629623

earch-article2016
ISS0010.1177/0268580916629623International SociologyWhittaker and Leng

Article
International Sociology
2016, Vol. 31(3) 286­–304
‘Flexible bio-citizenship’ and © The Author(s) 2016
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DOI: 10.1177/0268580916629623
Transnational mobilities for iss.sagepub.com

care in Asia

Andrea Whittaker
Monash University, Australia

Chee Heng Leng

Universiti Sains Malaysia, Penang, Malaysia

Abstract
International medical travel (IMT) challenges the notion of health care as a responsibility of a
nation-state to its citizens, tied to the territory of a nation-state. As patients travel for medical
care, they invoke not territorialised notions of citizenship, but make new claims. In this article, the
authors propose the term ‘flexible bio-citizenship’ that extends the notion of ‘flexible citizenship’
to describe transnational mobilities for the accumulation of biovalue. They argue that people
who travel for medical care come from a variety of backgrounds, identities and circumstances
for whom the physical and economic ability to travel and cross borders is a form of flexible
social capital enabling them to access levels of care otherwise inaccessible to them. The article
explores the implications upon citizenship for a diverse range of people who travel for their
health care: from highly mobile cosmopolitan professional expatriate workers, regional border
crossers, migrant workers, those who cannot afford care at home, patients whose status makes
treatments unavailable, and outsourced patients forced to travel for care. Their mobility allows
them to gain biovalue but also alters their citizenship relationships and perspectives.

Keywords
Biological citizenship, biovalue, international medical travel, medical tourism

Corresponding author:
Andrea Whittaker, Anthropology, School of Social Sciences, Faculty of Arts, Monash University, Clayton,
Melbourne, VIC 3800, Australia.
Email: andrea.whittaker@monash.edu

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Whittaker and Leng 287

Introduction
In this article we examine a particular form of cross-border mobility, that of people trav-
elling for medical care, also termed ‘medical tourists’, and consider the implications of
such travel for citizenship. Our article draws upon a burgeoning literature describing the
growing phenomenon of what is variously termed ‘international medical travel’, ‘cross-
border care’, medical tourism’ or ‘transnational health care practices’ across the public
health and health services, tourism, geography, ethics, migration studies, anthropological
and sociological literature (see e.g. Bell et al., 2015; Connell, 2011, 2013; Kangas, 1996,
2007; Lunt et al., 2015; Ormond, 2013; Ormond and Mainil, 2015; Snyder et al., 2011;
Stan, 2015; Whittaker, 2008). This work has tended to be largely descriptive, document-
ing North/South disparities and equity issues involved in the trade; the push and pull
factors that influence patient motivations and decision-making; the risks associated with
patients going abroad, and returning home for follow-up care; and the advantages and
disadvantages for sending and receiving countries’ health systems and communities (for
summaries see Connell, 2013; Crooks et al., 2010; Hopkins et al., 2010; Whittaker, 2008,
2015a). The proliferation of terms within this literature reflects the diversity of cross-
border medical travellers encountered in hospitals around the globe and the complexities
of the circumstances and motivations surrounding their movement. What is increasingly
recognised is that medical travel is not a singular phenomenon, but one that differs
depending on region, country of origin, destination, financial status, type and status of
the medical treatment required, legal status of patients, language and cultural affinity,
distance travelled and social support. As is described later in this article, people who
travel for treatment range from cosmetic surgery patients from Britain or Australia trav-
elling on group tours combining surgery with visits to exotic beaches (Bell et al., 2011,
Holliday et al., 2013), patients travelling to circumvent home country restrictions on
forms of treatment such as stem cell treatments (Song, 2010), ‘reproductive exiles’ seek-
ing services such as commercial surrogacy (Inhorn and Patrizio, 2009; Matorras, 2005),
members of diasporic communities travelling home for care (Inhorn, 2011; Whittaker,
2009) or undertaking short cross-border trips (Horton and Cole, 2011; Lee et al., 2010)
to patients from countries which lack particular expertise or equipment travelling to
undertake treatment in a more medically sophisticated location (Ormond and Sulianti,
2014) or ‘outsourced’ patients, who travel under agreements between countries’ health
systems or in business arrangements (Crush and Chikanda, 2015; Kangas, 2007; Lautier,
2008; Whittaker, 2015b). The difficulty that arises then is that of identifying how mobil-
ity links these diverse groups.
This complexity points to the need to develop conceptual tools to unpack the phenom-
enon. The purpose of this article is to develop a new conceptual tool for considering the
relationships between international medical travel (IMT) and citizenship. The meanings
and entitlements of citizenship are redefined as people move across nation-state borders,
whether legally or illegally (Lakhani and Timmermans, 2014). People who travel for
medical care come from a variety of backgrounds, identities and circumstances for whom
the physical and economic ability to travel and cross borders represents a form of flexible
social capital enabling them to access levels of care otherwise inaccessible to them. The
concept of flexible bio-citizenship developed in this article raises new questions about

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288 International Sociology 31(3)

the negotiation of citizenship rights and responsibilities within the now global trade in
medical care.

