health tourism research paper

Medical tourism: its research and implications for public health

Affiliations.

• 1 Department of Applied Linguistics, Faculty of Informatics and Management, University of Hradec Kralove, Hradec Kralove, Czech Republic.
• 2 Biomedical Research Centre, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
• 3 Centre for Basic and Applied Research, Faculty of Informatics and Management, University of Hradec Kralove, Hradec Kralove, Czech Republic.
• PMID: 32997479
• DOI: 10.21101/cejph.a5744

Objective: The purpose of this article is to describe current research trends in medical tourism and implications for public health, especially in destination countries.

Methods: The methods used for this article include a literature review of available sources on the research topic in the world's acknowledged databases Web of Science, Scopus, MEDLINE, and ScienceDirect.

Results: The findings indicate that there is no consensus on the definition of medical tourism. However, there are a few conceptual models which can be used in further medical tourism research and practice. The findings also reveal that there are still certain issues, which hinder the fast growth of medical tourism, such as unclear impact on healthcare systems, ethical concerns or a lack of effective tools for the measurement of quality assurance of the medical tourism services and their products.

Conclusions: There is a need for data collection on medical tourism, both at national and worldwide level to provide a realistic picture of this evolving field of tourism as well as implications for public health in destination countries.

Keywords: barriers; implications; medical tourism; research; trends.

• Medical Tourism*
• Public Health
• Research / trends

• Open access
• Published: 16 July 2018

Medical tourism and national health care systems: an institutionalist research agenda

• Daniel Béland 1 &
• Amy Zarzeczny 1  

Globalization and Health volume  14 , Article number:  68 ( 2018 ) Cite this article

22k Accesses

28 Citations

27 Altmetric

Metrics details

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for national health care systems, the comparative scholarship on the topic remains too limited in scope. In this article, we draw on the existing literature to discuss a comparative research agenda on medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, we claim that such characteristics shape the demand for medical tourism in each country. On the other hand, the institutional characteristics of each national health care system can shape the very nature of the impact of medical tourism on that particular country. Using the examples of Canada and the United States, this article formulates a systematic institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus with a view to informing future policy work in this field.

In this era of globalized medicine, when international travel and access to online health information are readily accessible, medical tourism is an important issue both for national health care systems and from a global health perspective [ 1 , 2 , 3 ]. Patients from countries around the world are exercising increasing degrees of autonomy over their health care options by obtaining information from sources other than their regular health care providers and, in some cases, by electing to pursue care alternatives outside their domestic medical system. Medical tourism is a broad and inclusive term that captures a wide range of diverse activities [ 3 ]. It has been defined as “the practice of travelling to another country with the purpose of obtaining health care (elective surgery, dental treatment, reproductive treatment, organ transplantation, medical checkups, etc.),” and is generally distinguished from both care sought for unplanned medical emergencies that occur abroad and from formal bi-lateral medical trade agreements [ 4 , 5 ]. Individual motivations for engaging in medical tourism vary widely and may include imperatives such as avoiding wait times, reducing costs, improving quality, and accessing treatments not available or legal in the home jurisdiction, or for which the individual is not eligible [ 5 , 6 , 7 , 8 ].

While medical tourism is far from new, shifting patient flow patterns and a growing recognition of the complex ethical, social, economic, and political issues it raises are underscoring renewed efforts to understand this phenomenon and its future [ 3 , 9 , 10 ]. Some of the current attention focused on medical tourism concerns its implications and potential risks for individual patients and health care systems [ 11 , 12 , 13 ]. Medical tourism impacts both importing and exporting health care systems, albeit in different ways [ 14 ]. Various terms exist to describe trade in health services [ 15 ]. For the purpose of this discussion, we will use importing or destination to describe systems whereby patients come from other jurisdictions to receive care, and exporting to describe the departure of individuals from their domestic medical system to pursue health services elsewhere. Recognizing that there are important knowledge gaps and a need for definitional clarity and further empirical work to understand the effects of medical tourism on the countries involved [ 16 ], concerns for importing or destination systems include, though are not limited to, ethical questions about inequity of access for local residents versus high paying visitors and about the “brain drain” of local talent into private, for-profit organizations focused on non-resident care [ 15 ]. Conversely, the issues exporting systems face often revolve around implications for domestic health care providers, the potential for patients to avoid domestic wait lists, and the costs of follow-up care upon patients’ return [ 12 ]. For example, research from Alberta, Canada, suggests that the financial costs associated with treating complications from medical tourism for bariatric surgery are substantial, and complication rates are considerably higher than similar surgeries conducted in Alberta (42.2–56.1% versus 12.3% locally) [ 6 ].

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for health systems [ 3 , 16 ], the comparative scholarship on medical tourism remains too limited in scope, a remark that should not hide the existence of a number of recent comparative studies in the field [ 17 , 18 , 19 ]. These studies demonstrate that comparative research is helpful in identifying both the unique and the most common policy challenges facing each country [ 20 ] and can, if done appropriately, offer learning opportunities [ 21 ]. Indeed, this process can facilitate policy learning (related terms include lesson drawing, policy transfer, diffusion, and convergence) whereby ideas, policies, or practices (e.g., regulatory tools) in one jurisdiction inform or shape those in another [ 22 , 23 ].

With a view to ultimately informing policy related to medical tourism, this article discusses the value of a comparative research agenda about medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, these characteristics may shape the content of the demand for medical tourism among the citizens of a particular country [ 24 ]. From this perspective, as argued, existing typologies of health care systems can shed light on the varying features of the demand for medical tourism across countries. In other words, different types of health care systems are likely to produce different configurations of demand for medical tourism, which influences the range of policy instruments available to governments and other actors seeking to influence decision-making and behavior within their particular context [ 25 ]. On the other hand, the institutional characteristics of each national health care system may also shape the very nature of the impact of medical tourism on that system. Accordingly, the institutional characteristics of health care systems, such as insurance structures [ 26 ], may impact both citizens’ demand for medical tourism and the ways in which medical tourism affects each country. Obtaining a better understanding of these relationships may inform new ways of thinking about both the challenges and opportunities medical tourism presents. As medical tourism markets continue to grow and diversify, and as domestic health care systems increasingly feel the stress of limited resources, this kind of work will be critical to support policymakers and health system leaders in their efforts to mitigate the potential harms of medical tourism while, at the same time, responding to the needs of the citizens they serve [ 3 ].

