Ensure healthy lives and promote well-being for all at all ages

The right to the highest attainable standard of health is a fundamental human right and a key indicator for sustainable development. Good health is a prerequisite for a dignified life and social and economic participation. Poor health, on the other hand, can negatively affect other human rights, e.g. pose a threat to a child’s right to education and limit women’s and men’s economic opportunities. Goal 3 calls for a healthy life for all at all ages. Central demands include universal health coverage for all, including access to basic health care as well as affordable medicines and vaccines.

Good health is closely linked to various aspects called for in other goals, such as food security (>> Goal 2), clean water and sanitation (>> Goal 6) or functioning ecosystems ( >>Goal 14, >> Goal 15). To achieve good health, structural and systemic inequalities have to be overcome (>> Goal 10) in order to ensure universal health care access and equity. Underlying factors for discrimination, such as gender (>> Goal 5), race, caste, disability have to be surmounted in order to achieve not only economic but also social equality.

There are numerous ways in which tourism can influence health. Health and safety are key factors for many tourists when deciding where to spend their holidays. While there is an abundance of literature analysing health risks for travellers based on hygiene, water quality, epidemiology or the availability and quality of health services in the host country, there are only few analyses of the effects of tourism on the host population’s health. Generally, tourism can influence their health either directly, e.g. through bad working conditions or infections from tourists, or indirectly, e.g. through environmental health hazards caused by tourism, such as contaminated drinking water.

Tourism development and health of the local population
Increased tourism arrivals generate more revenues for a region. To what extent this leads to better health care for locals (and tourists) has not been studied well. There is little evidence that taxes generated from tourism are to a large degree invested into reforming public health care systems in order to improve the health of local residents, especially those previously left behind. On the contrary, examples of negative impacts of tourism on locals’ health dominate.

Tourism increases competition for scarce resources such as clean drinking water, access to traditional farm land or fisheries, or existing health care services. Tourism can displace local people and destroy traditional livelihoods. Resulting poverty potentially fuelled by tourism induced inflation can increase malnutrition, morbidity and mortality – most severely among vulnerable groups such as minorities, youth and the elderly as well as women.

Environment and health
Frequently tourism planning does not provide adequate solutions to harmful effects of tourism on the environment that pose health hazards for local communities (as well as tourists). Inadequate waste and sewage management not only damage the environment, but may also spread waterborne diseases.
On a global scale, tourism is responsible for about five percent of all CO2 emissions (UNWTO, 2016) that are severely impacting the world’s climate. “Climate change affects the social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter. Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress”, according to the World Health Organization (WHO, 2016).

Health and working conditions
Tourism may offer jobs to local people. However, many jobs are not complying with health and safety standards and can therefore have detrimental effects on employees’ physical and mental health and even result in death. There is a lot of informal employment in tourism, leaving poorly paid workers with no health insurance and social security. The density of trade unions in the sector that could advocate for workers’ rights to fair pay and health coverage is low. (>> Goal 8)

Interaction between hosts and tourists
The bigger the financial disparities between travellers and hosts, the more hosts may perceive tourists to embody progress, wealth and a desirable lifestyle. This can lead to cultural changes and the erosion of traditional social protection mechanisms, such as care for the elderly and sick. Tourists may introduce new forms of food, tobacco and drugs to a destination. Studies indicate that tourist destinations can be epicentres of demographic and social change as transactional sex, elevated alcohol and substance use, and internal migration can increase the risk of infection with sexually transmitted diseases, such as HIV (Padilla et al, 2010).

Globalization, tourism and health
The growing mobility of tourists is a risk factor, as it can contribute to spreading infectious diseases and epidemics. Via international air travel infection risks can reach nearly every corner of the world within hours or days, as could be witnessed during the Ebola outbreak in Western Africa in 2014/15. A total of 28,616 Ebola cases were reported in Guinea, Liberia and Sierra Leone, with 11,310 deaths (WHO, 2016b). The first case of an infection outside of Africa was reported in September 2014 in the US. The patient travelled form Liberia to Dallas, Texas. He was treated in a hospital and died a couple of days later. Two nurses caught the Ebola infection while taking care of the patient, but could be cured and the disease was prevented from spreading further (Robert Koch Institut, 2016).

Patients without borders
Today, a growing number of patients (in 2014: over one million by conservative estimates according to Lundt et al, 2014) mainly from industrialized countries seek medical care in developing countries. Motives for medical tourism include relatively cheaper prices, shorter waiting lists or (experimental) procedures that are prohibited in the patients’ home countries. While medical tourism has the potential to create jobs and encourage investments and innovation in the medical system, the risks for local communities and questionable ethics predominate.

Medical tourism diverts scarce health care resources from local people to tourists. Heavily subsidized institutions catering to the needs of well-paying tourists drain public health care systems of skilled staff. Medial tourism threatens to further commercialize and privatize the health sector in the host countries and increase inequalities in accessibility and affordability of health care. Medical tourism also reduces the pressure on governments to provide affordable health care for their citizens that integrates preventative measures, if medical treatment can be outsourced at low costs.