Movements, citizenship and international medical travel

Utilising insights from the literature on citizenship, transnationality and biopower, we
propose a new term, ‘flexible bio-citizenship’, to capture the interconnectedness between
the transnational movements of patients and their relationships with nation-states or citi-
zenship. We argue that the mobility of patients for care is a product of their graduated
access to care in their home states, but in turn may have consequences for their relation-
ships with their states. The exact configuration of the relationships depends upon their
status, the nature of the health systems, contingencies, regulatory frameworks and poli-
cies applying in each location, and their health needs. However, we also note that the
relationships are deeply cultural, tied to histories of interactions between people and
places, which transform the meanings of citizenship. Such an account may lead to new
forms of analysis of medical travel, new connections between heterogeneous mobile
populations and a new way of thinking about the relationships between citizenship,
health and the state.
The outline of our article is as follows. First, we describe the growing trade in health
services in Asia and its manifestation in a select handful of private hospitals vying for the
foreign patient trade and the sociological debates over medical travel. Asia provides a
focus for this article as it is the site of our ongoing study into medical travel in the region.
Several governments in Asia such as Thailand and Malaysia aim to increase their export
of health services through the development of ‘medical tourism’; value-adding to the
existing tourism and private health infrastructure. They heavily support the development
of the medical tourism industry through tax concessions and other incentives – examples
of state facilitation of a supposed ‘free’ neoliberal market. This is occurring in the context
of growing privatisation and corporatism of health care in the region: a reworking of the
delivery of health care through neoliberalism. We then review the work done on relation-
ships between mobility, transnational citizenship and health status to develop a new con-
cept – that of the ‘flexible bio-citizen’. A typology of the different types of patients who
travel for health care allows an examination of how their mobility, health status and citi-
zenship are intertwined. We then consider the implications of flexible bio-citizenship and
factors influencing relationships between states, bodies and entitlements.

Methods
Although the purpose of this article is towards the development of theoretical insights,
it is informed by a broader project on medical travel in Asia. The examples used in this
article are drawn from observations and interviews with over 100 patients who had
travelled for care in four hospitals in Bangkok, Thailand as well as Penang and Kuala
Lumpur, Malaysia (see Whittaker and Chee, 2015). The sample was purposively
selected but contained a diverse population providing the case studies referred to in this
article. The article also draws upon previous research by the first author on travel for
assisted reproductive treatments in five clinics in Thailand in 2008–2009 (see Whittaker,

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Whittaker and Leng 289

2011, 2012). Interviews were conducted by the two authors and our research assistant
Por Heong Hong in English, Thai, Malay, Indonesian, Hokkien and Mandarin and inter-
preters were used for other languages. Permission to undertake interviews was granted
by the hospitals and access facilitated through the international coordination units in
2012 and 2013.1

Remapping responsibility for health care

Responsibility and provision of health care no longer necessarily coincides with national
boundaries, with a remapping of responsibility for health care away from national gov-
ernments towards private provision (Ormond, 2015b). The maintenance and protection
of the health and well-being of its population has long been viewed a fundamental
responsibility of the modern nation-state (Rabinow and Rose, 2006). Whether through
private or public means, nation-states regulate, administer and fund, to a greater or lesser
extent, national health systems to care for citizens. Early national redistributive health
care schemes in Europe developed in the late 19th century as part of welfare state build-
ing and national reconstruction after the Second World War. Historically they were
closed systems, organised and funded within sovereign territories. The principle of ter-
ritoriality governed the organisation of health care and citizens funded the health system
through taxation or social health insurance and access and entitlement to services was
limited to a given territorial community (Glinos Landolina, 2013).
Other states, with varying histories, such as colonial and post-colonial states across
Southeast Asia, differed in the levels of social welfare and health care offered to citizens
compared to European welfare states, but all were committed to providing some form of
social provision and regulation of health care. Across the 1970s and 1980s, guided by
recommendations from the WHO and the Alma Alta Declaration, countries in the region
invested in primary health care provision to provide access to essential preventive health
interventions and basic treatment to secure the health of their largely poor, agrarian pop-
ulations. The ability to provide health care became symbolic of a government’s claim to
legitimacy, as for example in Thailand where provision of primary health care in the
northeast was deliberately deployed in areas of insurgency during the 1970s as a counter-
insurgency effort (Whittaker, 2000: 61).
As Meghann Ormond (2015a) notes, the retreat of the welfare state in many post-
industrial countries, marketisation of health care, increased ease of travel and global com-
munication networks have challenged health care containerisation by enfolding it into ‘an
ever-broader array of transnational flows and configurations of people, goods, services
and ideas’ (2015a: 305). Across Southeast Asia, the provision of health care has been
increasingly subject to neoliberal logic manifested in privatisation, capital market liberali-
sation and social-sector reforms (Chee, 2008, 2010; Ormond, 2013). In countries such as
Malaysia, Singapore and Thailand there has been a move away from government-domi-
nated health services towards increased privatisation and corporatisation of the health care
systems in response to rising costs, concerns over future sustainability of tax-financed
health systems and higher public expectations (Chongsuvivatwong et al., 2011).
Since the 1990s, a growing number of governments in Asia have been developing and
promoting their countries as ‘medical tourism hubs’, eager to earn foreign currency