Using the examples of Canada and the United States (US), this article proposes the use of an institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus as a central element of future policy strategies. We first take a comparative perspective on medical tourism and present what we see as key aspects of the issue from a policy perspective. Drawing on current evidence and leading literature in the field, we highlight ways in which national health care systems shape the demand for medical tourism and then, in turn, how medical tourism impacts national health care systems. From this discussion, we identify four key lines of enquiry that we suggest are of critical importance in the medical tourism policy landscape and propose an agenda for future comparative research on medical tourism and national health care systems that could play an important role in informing future policy decisions in this area.

Medical tourism in comparative perspective

Although gathering robust data on the magnitude of medical tourism continues to be a challenge and more empirical work in this area is needed [ 3 , 5 , 10 , 12 ], a strong body of literature addresses different aspects of the issue. For example, research is improving understandings of how medical tourism impacts destination and departure jurisdictions [ 16 , 27 ], affects relationships with domestic health care providers [ 28 ], relates to economic factors including health system costs [ 29 ], and impacts clinical outcomes for patients [ 30 ], among other important lines of enquiry. However, much of this valuable scholarship focuses on particular forms of medical tourism in specific contexts (bariatric surgery [ 31 ], dental care [ 32 ], reproductive services [ 33 ], etc.) or on the policy and health system implications for individual jurisdictions [ 13 ]. There is an increasing amount of comparative research exploring how different features of health care systems may in some cases help drive demand for medical tourism and in other cases constrain it (i.e., push/pull factors), and how they relate to the impact of medical tourism [ 24 ], but more work remains to be done in this important area [ 4 , 10 ]. The potential value of data on the impact of medical tourism in one jurisdiction to structurally- similar systems (e.g., other universal public health care systems) has already been recognized [ 34 ]; we agree and suggest that going further with an associated analysis considering the role of their institutional features is critical. This approach is particularly valuable from a policy perspective, especially when it comes to maximizing opportunities for policy learning from other jurisdictions and to identifying and evaluating the respective strengths and limitations of different policy options for decision-makers seeking to, for example, discourage particular forms of medical tourism (e.g., organ transplant tourism [ 35 ]).

The governance of medical tourism in its various forms is complex and highly fragmented given its broad range of influential stakeholders (both state and non-state, individual and institutional), its international market-based nature, and its engagement of vastly different and often competing priorities and interests (e.g., profit-driven, patient care, autonomy, ethics, etc.). As a result, policy makers and health system leaders face considerable challenges when it comes to seeking to influence medical tourism markets, whether by encouraging their development or restricting access to them. Obtaining a better understanding of the institutional forces that shape the demand for, and impact of, medical tourism—and connecting those forces to the policy context—may help identify a broader range of tools and options decision- makers can employ to achieve their particular objectives with respect to medical tourism.

Looking at Canada and the US is an appropriate starting point for this comparative work and we use this comparison to ground our analysis of the value of an institutional research agenda as a policy strategy for addressing potential concerns and opportunities associated with medical tourism. While these neighboring countries are similar in many ways, there are dramatic differences in important institutional features of their respective health care systems, including funding and delivery models. The US is both an established importer and exporter of medical tourists, the latter supported in part by insurers offering medical tourism coverage in an effort to reduce the high costs associated with domestic health care services [ 11 , 36 ]. In contrast, the structure of Canada’s largely publicly-funded, single-payer medical system limits foreign access to non-emergent care and makes it challenging for Canadians to be reimbursed for care received abroad via medical tourism [ 7 ]. It also makes the current involvement of Canadians in medical tourism [ 37 ] a public policy issue because of its implications for the public purse.

How national health care systems shape demand for medical tourism

Because health care systems can be understood as relatively stable institutional settings that shape human behavior [ 38 , 39 ], their features are likely to impact the demand for medical tourism in a particular country or even, in the case of decentralized health care systems subject to considerable regional variation, in a particular region. Health care systems can vary greatly from one country to the next, or even from one region to the next within the same country. Accordingly, what citizens might be looking for when they seek medical treatment abroad is likely to fluctuate based on the nature of health care coverage, financing, and regulation they have at home. Research about these and other drivers is growing but important gaps in knowledge remain [ 5 ]. In other words, alongside factors like geographical mobility and travel costs, the institutional configurations of health care systems likely shape, at least in part, the types of services people are looking for based on what health services they can access in their home country, with what degree of quality and timeliness, and at what cost [ 24 ].

A comparison between Canada and the US is illustrative here. Starting with the Canadian context, universal coverage has existed in Canada since the early 1970s [ 40 , 41 ]. Under this framework, regardless of the province or territory in which they live, Canadian citizens and permanent residents are entitled to medically necessary health care services with no user fees, which are strictly prohibited under the 1984 Canada Health Act (CHA). Yet, although the CHA mandates comprehensive coverage for “all insured health services provided by hospitals, medical practitioners or dentists,” many services do not fall under this umbrella and the Canadian health care system has long waiting lists for many non-emergency surgeries like hip replacement [ 40 , 42 ]. Wait times vary from province to province but they are a source of frustration for many Canadians, some of whom elect to go abroad to get their non-emergency procedure done faster, even if they have to pay for it themselves, instead of relying on the slower public system back home [ 7 ]. Gaps in coverage within the single-payer system in important areas such as prescription drugs [ 43 ] and dentistry [ 44 ] also sometimes push Canadian citizens and permanent residents to go elsewhere for care to reduce costs. There are also a wide variety of medical treatments and health-related interventions offered in private markets that are either not available or not publicly funded in Canada. There are a variety of reasons for this lack of public funding, including those related to evidence (or, more precisely, the lack thereof) regarding safety and efficacy. For example, there is a large international market for unproven stem cell interventions that are not part of the approved standard of care in Canada or available in the publicly funded health care system [ 45 ]. Therefore, key motivations underlying the pursuit of Canadian medical tourism often relate to a desire to access care faster, to reduce out of pocket costs for care not covered by provincial health insurance, and/or to access options that are not available in Canada [ 7 ].

In the US healthcare system, where about 9% of the population remains uninsured despite the enactment of the Affordable Care Act (ACA) in 2010 [ 46 ], people who lack insurance coverage but who face a medical need might go abroad to seek cheaper treatment. In fact, the high cost of care in the US has been recognized as a major factor pushing Americans to seek care at lower cost outside the US, an option that is facilitated by health care globalization [ 2 ]. For example, there is research documenting the strong market in the Mexican border city of Los Algodones for Americans seeking dentistry, optometrist, and pharmacy services [ 47 ]. Others may be motivated to return to systems with which they are more familiar, as is the case with the Mexican diaspora [ 24 ]. In the US, in contrast to Canada where universal coverage prevails, the lack of health care coverage is likely to be a key factor driving the demand for medical tourism. At the same time, waiting times are much less likely to drive the demand for medical tourism in the US, where waiting lists are less of an issue [ 40 ].