Medical tourism raises moral and ethical issues, especially in the fields of reproductive health and organ transplants. Because of the lack of available donors, every day 18 individuals worldwide die while waiting for a transplant of a vital organ (Smith 2012). Organ trafficking as a black market activity is lucrative. Affluent recipients “buy” organs from the most disadvantaged and vulnerable, who may be forced or may technically give their consent, but may not be aware of the risks. Studies show that a donor’s health often worsens after the surgery, costing them more in lost employment or out-of-pocket remedial care than the minimal ‘donation’ they receive for offering their organ to a broker (Hopkins et al, 2010). Organ trafficking and transplant tourism clearly violate the principles of equity, justice and respect for human dignity.

In order for tourism to promote good health and well-being for all, a comprehensive, cross-sectoral and people-centred approach is needed, which takes local people’s as well as tourists’ health and safety into account and puts a strong focus on equity in order to ensure that local people are not structurally disadvantaged.

On a global scale, the risk of rapidly spreading infections due to more international travel has to be factored in when developing early warning mechanisms. The fact that more and more areas of the world get accessed by tourists can support the development of cures and vaccinations for health risks in the Global South which were earlier of little economic interest for pharmaceutical companies. However, these cures have to be made available and accessible not only to affluent tourists but to everyone at risk.

Taxes from tourist spending should be used to improve public health care systems, allowing for equity and access, particularly for vulnerable groups, in order to avoid further privatization and inflation of medical costs. It is the duty of governments to discourage a dual system of strong disparities where better quality services are reserved for foreign clients with a higher purchasing power while their citizens often lack access to basic health care. Governments in the Global South could set quota regulations, which require a set number of treatments of locals for every foreigner treated there.

Governments need to develop and enforce laws regarding bioethical questions with regard to tourism, such as organ trafficking, transplant and fertility tourism to effectively protect vulnerable groups within and beyond their borders in line with relevant international guidelines, such as the UN Convention against Transnational Organized Crime (UNTOC), specifically the Protocol to Prevent, Suppress and Punish Trafficking in Persons (which also includes organs and the Istanbul Declaration on Organ Trafficking and Transplant Tourism by the International Transplantation Society (TTS). Through transparent public donor programmes governments should strive to meet the demand for organs at the national level.

Not all forms of medical tourism involve surgeries or curative treatments. Beyond recreation, in the field of health-oriented travel there is a growing demand for alternative medicine and wellness treatments. This brings great chances for small-scale authentic tourism products that involve local and indigenous communities and their traditional concepts of medicine, health and well-being.

Until today, only a very small part of the world’s population is able to take vacations and to travel internationally. Tourists should bear in mind that, for example, in Europe the entitlement for paid leave was a long and hard struggle by the Trades Unions for workers’ rights to health and recreation. Tourists should critically reflect upon their personal consumer behaviour and make sure that it does not infringe on the local population’s rights to a healthy and dignified life.

Tourism has great potential to foster healthy lives and well-being for both tourists and local communities if the risks involved are reduced by effective preventative measures. For tourism to contribute significantly to Goal 3, revenues generated from tourism need to be invested in health care systems that are of good quality and accessible and affordable for all.

• Hopkins, L., Labonte, R., Runnels, V. and Packer, C. (2010): Medical tourism today: What is the state of existing knowledge? Journal of Public Health Policy Vol. 31 (2), pp. 185–198.
• ILO - International Labour Organisation (2012): HIV and AIDS: Guide for the tourism sector. Accessed online 01/11/2016 http://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/instructionalmaterial/wcms_185347.pdf 
• Lunt, N., Smith, R., Exworthy, M., Hanefeld, J. and Mannion R. (2014): Market size, market share and market strategy: three myths of medical tourism. In: Policy & Politics, Vol 42 (4), pp. 597-614.
• Padilla, M., Guilamo-Ramos, V., Bouris, A. and Reyes, M. (2010): HIV/AIDS and Tourism in the Caribbean: An Ecological Systems Perspective. In: Public Health. 2010 January; 100(1): 70–77.
• Robert Koch Institute: Informationen zum Ebolafieber-Ausbruch in Westafrika 2014/2015. Accessed online 01/11/2016 http://www.rki.de/DE/Content/InfAZ/E/Ebola/Kurzinformation_Ebola_in_Westafrika.html
• Smith, A. (2012): Medical tourism and organ trafficking. In: African Journal of Hospitality, Tourism and Leisure Vol. 2 (1).
• World Health Organization – WHO (2016): Fact Sheet Climate Change and Health accessed online 01/11/2016 http://www.who.int/mediacentre/factsheets/fs266/en/
• WHO - World Health Organisation (2016b): Situation Report- Ebola Virus Disease, 10 June 2016. Accessed online 01/11/2016 http://apps.who.int/iris/bitstream/10665/208883/1/ebolasitrep_10Jun2016_eng.pdf?ua=1
• UNWTO - World Tourism Organization (2016): Climate Change and Tourism. Accessed online 01/11/2016 http://sdt.unwto.org/content/faq-climate-change-and-tourism