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290 International Sociology 31(3)

through their existing health infrastructure and the provision of health services to select
non-citizens (Chee, 2010; Wilson, 2010). Even when this occurs through becoming a
consumer of privatised services, those private providers are embedded within the regula-
tions and support of the receiving state, i.e. it is not a simple binary contrast between
state/private corporation, rather health systems in most states are complex public–private
partnerships, and such movements shift relationships: from between the citizen–state to
citizen–consumer–corporation–other state. This marks a distinct shift in approaches to
health care by national governments from health as a social good to tradable commodity
(Ormond, 2013: 5).
The logic of such mobility is intimately linked to the rise of neoliberalism in health
care. The growth of this market was facilitated by the opening up of health sector trade
under the World Trade Organisation (WTO) General Agreement on Trade in Services
(GATS), which applies free trade principles to services (including health services) as
well as commodities (Pocock and Phua, 2011). This trade in health services has been
facilitated by the growth in transport and communication networks which have made the
travel by sick and elderly (non-citizens) more accessible. It is also facilitated by govern-
ment policies and interventions deliberately designed to support and facilitate the trade
in health services and provision of care to non-citizens. ‘International hospitals’ are
linked to global modes of production and consumption – in particular to the production
of health as trade in neoliberal, individualistic (versus public) privatised corporate medi-
cine. Although not exclusively catering to foreign patients (they usually also serve local
elite patients), such hospitals exist in practical terms through special incentives and in
symbolic terms as ‘international standard’ care (Whittaker and Chee, 2015).

The transformation of citizenship: Flexible citizenship

It is widely acknowledged that intensive globalisation is transforming the context of citi-
zenship (Brysk and Gershon, 2004; Falk, 2000). In this article, we build upon Aihwa
Ong’s (2006a) observation that under conditions of globalisation, citizenship is becom-
ing more fragmented:

We used to think of different dimensions of citizenship – rights, entitlements, a state,

territoriality, etc. – as more or less tied together. Increasingly, some of these components are
becoming disarticulated from each other, and articulated with diverse universalizing norms
defined by markets, neoliberal values, or human rights. At the same time, diverse mobile
populations (expatriates, refugees, migrant workers) can claim rights and benefits associated
with citizenship, even as many citizens come to have limited or contingent protections within
their own countries. (Ong, 2006a: 500)

All forms of mobility across national borders involve transformations in citizenship

status and subjectivity. There is a growth of ‘supraterritorial’ relations between people
(Scholte, 2005) facilitated by linkages through global communication and transport
technologies, mobility and ease of travel resulting in new global imaginaries and affili-
ations that disrupt the historic correspondence between citizens and spatially defined
territories.

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Whittaker and Leng 291

Theories of post-national citizenship have described the ways in which economic and
cultural structures upon which national citizenship depend are undermined, giving rise to
the development of other sites, forms of identities and claims not tied to a territorially
bound state. Such developments have been conceptualised as ‘post-national’, ‘multicul-
tural’ or ‘urban’ citizenship. The notion of human rights, biopolitical claims or religious
and ethnic identities that cross international borders are examples of such post-national
citizenship (Soysal, 1994). Similarly, Yuval-Davis (1999) has developed notions of
‘multi-layered’ or ‘multi-level’ citizenship, which is defined by engagement with multi-
ple scales in different contexts (for example through nation, locality, or religious faith).
In her work on the overseas Chinese diaspora in Southeast Asia, Aihwa Ong (1999)
describes a new form of post-national citizenship, that of ‘flexible citizenship’. She
describes how new strategies of flexible capital accumulation have promoted a flexible
attitude towards citizenship. The overseas Chinese entrepreneurs of whom she writes are
engaged not only in the accumulation of economic profits but in acquiring a range of
symbolic and cultural capitals that facilitate their economic negotiations, social position-
ing and cultural acceptance in different geographical sites. Aihwa Ong (1999: 6) defines
‘flexible citizenship’ as referring: ‘to the cultural logics of capitalist accumulation, travel,
and displacement that induce subjects to respond fluidly and opportunistically to chang-
ing political-economic conditions’. Within transnationality, she suggests ‘flexibility,
migration and relocations, instead of being coerced or resisted, have become practices to
strive for rather than stability’ (1999: 19). Further, she explores the ways in which new
modes of constructing identity are linked with such flexibility, and suggests how states
facilitate transnationality through also becoming more flexible in their management of
sovereignty.
Applying the notion of flexible citizenship to health provides a means to describe the
ways in which patients may cross borders to exercise their citizenship responsibilities (to
maintain their individual health/biovalue) and claim rights to health care outside the
boundaries of their nation-state.

Flexible bio-citizenship
To analyse the situation of international medical travellers, we combine the concept of
‘flexible citizenship’ with an analysis of biopolitical citizenship. Biopolitical citizenship
refers to situations in which biology and health become the basis for citizenship, whether
legally recognised or socially legitimated. The concept of biopolitical citizenship has
been used to connote the legal relationship of individuals to a nation-state (Petryna,
2013) or a broader meaning related to political organising on the basis of a biological
attribute or biological condition and may take supra-national forms (Rose and Novas,
2005). A number of terms are used to describe various aspects of biopolitical citizenship.
Carl Novas (2005: 446) argues that ‘biological citizens’ acquire knowledge about their
biological conditions and demand access to state services through collective action with
others of similar ‘biovalue’. For example, utilising this concept, Vinh-Kim Nguyen
(2005) has introduced the term ‘therapeutic citizenship’ to describe the strong sense of
rights, claims upon the state and political alliances among people living with HIV-AIDS
in South Africa. Attributions of biopolitical citizenship may be imposed by the state, as