These brief remarks highlight how key institutional features in both Canada and the US shape patterns in the demand for medical tourism in these two countries, creating both similarities and differences between them. At the same time, regional differences in health system institutions within the two countries can also shape the demand for medical tourism within their borders. For instance, in states like Texas, where elected officials have thus far refused to expand Medicaid as part of the ACA [ 48 ], more people live without health care coverage than elsewhere (about 18% of the population as of March 2016 [ 49 ]), which may push them to look to Mexico for cheaper health care. Here the institutional characteristics of a state’s health care system and the geographical proximity to Mexico, coupled with the presence of a large population of Mexican descent who speak Spanish, are likely to favor cost-saving medical tourism from Texas to Mexico. This example highlights how geographical and even ethno-cultural factors can shape medical tourism alongside and even in combination with the institutional features of a particular health care system. This is also the case when we deal with issues such as dental care and cosmetic surgeries, which are not covered by many US public and private insurance plans [ 50 ].

How medical tourism impacts national health care systems

At the most general level, existing national and sub-national institutions may mediate the impact on particular countries of transnational processes stemming from globalization [ 20 , 51 ]. This general remark also applies to global medical tourism, which is unlikely to affect all national health care systems in the same way. Put bluntly, systems will react differently to external pressures, based in part on their own institutional characteristics. Those same institutional characteristics also form part of the policy matrix that shapes the options available to decision makers.

There are two central aspects to this story. First, we can look at how domestic health care institutions are specifically impacted by inbound medical tourism (i.e., destination countries at the receiving end of medical tourism). Research suggests that the way in which health care systems cope with foreign users, and what impact those foreign users have on the system, will vary according to the institutional characteristics of that system [ 16 ]. For instance, countries that attract many medical tourists could witness price increases and the diversion of services away from their less-fortunate citizens [ 1 ]. At the same time, the institutional features of national health care systems can explain why some countries attract more medical tourists than others. The comparison between Canada and the US is particularly revealing here. On the one hand, although some provinces have considered alternate approaches that would encourage inbound medical tourism as a source of revenue generation [ 52 ], at present the limited scope of private health care in Canada restricts the availability of medical tourism opportunities for wealthy foreigners seeking treatments. On the other hand, the large scope of private health care in the US makes that country an obvious target for wealthy medical tourists who can afford its high medical costs.

Second, and more important for this article, national health care institutions may also shape the way in which each country is affected by outbound medical tourism. For example, in a single-payer health care system such as Canada’s, both routine follow-up care and complications resulting from medical acts performed abroad are typically dealt with within the public system, engendering direct costs to taxpayers and potentially impacting access for others in the system (i.e., if physicians’ time is diverted to attend to emergent issues) [ 6 ]. The extent of these concerns varies depending on the urgency of the issue and whether it falls within hospital and physician services covered by the universal system (versus, for example, dental care where public coverage is more limited) [ 52 ]. By comparison, within the fragmented public-private US health care system, public programs may only absorb a fraction of the costs of complications related to outbound medical tourism, thus reducing their direct negative impact on taxpayers, whereas private insurance companies or individuals themselves might bear the majority of these costs.

The potential savings for outbound countries medical tourism generates are also likely to depend on the institutional features of each national or sub-national health care system [ 16 ]. In Canada, for instance, people who decide to go abroad for non-emergency surgeries might help reduce the length of waiting lists, although this positive impact might be limited by the fact that some of these surgeries are simply not available in Canada or, at least, not available to the individuals who seek treatments abroad (e.g., because of their age or health status). Because waiting lists are much less of an issue in the US [ 40 ], this potential benefit of medical tourism to domestic health care systems may be less relevant there.

Conversely, the prospect of affordable medical tourism may convince people in the US who do not have access to Medicaid, Medicare, or employer-based coverage that they do not need coverage at all, because they can always go abroad and save money should they need medical treatment. In this context, global medical tourism could interact with the question of whether people will seek coverage or not. At the same time, to save money, “US companies, such as Anthem Blue Cross and Blue Shield and United Group Programs, are now exploring the idea of including medical tourism as a part of their coverage,” a situation that could increase their administrative burden and create further complications along the road [ 53 ].

Policy implications

Our aim with the preceding high-level overview was to draw on existing knowledge to highlight not only that national health care institutions may shape the demand for medical tourism in a particular country or region, but also that the consequences of such tourism for national health care systems are likely similarly mediated by the institutional features of these systems. These connections have a number of important potential implications for health system governance of medical tourism and, more specifically, for the options available to policy makers seeking particular objectives. For example, depending on the jurisdiction, efforts to reduce demand for medical tourism could include a range of options such as investing resources targeted at reducing domestic wait times, expanding public health insurance, limiting public coverage for follow-up care needs, or educating the public about the potential risks associated with medical tourism [ 2 ], among other options. Conversely, efforts to encourage the development of a medical tourism industry within a particular jurisdiction might involve regulatory change to expand options for private system offerings and targeted marketing campaigns, again among other possibilities [ 5 , 17 ].

In fact, it has long been recognized the governments have a variety of tools or policy levers at their disposal when they seek to influence behavior [ 54 ]. Identifying which tool (or combination of tools) is likely to be most effective in a particular set of circumstances, such as medical tourism, requires a nuanced understanding of relevant institutional characteristics and situational factors. Accordingly, we propose that a comparative research agenda should be a key element of future analysis and decision-making efforts in this field. Such an agenda would not only help empirically test the above hypotheses about the institutional-medical tourism nexus, it could also help facilitate lesson drawing between jurisdictions that have attempted different approaches by helping pinpoint salient commonalities and points of difference between the systems that might initially explain, and ideally ultimately even predict, the likely results of particular policy initiatives.

Research agenda

We propose a comparative research agenda that aims to explore the relationship between medical tourism and key institutional features of national health care systems. Although some aspects of our research agenda are already present in the existing literature, we think studying these elements together and with a comparative policy lens would be of tremendous value to health system decision -makers seeking to navigate different objectives including, for example, avoiding “brain drain” from public to private health care, minimizing added costs to publicly funded systems, protecting vulnerable individuals, and facilitating patient autonomy.

Drawing on our review of the health care systems in Canada and the US, we have identified three key institutional features that we suggest are particularly relevant to medical tourism and its broader policy context. These key features are health care funding models, delivery structures (e.g., public/private mix, provider payment models, role of user choice, and competition between providers), and governance systems (e.g., location of authority, health care provider regulation, liability systems). Future empirical research may identify other more salient features and certainly an iterative approach may be valuable. Nonetheless, we suggest that these features would provide a useful starting point for the next step, which we propose be an exploration of how these institutional features relate to the following areas:

Patient flow patterns – e.g., inbound versus outbound, treatment destinations, types of treatment sought.

