transnational Bio-medical Tourism,” examines the political and ethical implications of the cross-border movement of “health tourists” for host countries’ health care systems. One of the main achievements of this section is to illustrate the striking inequities hidden behind the contemporary rhetoric of individual autonomy and consumer choice, notably through John Connell’s critical overview of the medical tourism industry. Connell’s article contrasts sharply with Yea’s account of male kidney donors’ attempts to regain a sense of agency as he highlights how patients are, within the medical tourism industry, reconfigured as cosmopolitan consumers entitled to the best (and longest) health they can afford. His analysis thus outlines how transnational medical travel contributes to the rise of a new global divide, between new mobile “biocitizens” (Rose, 2007) seeking the best therapies and biomaterials worldwide and the less mobile “donors” and patients who cannot afford to travel overseas to access quality health care.
Section III, “Migrating Medical Expertise,” addresses issues relating to the transnational migration of health care practitioners from low-income to higher-income regions—a phenomenon often obscured by sensationalist accounts of both medical tourism and the illicit trade in human body parts. The two contributions in this section, however, do not focus on the impact of “care drain” (Hochschild, 2002) on source countries, but on the gendered and racialized dimensions of nurse migration. In particular, Sheba George’s ethnographic study thoroughly documents how the incorporation and career advancement of Indian immigrant female nurses within the US context are mediated by experiences of marginalization tied to normative assumptions about their attributes and skills from patients, colleagues, and managers. Sheba illustrates how these assumptions are tied to gendered expectations of emotional labor (“public expression of closeness”; “emotional intimacy”) which cannot be fully met by these nurses because of their ethnic and religious background, and how these unmet expectations in return create patterns of professional disadvantage.
Finally, section IV, “Regulating Bodies Across Borders,” addresses the implications of the flows of people and body parts for effective governance and examines what tools are available for intervention. Surprisingly, however, the three articles offered in this section are exclusively concerned with the regulation of medical travel, leaving the legal challenges related to the circulation of health practitioners and body parts across borders unaddressed. By only focusing on protective concerns regarding medical tourists, they also leave aside medical tourism’s effects on patients in both the home and destinations countries. This section nevertheless provides a comprehensive overview of the implications for patients of seeking medical care beyond the protection provided by their national governments’ criminal and civil law measures. Both Glenn Cohen and Ingrid Schneider’s articles highlight the problems faced by patients traveling abroad, who may have difficulty obtaining proper information regarding quality of care given the lack of universal accreditation and objective metrics and standards, and who often have little or no recourse in cases of medical malpractice. These shared concerns also lead them to suggest some interesting points of entry for intervention. Schneider, after providing a review of existing forms of governance, argues for a form of supranational regulation that works toward “the setting and heightening of international minimum standards” (207). Such regulation would be attentive to moral and legal pluralism (and thus not try to set uniform standards of practices) but would not fall into relativism. It would be endorsed—and ideally progressively updated—by all states. While Schneider’s demand for supranational governance remains quite abstract, Cohen inventively suggests inducing the medical tourism industry to self-regulate through already existing practices. Because private insurers and self-insured businesses in the US (and elsewhere) are beginning to incorporate medical tourism in their health insurance plans to improve their profit margins, he proposes building upon the existing structure of private health-insurance regulation to create “channeling regimes” that would direct patients toward high-quality providers.
Overall, the disproportionate attention the volume gives to medical tourism over the migration of health professionals and the trade in bodily commodities as well as the diffuse thematic focus within the sections of the book produce a somewhat unclear thematic tread. The volume would have benefited from short introductions before each section to integrate the different chapters or from a conclusion reflecting on the larger intellectual advancements achieved by the book. While the editors suggest some cross-cutting issues at the end of the introduction, the theoretical implications of these for further research could also have been explicitly put forward. Even though the collection as a whole fails to some extent to show continuity across the contributions and offer clearer theoretical hindsight, it gathers several analytically strong and nuanced contributions that make it a valuable read for advanced scholars interested in issues tied to the commodification of health care, the growth of medical transnational mobility, and the gender and racial dimensions of globalized health.