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292 International Sociology 31(3)

in the case of medical screening of potential migrants (Lakhani and Timmermans, 2014);
or may be claimed by collective, lay or NGO support directed at state entities with the
power to grant or deny access to state resources (see Fassin and d’Halluin, 2005). Either
way, biological citizenship claims inherently involve processes of stratification as they
privilege or exclude people based on their biological or genetic basis (Petryna, 2013;
Lakhani and Timmermans, 2014; Rose and Novas, 2005). As we discuss later, they also
involve notions of biovalue: the inherent economic worth of their biological status.
We extend Ong’s notion of flexible citizenship to propose a concept of ‘flexible bio-
citizenship’, defined as transnational mobilities for the accumulation of biovalue. This
term differs from the notion of ‘flexible citizenship’ in several ways. Although the move-
ments of patients are deeply embedded within the logic of ‘post-Fordist’ or global late
capitalism (which has produced the range of private hospitals catering for international
patients), the movements of these patients is not a strategy towards capital accumulation
and power. Rather, their movement is an investment in their health, or life itself, an invest-
ment in ‘biovalue’, rather than economic capital. By ‘biovalue’ we refer to the concept
developed by Catherine Waldby (2002) to describe how bodily tissues or a body itself can
become productive of value both in terms of their augmentation of human health but also
through trades for the creation of economic wealth. As we describe below, the flexible
bio-citizen acts within the logics of transnationality, embedded within regional circuits
related to existing employment, regional flows of trade and cultural and linguistic ties and
facilitated by global transport and communication links (Toyota et al., 2013).
A focus upon biovalue within our definition also leads to a new perspective of the
trade in health services or ‘medical tourism’ trade, as not only an economic venture, but
a trade circuit in biovalue. The medical tourism trade transfers and converts biovalue to
economic capital. In short, a sick individual may travel to increase their personal bio-
value through the acquisition of health – a healthy or attractive body being essential to
their economic status in their home state. Similarly, sick citizens usually constitute an
economic burden to their home state public health systems. However, mobility to another
health system converts their illness to a positive: they increase in economic value when
they travel. As an international patient, the sicker a patient is, the more complicated the
procedures and longer stays required and the more valuable they become to the interna-
tional hospitals vying to earn export dollars through their care. Within this view, the
international trade in medical services can be seen as a transfer of biovalue and the con-
version of bodily states of ill health into economic capital. Sick bodies and their conver-
sion to healthy states have become a new valuable trade.
Our use of the term ‘flexible bio-citizenship’ does not imply clear distinctions between
inclusion and exclusion in the confines of a bounded territorial society. The people we
describe carry passports; they are not excluded from their states nor are they dispos-
sessed. Although not all are wealthy, they do have the means to mobilise the social capi-
tal and economic resources needed to fund their travel, whether through borrowing
money, family support or debt. Yet for a variety of reasons, whether economic, legal,
occupational, geographical, historical or cultural, their resort to health care depends upon
their mobility. This view of flexible bio-citizenship poses a more flexible, contingent,
graduated and potentially fragile view of an individual’s relation with their state and a
more unstable view of state regimes of governmentality and care.

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Whittaker and Leng 293

In her work, Ong (2006a, 2006b) maps how the contents of citizenship have been
shifting towards graduated access to opportunities in a global capitalist economy.
Our notion of ‘flexible bio-citizenship’ is meant to capture this notion of graduated
access to opportunities, care and protection offered by states. In this manner, we sug-
gest it is one form of ‘mutated citizenship’ that has arisen with neoliberalism (Ong,
2006a).

Flexible bio-citizenship: Relationships to states,

transnational mobilities and biovalue
In the second part of this article we apply the concept of flexible bio-citizenship to the
various forms of medical travel encountered in the literature and in our research to
date. An analytic lens of flexible bio-citizenship provides a means to consider com-
monalities between otherwise disparate groups of people who travel for health care. As
noted earlier, a range of authors have described the heterogeneous groups involved in
medical travel. In many respects, these are disparate phenomena, with little in common
with each other apart from mobility. As Ormond (2013: 7) notes, this is reflected in the
very language used in the literature to describe international medical travellers, which
involves different imaginaries: from ‘medical tourists’, implying empowered, inde-
pendent free choice and free movement, to the language of exiles, implying force and
exclusion. Thompson further writes of ‘medical migrations’ to differentiate move-
ments across regional boundaries and migrant status (2008: 435). In this exercise, we
are mindful of the differences between these various patient-subjects and the nuanced
structural forces influencing their mobility. But, we suggest a consideration of flexible
bio-citizenship allows a new perspective – that although deriving from different con-
figurations of class, economic status and geography, a common element across these
groups are the cultural logics of transnationality through which their claims for care
are satisfied.
As is described below, in some cases the patients involved in these movements have
weak, attenuated citizenship relationships with their states, both causal to and caused by
their travel for care. These graduated relationships to their states may derive from pre-
existing histories (such as pertains between Acehnese and the Indonesian state), or be the
result of institutional failures by a state to provide care. In other cases, status as expatri-
ate workers, or poor state of health, marginalises patients within their home state and
mobility and flexibility is the logical solution to acquire care. For other patients, how-
ever, the state is intimately involved in sending patients across borders for care, out-
sourcing patients as a flexible means of providing health services in a more cost-efficient
manner or to provide services not provided within their own health system (Whittaker,
2015b). Further, as we describe later, the act of travelling for health care itself and the
disruptions associated with such travel have their own effects upon the subjectivity of
IMT patients and may in turn affect their status as citizens. The following categories of
patients relates how although travelling for different reasons and from different social
backgrounds, their mobility is linked to their citizenship and the negotiation of their
rights to health care.