Patient motivations – e.g., cost reduction, wait list avoidance, pursuit of quality, circumvention tourism.

Health system interactions – e.g., costs and options for follow-up treatment, roles of domestic health care professionals.

Existing policy levers – e.g., public and private insurance structures, incentive schemes, information campaigns, regulation.

These four areas are not intended to serve as a comprehensive list of all relevant lines of enquiry. However, they present a valuable starting point, particularly because of their relevance to policy instrument selection processes. Having said that, and although it is beyond the scope of this piece to go further than laying a foundation for this proposed research agenda, we suggest that future research take a broad and scoping approach to draw on existing data and information and, where possible, conduct new empirical work addressing these critical areas. With a view to identifying patterns and generating hypotheses, researchers will likely need to continually refine the initial assumptions, outlined above, about the relationships between different institutional features and aspects of medical tourism. Doing so will require careful thought regarding the selection of an appropriate scientific paradigm, with a view to research validity and reliability [ 55 ].

We also anticipate that end-users and important stakeholders, including elected officials, civil servants, health care providers, and patients and families, would have an important contribution to make to the research design and with respect to interpreting the findings, particularly as they relate to the identification and evaluation of policy options. One important limitation in this type of work will relate to data availability. We expect that comparative work of this nature and any future empirical analyses it includes will highlight gaps in knowledge and potentially trigger future research agendas. Overall, the research envisioned here should complement and augment ongoing efforts in the field to improve understandings of important factors including patient flows, expenditure trends, system impacts, and individual decision-making determinants, among others.

Conclusions

This article discussed the relationship between medical tourism and key institutional aspects of national health care systems with a view to highlighting the value in a comparative research agenda focused on identifying and evaluating policy options. First, we argued that these characteristics directly affect the demand for medical tourism in each country. Second, we suggested that such institutional characteristics shape the actual impact of medical tourism on that particular country . This discussion led to the formulation of an institutionalist research agenda about medical tourism. It is our hope that this proposed agenda will trigger discussion and debate, help develop future research, and inform new ways of thinking about medical tourism in the global landscape. Medical tourism is a complex phenomenon and we suggest that applying a comparative, institutional lens will shed new light on its drivers, constraints, and impacts and, in so doing, ultimately help inform policy development in this area.

Hall C. Health and medical tourism: a kill or cure for global public health? Tourism Rev. 2011;66(1/2):4–15.

Google Scholar  

Maniam G. Medical tourism as the result of rising American healthcare costs in the context of healthcare globalization. J bus. Behav Sci. 2015;27(2):112–22.

Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014;21(6):410–7.

PubMed   Google Scholar  

Smith R, Martinez Alvarez M, Chanda R. Medical tourism: a review of the literature and analysis of a role for bi-lateral trade. Health Pol. 2011;103:276–82.

Crooks VA, Kingsbury P, Snyder J, Johnston R. What is known about the patient’s experience of medical tourism? A scoping review BMC Health Servi. 2010;10:266. https://doi.org/10.1186/1472-6963-10-266 . Accessed 12 June 2018.

Kim D, Sheppard C, de Gara C, Karmali S, Birch D. Financial costs and patients' perceptions of medical tourism in bariatric surgery. Can J Surg. 2016;59(1):59–61.

CAS   PubMed   PubMed Central   Google Scholar  

Snyder J, Crooks V, Johnston R, Kingsbury P. What do we know about Canadian involvement in medical tourism? A scoping review Open Med. 2011;5(3):e139–48.

Horowitz M, Rosensweig J, Jones C. Medical tourism: globalization of the healthcare marketplace. Med Gen Med. 2007;9(4):33.

Connell J. From medical tourism to transnational health care? An epilogue for the future. Soc Sci & Med. 2015;124:398–401.

Behrmann J, Smith E. Top 7 issues in medical tourism: challenges, knowledge gaps, and future directions for research and policy development. Glob J Health Science. 2010;2(2):80–90.

Turner L. “Medical tourism” and the global marketplace in health services: U.S. patients, international hospitals, and the search for affordable health care. Int J Health Serv. 2010;40(3):443–67.

Hopkins L, Labonte R, Runnels V, Packer C. Medical tourism today: what is the state of existing knowledge? J Public Health Policy. 2010;31(2):185–98.

Lunt N, Mannion R, Exworthy M. A framework for exploring the policy implications of UK medical tourism and international patient flows. Soc Policy Admin. 2013;47(1):1–25.

Cohen IG. Medical tourism: the view from ten thousand feet. Hast Cent Rep. 2010;40(2):11–2.

Chanda R. Trade in health services. B World Health Organ. 2002;80(2):158–63.

Johnston R, Crooks VA, Snyder J, Kingsbury P. What is known about the effects of medical tourism in destination and departure countries? A scoping review Int J Equity Health. 2010;9:24. https://doi.org/10.1186/1475-9276-9-24 . Accessed 12 June 2018.

Snyder J, Crooks VA, Johnston R, Cerón A, Labonte R. “That’s enough patients for everyone!”: local stakeholders’ views on attracting patients into Barbados and Guatemala’s emerging medical tourism sectors. Glob Health. 2016;12:1–13.

Leng CH. Medical tourism and the state in Malaysia and Singapore. Glob Soc Policy. 2010;10(3):336–57.

Pocock NS, Phua KH. Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia. Glob Health. 2011;7(1):12.

Béland D. What is social policy? Understanding the welfare state. Cambridge: Polity Press; 2010.

Marmor T, Freeman R, Okma K. Comparative perspectives and policy learning in the world of health care. J comp. Foreign Policy Anal. 2005;7(4):331–48.

Stone D. Transfer and translation of policy. Policy Stud. 2012;33(6):483–99.

Benson D, Jordan A. What have we learned from policy transfer research? Dolowitz and marsh revisited. Polit Stud Rev. 2011;9:366–78.

Bustamante A. Globalization and medical tourism: the north American experience. Int J Health Policy Manag. 2014;3(1):47–9.

PubMed   PubMed Central   Google Scholar  

Howlett M. What is a policy instrument? Tools, mixes, and implementation styles. In: Eliadas P, Hill MM, Howlett M, editors. Designing government: from instruments to governance. Montréal and Kingston: McGill-Queen’s press; 2015. p. 31–50.