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294 International Sociology 31(3)

Relationship 1: Cosmopolitan global citizens

An important group of patients encountered in the global health trade are the elite expa-
triate mobile workforce (Whittaker, 2009). Like the Chinese diasporic business families
described by Ong (1999) these people are cosmopolitan in their lifestyle and orientation,
maintaining flexible transnational links with their nation-states for the period of their
non-residence. For example, workers in certain multinational industries such as engi-
neers, financiers, mining and petrochemical company staff (and academics) frequently
live and work across borders. New forms of commodified IMT dovetail with these global
modes of production. Such transient elite professionals work, live and play within trans-
national spaces founded on networks of company headquarters, business centres, resorts,
construction and mining sites, and are often beneficiaries of neoliberal exceptions allow-
ing tax incentives, special visa categories and employment status to do so. They negoti-
ate health care in similar spaces, often financed by corporate health insurers which may
specify the hospitals they visit for care which may not be in the countries in which they
work.

Relationship 2: Supra-national regional relationships

Patients who live close to national borders which they cross to obtain services in another
state may be considered regional border crossers. In this case, geography influences their
relationship with the nation-state and the existence of supra-national systems/order ena-
ble them to easily obtain services across the border. This is a common situation in many
parts of Europe where European Court of Justice rulings allow EU citizens the right to
seek health care services if care is not available within medically justifiable time limits
in the home country system. In such a case their status as members of the supra-national
entity of the EU supersedes their citizenship as members of their nation-state. This for-
mally recognised flexible bio-citizenship allows them to pursue health care across bor-
ders. Glinos Landolina (2013) provides examples of cross-border movements enabled by
supra-national arrangements, including health system contracting within the EU and hos-
pitals developing agreements to share certain specialist care across the border regions of
Germany and the Netherlands. However, she notes that most patients would still prefer
to be treated within familiar settings and much border crossing involves return patients
travelling ‘home’ for care.

Relationship 3: Circumvention of the state

Another category of IMT patients, whom we might call ‘circumvention travellers’, con-
stitute those patients who travel due to legal restrictions on desired medical treatments in
their home countries. Examples are those seeking commercial surrogacy or commercial
ova donation (self-described ‘reproductive exiles’) (Inhorn and Patrizio, 2009; Matorras,
2005), commercial organ donation or certain stem cell treatments (Song, 2010), and non-
medical sex selection, which are banned in many jurisdictions (Whittaker, 2011). It also
includes those whose status makes them ineligible for treatments or ineligible for state-
subsidised treatments, as is the case with many treatments for infertility due to age,

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Whittaker and Leng 295

marital status or sexual orientation. These people epitomise flexible bio-citizenship as

they act pragmatically and flexibly to take advantage of opportunities available in other
states’ medical systems to avail themselves of the services unavailable or restricted in
their home medical systems. By acting beyond their state’s jurisdiction, such citizens
remove themselves from their state’s regulatory reach and protections and will travel to
whichever jurisdiction allows them access to the services they want. Whether for hope of
a child or a cure, their movements typically involve a trade in biovalue, often those of
third party tissue, ova donors or surrogates in what has been described as forms of rentier
capitalist relations (Cooper and Waldby, 2014).
The issue of juridical citizenship is clearly entangled in the health care seeking move-
ments of such travellers. In some cases, their travel breaches their national laws. For
example, Turkish citizens are banned from participating in third party assisted reproduc-
tion in other jurisdictions (Gürtin, 2011). Likewise, in certain states in Australia, extrater-
ritorial laws apply to residents to ban travelling for commercial surrogacy. The issue of
citizenship becomes especially salient when people who undergo international surrogacy
arrangements bring the child born of these procedures back to their home nation-state.
States vary in the ways in which they will recognise these children, whether through
genetic heritage, adoption, legal parentage orders, through the person who gives birth or
place of birth. In some highly publicised cases, the children born through overseas sur-
rogacy may be left in a legal limbo, effectively stateless, or may end up with passports
but their parentage may not be recognised (Whittaker, 2012). Likewise, patients under-
taking experimental treatments in other countries may be unable to access their home
health care systems for follow-up care and will find it difficult to pursue any extraterrito-
rial legal claims in cases of malpractice.

Relationship 4: State failures to care for citizens

Another category of IMT patients are those from countries where the health services
required or particular expertise are unavailable (Ormond, 2013), or where the adequacies
of the home state’s medical services cannot fulfil citizens’ claims to care. For example,
sophisticated tertiary treatments for cardiac disease, neurological diseases, or cancer care
may be unavailable and patients requiring such interventions may need to travel to
acquire them. For such patients, their only access to health care is through mobility. For
example, in a Thai hospital we spoke to Hagos, who spent over US$45,000 of borrowed
money on his rehabilitation treatment following a car collision in Ethiopia which left him
paralysed. With only basic rehabilitation services available in Ethiopia, he travelled to
Thailand three days after the car crash for specialist spinal care and rehabilitation. For
Hagos, Ethiopian citizenship offers little protection or care for his present disabled state.
Only his ability to garner the finances needed for care allowed him access to health
resources required to improve his quality of life. Other cases illustrate directly the link-
ages between citizenship status and access to care. For example, Somalian patients in a
Malaysian hospital spoke of how they travelled to Malaysia for care as it was one of the
few countries that allowed them to obtain a visa, while most other countries denied them
entry. Their citizenship status directly determined the nature of their access to biomedical
health care given their own failed state was unable to provide care.

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296 International Sociology 31(3)

Such movement often follows a history of marginalisation, such as for people of par-
ticular ethnicity within a state. For example, within the context of a long history of insur-
gency against the Indonesian state, many Acehnese travel to Penang for care rather than
seek care in Indonesia (Smith, 2011: 256; Whittaker et al., 2015). Although such patients
may appear to have little in common with the mobile cosmopolitan elite expatriates
described earlier, their relationship with their home state and willingness to travel for
health care displays a similar contingent pragmatism.
This category of mobile patients also includes subaltern patients from inadequate
health systems who cross borders for care. For example, it is common for subaltern
Burmese or Laotian citizens living on the Thai border to cross over to Thailand for care,
many to utilise the public health system. Such movement is viewed negatively due to the
costs to the Thai public system (Bochaton, 2015). Unlike others involved in IMT, these
patients are excluded from neoliberal calculations and their claims to care are seen as
illegitimate as the costs of the exchange are not in favour of the receiving state. For pri-
vate hospitals involved in IMT, any patients are valuable; for public hospitals they con-
stitute a burden and imposition for the receiving state.

Relationship 5: Transnational migrants/dual citizens

Another set of patients important to IMT involves members of various diasporic and
migrant communities returning to their countries of origin for medical treatment. For
example, Warner cites an airline survey which found 46% of those travelling from the
United States for health care were foreign-born US citizens (Warner, 2009). Likewise,
Inhorn (2011: 587) describes the return of diasporic Middle Eastern infertile couples as
‘medical expatriotism’. She notes that these couples are motivated by both nostalgic and
patriotic attachments to ‘home’ and the quality of medical services there, even if they had
never lived in the country. Such transnational communities retain close links to their
countries of origin and seek care there at a time of health crisis rather than in their new
country of citizenship (Lee et al., 2010).

Relationship 6: Outsourced patients

The outsourcing of patients can be a cost-effective strategy for wealthy countries, par-
ticularly by relieving cost pressures on health insurers. This category consists of patients
who are not given a choice to be treated in their home nation-state; rather they are trans-
ferred as patients to other countries for care. For example, a number of patients from
Gulf Cooperation Council countries we interviewed in a hospital in Thailand had been
‘outsourced’ through arrangements with their home government health systems or
through tie-in arrangements with their insurers to receive care outside their countries of
origin (Whittaker, 2015b). Such arrangements are relatively common either to fill gaps
in health care services available in-country or as a cost-efficiency measure. For example,
we interviewed Fatimeh from the United Arab Emirates whose elderly mother was sent
to Bangkok after suffering a stroke to receive intensive rehabilitative care unavailable in
the UAE. For 15 months family members have been flying back and forth to Bangkok to
support her. A medical committee oversees the requests for care overseas, costs may be

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Whittaker and Leng 297

fully paid for, including those of a medical companion, and citizens are provided a range
of consular assistance while undergoing treatment overseas. In such cases, states,
employers and insurers have institutionalised flexible bio-citizenship by sending patients
overseas.

Subjectivity and medical travel

International medical travel also affects the relationship between the migratory sub-
ject, the patient, and their state. Mobility for health care can change the ways in which
people think about their citizenship, their sense of belonging and their sense of rights
and responsibilities. Patients who travel outside their nation-state to access the care
they need or want may become disaffected from a state that either restricts their access,
fails to provide it or makes it unaffordable. Travelling for care produces a greater
awareness of their status as citizens of a state and the limits to their entitlements. Their
affiliations with their home state may become more tenuous through the experience.
As Deforges et al. (2005: 442) note, a creative effect of mobility is to ‘change the ways
in which people think about their sense of citizenship, their sense of belonging and
sense of responsibility. In these ways geography is intrinsic to the practical reworking
of citizenship.’
In her ethnography of Yemeni patients travelling abroad, Kangas (1996) reported they
expressed gratitude to their government for facilitating and financing their treatment
abroad. However, although appreciative, the patients and families we interviewed from
Gulf Cooperation Council countries expressed dismay at their need to travel overseas as
a sign of their government’s inadequate planning and provision of health care. Their
effusive praise of the care they received in the Thai hospital only served to underscore
the inadequacies in service provision back home (Whittaker, 2015b).
Likewise, the effect of heath consumers’ dissatisfaction upon home health systems
has been discussed by Ormond (2015a), who notes the lack of scholarship on the effects
of international medical travel upon home health systems. Taking the case of Indonesians
travelling to Malaysia for care, she points to their recognition of the negative effects of
taking their medical expenditure abroad upon the Indonesian health system and suggests
that the exit of patients alters their expectations, perspectives and accountability regard-
ing health access, rights and recognition.