Laugesen M, Vargas-Bustamante A. A patient mobility framework that travels: European and United States-Mexico comparisons. Health Policy. 2010;97:225–31.

For example, seeSnyder J, Crooks V, Turner L, Johnston R. Understanding the impacts of medical tourism on health human resources in Barbados: a prospective, qualitative study of stakeholder perceptions. Int J Equity Health. 2013; https://doi.org/10.1186/1475-9276-12-2 .

For example, seeSnyder J, Crooks V, Johnston R, Dharamsi S. “Do your homework … and then hope for the best”: the challenges that medical tourism poses to Canadian family physicians’ support of patients’ informed decision-making. BMC Med Ethics. 2013; https://doi.org/10.1186/1472-6939-14-37 .

For example, seeMilstein A, Smith M. Will the surgical world become flat? Health Aff. 2007;26(1):137–41.

For example, seePrasad GV, Shukla A, Huang M, D’A Honey RJ, Zaltzman J. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation. 2006;82(9):1130–5.

Snyder J, Crooks VA. Medical tourism and bariatric surgery: more moral challenges. Am J Bioeth. 2010;10(12):28–30.

Turner L. Cross-border dental care: ‘dental tourism’ and patient mobility. Brit Dent J. 2008;204:553–4.

CAS   PubMed   Google Scholar  

Deonandan R. Recent trends in reproductive tourism and international surrogacy: ethical considerations and challenges for policy. Risk Manag Healthc Policy. 2015;8:111–9.

Hanefeld J, Horsfall D, Lunt N, Smith R. Medical tourism: a cost or benefit to the NHS? PLOSOne. 2013; https://doi.org/10.1371/journal.pone.0070406 .

Gill J, Diec O, Landsberg DN, Rose C, Johnston O, Keown PA, Gill JS. Opportunities to deter transplant tourism exist before referral for transplantation and during the workup and management of transplant candidates. Kidney Int. 2011;79(1):1026–31.

Kumar S, Breuing R, Chahal R. Globalization of health care delivery in the United States through medical tourism. J Health Comm. 2012;17(2):177–98.

Runnels V, Labonte R, Packer C, Chaudhry S, Adams O, Blackmer J. Canadian physicians’ responses to cross border health care. Glob Health. 2014; https://doi.org/10.1186/1744-8603-10-20 .

Hacker JS. The historical logic of national health insurance: structure and sequence in the development of British, Canadian, and U.S. medical policy development. Stud am Polit. Dev. 1998;12(1):57–130.

Tuohy CH. Accidental logics: the dynamics of change in the health care arena in the United States, Britain, and Canada. Oxford: Oxford University Press; 1999.

Maioni A. Parting at the crossroads: the emergence of health insurance in the United States and Canada. Princeton: Princeton University press; 1998.

Marchildon GP. Health systems in transition: Canada. Toronto: University of Toronto Press; 2013.

McQuigge M. Canadian health care wait times still unacceptably high, two reports say. National Post. 2015; https://nationalpost.com/health/canadian-health-care-wait-times-still-unacceptably-high-two-reports-say . Accessed 3 Nov 2016.

Boothe K. Ideas and the pace of change: national pharmaceutical insurance in Canada, Australia, and the United Kingdom. Toronto: University of Toronto Press; 2015.

Locker D, Maggirias J, Quinonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Pub Health Den. 2011;71(4):327-34.

Berger I, Ahmad A, Bansal A, Kapoor T, Sipp D, Rasko J. Global distribution of businesses marketing stem cell-based interventions. Cell Stem Cell. 2016;19:158–62.

Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2015. Washington, DC: Centers for Disease Control and Prevention (National Center for Health Statistics); 2016. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf : 1. Accessed 3 Nov 2016.

Judkins G. Persistence of the U.S. – Mexico border: expansion of medical tourism amid trade liberalization. J Lat Am Geog. 2007;6(2):11–32.

Béland D, Rocco P, Waddan A. Obamacare wars: federalism, state politics, and the Affordable Care Act. Lawrence, KS: University Press of Kansas; 2016.

Mangan D. Big drop in Texans without health insurance, but poor lag. CNBC I June. 2016; http://www.cnbc.com/2016/06/01/big-drop-in-texans-without-health-insurance-but-poor-lag.html . Accessed 3 November 2016

IMTG. Most medical tourism to Mexico is dental or cosmetic. Int Med Travel Journal (Intuition Communication). 26 August 2015; http://www.imtj.com/news/most-medical-tourism-mexico-dental-or-cosmetic/ . Accessed 3 November 2016

Campbell JL. Institutional change and globalization. Princeton: Princeton University Press; 2004.

Snyder J, Johnston R, Crooks VA, Morgan J, Adams K. How medical tourism enables preferential access to care: four patterns from the Canadian context. Health Care Anal. 2017;25:138–50.

Kirchner E, Carroll J, Nious K. US insurance companies expanding medical tourism coverage. NBC (Bay Area). 4 December 2013; http://www.nbcbayarea.com/news/local/Medical-Tourism-The-Future-of-Healthcare-233414371.html . Accessed 3 November 2016

Hood C. The tools of government. Chatham: Chatham house: Publishers; 1986.

Healy M, Perry C. Comprehensive criteria to judge validity and reliability of qualitative research within the realism paradigm. Qual Market Research. 2000;3(3):118–26.

Download references

Acknowledgements

The authors thank Rachel Hatcher for the copy-editing support and anonymous reviewers for their helpful suggestions. DB acknowledges support from the Canada Research Chairs Program, and AZ funding from the Canadian National Transplant Research Program.

Author information

Authors and affiliations.

Johnson Shoyama Graduate School of Public Policy, 101 Diefenbaker Place, Saskatoon, SK, S7N 5B8, Canada

Daniel Béland & Amy Zarzeczny

You can also search for this author in PubMed   Google Scholar

Contributions

DB wrote the theoretical paragraphs and AZ the paragraphs focusing more directly on medical tourism. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Daniel Béland .

Ethics declarations

Authors information.

DB has published extensively on institutionalism and on health care systems, and AZ has published extensively on health law and policy issues, including topics related to medical tourism.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Béland, D., Zarzeczny, A. Medical tourism and national health care systems: an institutionalist research agenda. Global Health 14 , 68 (2018). https://doi.org/10.1186/s12992-018-0387-0

Download citation

Received : 30 November 2016

Accepted : 29 June 2018

Published : 16 July 2018

DOI : https://doi.org/10.1186/s12992-018-0387-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health care
• Medical tourism
• Institutions
• Institutionalism
• United States

Globalization and Health

ISSN: 1744-8603

• Submission enquiries: [email protected]
• General enquiries: [email protected]

UN Tourism | Bringing the world closer

• All Regions
• Exploring Health Tourism

The ETC/UNWTO publication on Exploring Health Tourism aims to provide a better understanding of the growing segment of wellness and medical tourism. The study introduces the evolution of health-related tourism products and services from all around the world and provides insights into the current situation of the industry, as well as the future potential. It also includes a comprehensive taxonomy that serves as a common reference for tourism destinations operating in this field, as well as a practical toolkit to assist NTOs and DMOs with their planning and management of health-related tourism activities.