Bio-citizenship claims and the trade in health services

Ong notes how within global circuits, it is ‘possible for certain categories of people to
claim citizenship-like entitlements and benefits, even at the expense of territorialized citi-
zens’ (2006b: 16). Although she was describing the special provisions made for employ-
ment of those with specialist expertise in Singapore, the same observation may be made
for patients with the knowledge, resources and ability to travel overseas to avail them-
selves of health care. Movement allows for the access to health care that would otherwise
be unavailable, too expensive, restricted, not legal or in other ways inaccessible to them
in their home states. With travel and finances, they become entitled to care previously
provided for local citizens – something that can become especially contentious if they

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298 International Sociology 31(3)

utilise the public health system. In this way mobility is a strategy allowing them access to
forms of social capital and biovalue.
The growth of health care as a market-driven export business also impacts upon the
citizenship claims of local residents in receiving countries and raises questions about the
ethical goals of such globalised health care. The trade has implications for the develop-
ment of the national public health systems of receiving countries and relationships
between their citizens and their doctors. For example, within Thailand, NaRanong and
NaRanong (2011) have documented the brain drain of medical staff from the local public
health system influenced in part by the growth of international standard hospitals in the
private sector. Although the trade is estimated to be worth 0.4% of Thailand’s economy
every year, the negative effects for the Thai health system include the shortage of physi-
cians for the public sector and increased medical fees for self-paying Thais. A two-tiered
hospital system is developing in which expensive well-equipped hospitals catering for
foreigners and wealthy locals offer a level of care impossible to attain within the public
hospitals serving the majority of locals.

Conclusions: Mobile markets, flexible bio-citizens

Mobile markets, technologies and populations interact to shape social spaces in which
mutations in citizenship are crystallised. The different elements of citizenship (rights,
entitlements, etc.), once assumed to go together, are becoming disarticulated from each
other, and rearticulated within transnational spaces. So while in theory political rights
depend on membership in a nation-state, in practice, new entitlements are being realised
through situated mobilisations and claims in milieus of globalised contingency (Ong,
2006a: 499).
In this article, we have applied these ideas to consider the trade in health services. We
suggest that international hospitals participating in this trade are such spaces of glo-
balised contingency, resorted to by a diverse range of subjects. In doing so, new entitle-
ments and claims to health care resources are being realised. Previously dependent upon
one’s status as a citizen of a particular nation-state, now access to health care is increas-
ingly arbitrated by one’s economic, consumer or insurance status, mobility and biologi-
cal status. The notion of rights to health as a universal claim is being rearticulated within
a global market.
Further, we suggest we might view those who travel for health care as symptomatic of
the mutations to citizenship of which Ong (2006a) writes. We propose that a concept of
‘flexible bio-citizenship’ may be useful for describing the links between one’s health
status, transnational mobility and ability to fully access care and protection as citizens of
a state. In the case of patients travelling across borders, access to care is related to the
nature of their relationships to their state and their strategic choices to move to access
care elsewhere. We identify six different relationships between patients and the state
among those crossing international borders for their medical care. Their biological sta-
tus, as ill, infertile, disabled and diseased affects their entitlements as citizens and results
in either voluntary or forced mobility to seek health care within other jurisdictions.
In turn, as we have suggested, such mobility may also damage patients’ sense of their
nation-state. Hence medical travel is both a product of and produces new relationships

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Whittaker and Leng 299

with nation-states, may be productive of new political consciousness and claims, and
blurs distinctions between the entitlements of citizens and foreigners (Ormond, 2015a).
This differs from the descriptions of ‘biological citizenship’ as a form of political
mobilisation that involves ethical claims to resources in terms of the politics of sheer life
and shared humanity (Collier and Lakoff, 2005: 29; Petryna, 2013). Rather, the claims to
care evoked are post-national, neoliberal, contingent and often self-managed. As nation-
states withdraw responsibility for health or are increasingly incapable of taking respon-
sibility, they place responsibility for health and self-care upon individuals, or forge
alternative arrangements, such as supra-national/regional arrangements in the case of the
EU or outsourcing. These all have varying implications for citizenship. What appear to
be neoliberal choices made to access care within a global market are in fact movements
through a complex assemblage of medicorps, state actors, insurance agencies, banks and
medical councils who define and categorise these patients and determine their care. As
they cross borders, these patients increase in biovalue – while as ill individuals they may
be a burden to their home state, as mobile patients they become a source of value for
another state’s export industry.
The concept of ‘flexible bio-citizenship’ also serves as a warning against an overly
positive portrayal of the liberating and empowering aspects of cosmopolitanism or
mobility away from the confines of national borders. While we recognise the potential
for a degree of liberation and sense of empowerment in the movements of patients over-
seas for care, and indeed some patients themselves describe their movements in such
terms, we caution against ascribing a necessary link between such travel and empower-
ment. Rather, we suggest we need to pay further attention to the losses as well as the
gains in such movements and the relationships these entail.
The example of medical travel highlights how a nation-state can no longer be seen as
a single bounded national economy, social service or health system. Economic globalisa-
tion has had a number of consequences including new relations between bodies and the
state, belonging and extraterritoriality, transformations in political governance, and rea-
lignments of medical citizenship and the meanings of public health (Collier and Lakoff,
2005). Obligations between a citizen and their nation-state have transformed such that
now the responsibility for the care of citizens at time of a health crisis is increasingly
referred to the private market and transferred across borders. As many of these patients
and their families note, this signals a fundamentally changed relationship between citi-
zen and state, bringing with it mistrust, frustration and anger at the perceived failure of
the state in its responsibilities to care for citizens. Such failings may be realised only at
such times of crisis. The case of medical travel highlights the changed relationships,
responsibilities, obligations and practices between individuals and the state within a glo-
balised neoliberal market. These changes are not equal but uneven; changing over time
and contingent, they operate at multiple scales from national populations to the most
intimate care of one’s health.