Click here   for the Executive Summary of this publication.

ISBN : 978-92-844-2020-9

share this content

• Share this article on facebook
• Share this article on twitter
• Share this article on linkedin

Related Content

Am news | vol. 64 may 2024, africa news issue 23, un tourism news 82: sustainable development of tourism, am news | vol. 63 april 2024.

To read this content please select one of the options below:

Please note you do not have access to teaching notes, health tourism in china: a 40-year bibliometric analysis.

Tourism Review

ISSN : 1660-5373

Article publication date: 6 December 2022

Issue publication date: 20 January 2023

The purpose of this study is to systematically analyze the evolution of health tourism development, identify relevant themes and segments of health tourism research and offer future research directions and practical implications for academic researchers and tourism practitioners worldwide using China as an example.

Design/methodology/approach

Using a bibliometric analysis, the present study comprehensively analyzes the theme, segments and the evolution of health tourism research over the past 40 years in China.

Major findings show that health tourism research in China could be divided into four stages with different characteristics, and three segments, including wellness tourism, health and wellness tourism and medical tourism. Findings also reveal the trend of health tourism development tends to be industrialized, diversified and systematic under the guidance of recent policies. Theoretically, based on the theoretical framework developed by Hall (2011), the present study contributes to the establishment and extension of the framework for health tourism within the context of China. Practically, findings can provide health tourism-related policy implications for the future development of health or health sector-integrated tourism.

Research limitations/implications

The study proposes possible collaboration between government and academia in terms of health tourism-related policy formulation.

Originality/value

Through 40-year bibliometric analysis of health tourism evolution in China, the present study explores the main themes of health tourism development, identifies the segments of health tourism and analyzes the development stages of health tourism. Findings should be of use to international readers to better understand the uniqueness of health tourism development and find out possible future health tourism development research directions. As a result, major contributions of this paper are the comprehensive analysis of the evolution of health tourism research and the implications on other countries and regions to adopt a pragmatic approach to explore the trend and unique characteristics of health tourism for future development.

本研究旨在系统地分析中国健康旅游的演变过程, 探索健康旅游研究的相关主题及细分领域, 并为全球学术研究人员及旅游从业者提供未来的研究方向。

此研究通过文献计量学的研究方法, 全面分析了中国近40年健康旅游研究的主题、细分以及演变。

中国健康旅游研究根据其发展特点可以分为四个阶段及三个细分主题：分别是养生旅游, 康养旅游及医疗旅游。调查结果还表明, 在近期政策的引导下, 健康旅游发展趋于产业化、多元化和系统化。从理论意义来说, 本研究基于Hall (2011) 提出的理论框架, 构建了中国背景下的健康旅游框架。从实践意义来说, 研究结果可以为健康和旅游业相关部门提供政策建议。

此研究还有助于促进政府和学术界在健康旅游政策制定方面的合作。

此研究通过对中国近40年健康旅游的研究进行文献计量分析, 探索了健康旅游发展的主题, 分析了健康旅游的细分市场以及发展阶段。研究结果有助于学术界及旅游业更好地了解健康旅游发展的独特性及未来健康旅游的研究方向。因此, 本研究的主要贡献是全面地分析了健康旅游研究的演变, 并有助于其他国家/地区探索未来健康旅游的发展趋势和其独特特征。

El propósito del presente estudio es analizar sistemáticamente la evolución del desarrollo del turismo de salud, identificar temas y segmentos relevantes de la investigación en turismo de salud y ofrecer direcciones de investigación futuras e implicaciones prácticas para investigadores académicos y profesionales del turismo en todo el mundo utilizando a China como ejemplo.

Diseño/metodología/método

Mediante un análisis bibliométrico, el presente estudio analiza exhaustivamente la temática, los segmentos y la evolución de la investigación sobre turismo de salud en los últimos 40 años.

Los principales hallazgos muestran que la investigación del turismo de salud en China podría dividirse en cuatro etapas con diferentes características y tres segmentos, incluido el turismo de bienestar, el turismo de salud y bienestar y el turismo médico. Los hallazgos también revelan que la tendencia del desarrollo del turismo de salud tiende a ser industrializado, diversificado y sistemático bajo la guía de políticas recientes. El presente estudio hace aportes tanto teóricos como prácticos. Teóricamente, basado en el marco teórico desarrollado por Hall (2011), el presente estudio contribuye al establecimiento y extensión del marco para el turismo de salud en el contexto de China. En la práctica, los hallazgos pueden proporcionar implicaciones políticas relacionadas con el turismo de salud para el desarrollo futuro de la salud o el turismo integrado en el sector de la salud.

Implicaciones

El estudio también propone una posible colaboración entre el gobierno y la academia en términos de formulación de políticas relacionadas con el turismo de salud.

Originalidad/valor

A través del análisis bibliométrico de 40 años de la evolución del turismo de salud, el presente estudio explora los temas principales del desarrollo del turismo de salud, identifica los segmentos del turismo de salud y analiza las etapas de desarrollo del turismo de salud. Los hallazgos deberían ser de utilidad para los lectores internacionales para comprender mejor la singularidad del desarrollo del turismo de salud y descubrir posibles direcciones futuras de investigación sobre el desarrollo del turismo de salud. Como resultado, las principales contribuciones de este documento son el análisis exhaustivo de la evolución de la investigación en turismo de salud y las implicaciones en otros países y regiones para adoptar un enfoque pragmático para explorar la tendencia y las características únicas del turismo de salud para el desarrollo futuro.

• Development
• Health tourism
• Turismo de salud

Acknowledgements

The study was supported by Beijing Social Science Foundation Major Project: 21JCA042; and Ethnic research project of the National Committee of the People’s Republic of China. Funding No.: 2020-GMD-089.

Zhong, L. , Sun, S. , Law, R. , Li, X. and Deng, B. (2023), "Health tourism in China: a 40-year bibliometric analysis", Tourism Review , Vol. 78 No. 1, pp. 203-217. https://doi.org/10.1108/TR-03-2022-0112

Emerald Publishing Limited

Copyright © 2022, Emerald Publishing Limited

Related articles

We’re listening — tell us what you think, something didn’t work….