Acknowledgements
We wish to thank all hospitals’ staff members and patients who contributed to the study from
which this work is derived. Dr Por Heong Hong assisted with the interviews in Penang and Kuala
Lumpur. This article is based upon a paper presented at the workshop ‘Mobilities and Exceptional

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300 International Sociology 31(3)

Spaces in Asia’, 9–10 July 2014, held at the Asian Research Institute, National University of
Singapore. We wish to thank the workshop convenors, Dr Kumiko Kawashima of Macquarie
University, Australia and Professor Brenda SA Yeoh of National University of Singapore for the
invitation to participate and other participants for their helpful comments.

Conflict of Interest
The authors declare that there is no conflict of interest.

Funding
This work was supported by the Australian government through an Australian Research Council
Future Fellowship (FT110100054) and an ARC Discovery Project (DP1094895).

Note
1. Staff of those units identified patients who were medically fit for interview or family members
who had accompanied patients as medical companions and approached them initially to find out
if they were willing to meet with the interviewers. All informants then received an information
sheet and gave either signed or oral consent to be interviewed. The names of all patients used
in this article are pseudonyms. All interviews were conducted in the patients’ own language,
sometimes with the use of a hospital-trained simultaneous interpreter; those who were fluent in
English were interviewed without an interpreter. Interviews were conducted in hospital rooms,
and took from 20 minutes to over an hour, depending upon the patient’s schedule, medical
condition and escorting family member’s time. All interviews were audio-recorded and tran-
scribed. Ethical clearance was obtained through the Human Ethics Research Committee of the
University of Queensland and Monash University (CF12/1546 - 2012000517).

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Author biographies
Andrea Whittaker is Associate Professor and Australian Research Council Future Fellow at the
School of Social Sciences, Monash University, Melbourne. Her research interests include mobili-
ties and health, reproductive health, cross-border reproductive travel, and biotechnologies, primar-
ily in Thailand, Southeast Asia and Australia.
Chee Heng Leng is Honorary Associate at KANITA (Women’s Development Research Centre
–Pusat Penyelidikan Wanita & Gender), Universiti Sains Malaysia, Penang, Malaysia. She con-
ducts research specialising in health policy, transnational migrations and gender in Malaysia and
Southeast Asia.

Résumé
Le tourisme médical remet en question la notion selon laquelle les soins de santé seraient la la
responsabilité d’un État-nation à l’égard de ses citoyens, applicable dans le cadre d’un territoire.
Lorsque des patients vont à l’étranger pour se faire soigner, ils ne font pas référence à la notion
territorialisée de citoyenneté mais expriment de nouvelles revendications. Dans cet article,
nous proposons la notion de « bio-citoyenneté flexible », dans le prolongement de celle de «
citoyenneté flexible », pour désigner les mobilités transnationales destinées à accumuler de la «
biovaleur ». Nous montrons que pour les personnes qui vont se faire soigner à l’étranger – aux
origines, identités et conditions diverses – la possibilité physique et économique de voyager et de
traverser les frontières constitue une forme de capital social flexible qui leur permet d’accéder
à des niveaux de soins auxquels elles n’auraient sans cela pas accès. Nous nous intéressons aux

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implications sur la notion de citoyenneté pour différentes catégories de personnes qui partent
se faire soigner à l’étranger : professionnels expatriés au profil fortement cosmopolite et mobile,
habitants des régions frontalières, travailleurs immigrés, personnes qui n’ont pas les moyens de
se faire soigner dans leur pays, patients dont le statut ne leur permet pas l’accès à certains
traitements, ou encore patients forcés de se soigner à l’étranger en cas de soins externalisés. La
mobilité de ces personnes leur permet d’acquérir de la « biovaleur » mais modifie également leur
relation à, et leur conception de, la citoyenneté.

Mots-clés
Biovaleur, citoyenneté biologique, tourisme médical, transnationalisme

Resumen
Los viajes internacionales por motivos médicos (IMT) desafían la noción de que la atención
sanitaria es una responsabilidad de un Estado-nación con respecto a sus ciudadanos y vinculada
al territorio de un Estado-nación. Al viajar para recibir atención médica, los pacientes invocan
nociones no territorializadas de la ciudadanía, pero hacen reivindicaciones adicionales. En este
trabajo se propone el término “bio-ciudadanía flexible” que extiende la noción de “ciudadanía
flexible” para describir movilidades transnacionales para la acumulación de “biovalor”. Se sostiene
que las personas que viajan para recibir atención médica tienen una variedad de orígenes,
identidades y circunstancias y que, para estas personas, la capacidad física y económica de viajar
y cruzar fronteras es una forma de capital social flexible que les permite niveles de acceso a la
atención sanitaria que serían inaccesibles sin esa capacidad. Se exploran las implicaciones sobre la
ciudadanía para una amplia gama de personas que viajan para recibir atención médica: profesionales
cosmopolitas expatriados altamente móviles, habitantes de regiones fronterizas, trabajadores
migrantes, personas que no pueden pagar la atención sanitaria en sus países, pacientes cuyo
estatus no les permite acceder a ciertos tratamientos, y pacientes terciarizados obligados a viajar
para recibir atención médica. La movilidad de estos pacientes les permite ganar “biovalor” pero
también altera su concepción y sus relaciones de ciudadanía.

Palabras clave
Biovalor, ciudadanía biológica, transnacionalismo, turismo médico, viajes médicos
internacionales

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