Report bugs here

All feedback is valuable

Please share your general feedback

Join us on our journey

Platform update page.

Visit emeraldpublishing.com/platformupdate to discover the latest news and updates

Questions & More Information

Answers to the most commonly asked questions here

U of T students conduct research in South Korea, thanks to Insights Through Asia Challenge

Last year, Chloe Panganiban, Nadia Schwartz Rivero and Catherine Yang decided they wanted to collaborate on a big research project that could incorporate all their academic specialties – global health for Panganiban, history and psychology for Schwartz Rivero, and criminology and sociolegal studies for Yang.

The three University of Toronto undergrads just had to figure out exactly what that would be.

After several conversations and some brainstorming, they landed on the topic of medical tourism in South Korea. For more than a decade, there’s been a rapid rise in people travelling to South Korea for medical care, which can range from plastic surgery to cancer treatment.

“We were really trying to find an intersection of all our different interests and at the same time look for something where there was a research gap,” says Yang.

In-person research

Thanks to the Richard Charles Lee Insights Through Asia Challenge (ITAC), an experiential learning program at the Asian Institute in the Munk School of Global Affairs & Public Policy, the students were able to travel to Seoul for two-and-a-half weeks last summer for in-person research.

We were really trying to find an intersection of all our different interests and at the same time look for something where there was a research gap.

They conducted interviews with South Koreans, visited local hospitals and agencies, and toured around South Korea “to see the effects of medical tourism itself and just how the industry works with international patients and tourists,” explains Schwartz Rivero, who first met Panganiban through another ITAC research project the previous year, and has been friends with Yang since they first met in the Vic One program in their first year.

Titled “Why here and not there? An exploratory, qualitative study about medical tourism in South Korea,” the goal of their research was to better understand the country’s role in medical tourism on a global scale and why people choose South Korea and Seoul over other destinations.

Combining their different academic backgrounds made the study more insightful, says Panganiban.

Medical tourism shaped by many different fields

“Medical tourism is something that’s shaped and influenced by so many different fields. Particularly, in South Korea, it’s backed up by legislation that allows tourists to come there for medical purposes – and actually encourages that,” she explains.

The ITAC program supports original student research and research-related travel; any U of T undergraduate or graduate students can apply, with priority given to students at the Asian Institute.

“The program was instrumental in supporting our travel to Korea. I think being there in person brings about a very different opportunity when you’re interviewing people. You can develop deeper conversations, relationships and connections, which otherwise wouldn’t have been possible,” says Yang.

I think being there in person brings about a very different opportunity when you’re interviewing people. You can develop deeper conversations, relationships and connections, which otherwise wouldn’t have been possible.

“Another important facet is the guidance systems made available through programs like ITAC. It’s not just monetary funding; there are also mentors and other academics you can look to for help through this program,” she adds, noting that they’re all very grateful for the guidance they received from their research supervisor on this project, Professor Rachel Silvey, who is also the Richard Charles Lee Director of the Asian Institute.

Named after prominent Hong Kong businessman and philanthropist Richard Charles Lee (who was also the father of former Canadian senator, U of T chancellor and alumna Vivienne Poy), the Richard Charles Lee Insights Through Asia Challenge was launched in 2016 and is funded by an anonymous donor.

In 2023, 10 research teams received ITAC funding. Other recipients include a team studying mental health discourses in the recruitment and training of overseas Filipina workers and a team exploring climate change and environmental degradation in a Cambodian floating village.

Invaluable opportunity

For Panganiban, Schwartz Rivero and Yang, the opportunity to lead an original research study overseas was invaluable. “Leading a research project in your undergrad is quite rare,” says Panganiban. “It was an unforgettable experience and something that was really a highlight for all of us in our undergraduate journeys.”

Yang adds that it helped her decide whether academic research was something she wanted to pursue long term. It turns out it is – after she graduates with her BA this June, she plans to apply for grad school in the future.

It was an unforgettable experience and something that was really a highlight for all of us in our undergraduate journeys.

Panganiban, who will graduate with an Honours Bachelor of Science this June, plans to pursue a Master of Public Health in the near future. Schwartz Rivero, who graduated a year ahead of the other two, has just completed the first year of a Master of Arts degree at the Centre for European, Russian, and Eurasian Studies (CERES) at the Munk School.

Meanwhile, the trio is continuing their research on the medical tourism study by adding a systematic data analysis of their findings, says Panganiban. “We’re in the data cleaning phase right now and looking to hopefully get an academic publication out with our research and findings.”

Want to help fuel research at the Asian Institute at U of T’s Munk School of Global Affairs & Public Policy?

There are several funds you can support, including the Asian Institute Student Excellence Award, the Asian Institute Vision Fund and the Joseph Wong Student Experience Fund.

Cultural Relativity and Acceptance of Embryonic Stem Cell Research

Article sidebar.

Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

Two decades of studies suggest health benefits associated with plant-based diets

But researchers caution against broad diet recommendations until remaining knowledge gaps are filled.

Vegetarian and vegan diets are generally associated with better status on various medical factors linked to cardiovascular health and cancer risk, as well as lower risk of cardiovascular diseases, cancer, and death, according to a new review of 49 previously published papers. Angelo Capodici and colleagues present these findings in the open-access journal PLOS ONE on May 15, 2024.

Prior studies have linked certain diets with increased risk of cardiovascular disease and cancer. A diet that is poor in plant products and rich in meat, refined grains, sugar, and salt is associated with higher risk of death. Reducing consumption of animal-based products in favor of plant-based products has been suggested to lower the risk of cardiovascular disease and cancer. However, the overall benefits of such diets remain unclear.

To deepen understanding of the potential benefits of plant-based diets, Capodici and colleagues reviewed 48 papers published between January 2000 and June 2023 that themselves compiled evidence from multiple prior studies. Following an "umbrella" review approach, they extracted and analyzed data from the 48 papers on links between plant-based diets, cardiovascular health, and cancer risk.

Their analysis showed that, overall, vegetarian and vegan diets have a robust statistical association with better health status on a number of risk factors associated with cardiometabolic diseases, cancer, and mortality, such as blood pressure, management of blood sugar, and body mass index. Such diets are associated with reduced risk of ischemic heart disease, gastrointestinal and prostate cancer, and death from cardiovascular disease.

However, among pregnant women specifically, those with vegetarian diets faced no difference in their risk of gestational diabetes and hypertension compared to those on non-plant-based diets.

Overall, these findings suggest that plant-based diets are associated with significant health benefits. However, the researchers note, the statistical strength of this association is significantly limited by the many differences between past studies in terms of the specific diet regimens followed, patient demographics, study duration, and other factors. Moreover, some plant-based diets may introduce vitamin and mineral deficiencies for some people. Thus, the researchers caution against large-scale recommendation of plant-based diets until more research is completed.

The authors add: "Our study evaluates the different impacts of animal-free diets for cardiovascular health and cancer risk showing how a vegetarian diet can be beneficial to human health and be one of the effective preventive strategies for the two most impactful chronic diseases on human health in the 21st century."

• Diet and Weight Loss
• Diseases and Conditions
• Colon Cancer
• Endangered Plants
• Veterinary Medicine
• Colorectal cancer
• Ovarian cancer
• Polyphenol antioxidant
• Stomach cancer
• Cervical cancer
• HPV vaccine
• Breast cancer

Story Source:

Materials provided by PLOS . Note: Content may be edited for style and length.

Journal Reference :

• Angelo Capodici, Gabriele Mocciaro, Davide Gori, Matthew J. Landry, Alice Masini, Francesco Sanmarchi, Matteo Fiore, Angela Andrea Coa, Gisele Castagna, Christopher D. Gardner, Federica Guaraldi. Cardiovascular health and cancer risk associated with plant based diets: An umbrella review . PLOS ONE , 2024; 19 (5): e0300711 DOI: 10.1371/journal.pone.0300711

Cite This Page :

Explore More

• High-Efficiency Photonic Integrated Circuit
• Life Expectancy May Increase by 5 Years by 2050
• Toward a Successful Vaccine for HIV
• Highly Efficient Thermoelectric Materials
• Toward Human Brain Gene Therapy
• Whale Families Learn Each Other's Vocal Style
• AI Can Answer Complex Physics Questions
• Otters Use Tools to Survive a Changing World
• Monogamy in Mice: Newly Evolved Type of Cell
• Sustainable Electronics, Doped With Air

Trending Topics

Strange & offbeat.

• Introduction
• Article Information

Results are from logistic regression models controlling for age, Hispanic or Latina/x ethnicity, marital status, parity, tobacco use, prenatal visit utilization, stillbirth, and placental abruption. Other race includes Alaska Native, American Indian, Chinese, Filipino, Guam/Chamorro Hawaiian, Indian, Japanese, Korean, Other Asian/Pacific Islander, Samoan, and Vietnamese. In the sample, 4100 patients had a history of substance use, and 33 760 had no history of substance use; 4636 had a urine toxicology test, and 2199 had any positive test result at labor and delivery. Error bars indicate 95% CIs.

Data Sharing Statement

See More About

Select your interests.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Others Also Liked

• Download PDF
• X Facebook More LinkedIn

Jarlenski M , Shroff J , Terplan M , Roberts SCM , Brown-Podgorski B , Krans EE. Association of Race With Urine Toxicology Testing Among Pregnant Patients During Labor and Delivery. JAMA Health Forum. 2023;4(4):e230441. doi:10.1001/jamahealthforum.2023.0441

Manage citations:

© 2024

• Permissions

Association of Race With Urine Toxicology Testing Among Pregnant Patients During Labor and Delivery

• 1 Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
• 2 Friends Research Institute, Baltimore, Maryland
• 3 Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
• 4 Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
• 5 Magee-Womens Research Institute, Pittsburgh, Pennsylvania

An estimated 16% of pregnant persons in the US use alcohol (10%) or an illicit substance (6%, including cannabis). 1 Urine toxicology testing (UTT) is often performed at the time of labor and delivery for pregnant patients to evaluate substance use. 2 , 3 We sought to elucidate associations between race and receipt of UTT and a positive test result among pregnant patients admitted to the hospital for delivery.

This cohort study followed the STROBE reporting guideline. Data were extracted from electronic medical records (EMRs) of patients with a live or stillbirth delivery between March 2018 and June 2021 in a large health care system in Pennsylvania. The study was approved by the University of Pittsburgh institutional review board. Informed consent was waived because the research constituted minimal risk. All patients presenting for delivery were verbally screened for substance use using questions adapted from the National Institute on Drug Abuse Quick Screen. 4 Policy specified UTT would be performed for those with a positive screen result, history of substance use in the year prior to delivery, few prenatal visits, or abruption or stillbirth without a clear medical explanation.

We studied 2 binary outcomes: the receipt of UTT (point of care presumptive testing) and a positive test result at delivery. The primary variable of interest, patient race, was conceptualized as a social construct that could manifest in biased or discriminatory delivery of health care. Self-reported race was categorized as Black, White, and other (Alaska Native, American Indian, Chinese, Filipino, Guam/Chamorro Hawaiian, Indian, Japanese, Korean, Other Asian/Pacific Islander, Samoan, and Vietnamese). Substance use history was defined as having a diagnosis of an alcohol, cannabis, opioid, or stimulant use or disorder during pregnancy in the EMR within 1 year prior through delivery. A positive UTT result was defined as at least 1 positive result of a test component, including amphetamines, barbiturates, benzodiazepines, buprenorphine, cocaine, cannabis, methadone, opiates, or phencyclidine. We used multivariable logistic regression models including race and substance use history, adjusting for age, Hispanic or Latina/x ethnicity, marital status, parity, tobacco use, prenatal visit utilization, stillbirth, and placental abruption. We derived mean predicted probabilities of outcomes by race and substance use history. 5 Analyses were conducted using Stata, version 17.

Among 37 860 patients (100% female; mean [SD] age, 29.8 [5.5] years), 16% Black, 76% were White, and 8% were other race ( Table ). Overall, 11% had a history of substance use; opioid use was more common among White patients (40% of all substance use), whereas cannabis use was most common among Black patients (86% of all substance use). The mean predicted probability of having a UTT at delivery was highest among Black patients compared with White patients and other racial groups regardless of history of substance use ( Figure ). For Black patients without a history of substance use, the mean predicted probability of receiving a UTT at delivery was 6.9% (95% CI, 6.4%-7.4%) vs 4.7% (95% CI, 4.4%-4.9%) among White patients. Among Black patients with a history of substance use, the mean predicted probability of receiving a UTT at delivery was 76.4% (95% CI, 74.8%-78.0%) vs 68.7% (95% CI, 67.3%-70.1%) among White patients. In contrast, among those with a history of substance use, the mean predicted probability of having a positive test result was 66.7% (95% CI, 64.8%-68.7%) among White patients and 58.3% (95% CI, 55.5%-61.1%) among Black patients.

In this cohort study, Black patients, regardless of history of substance use, had a greater probability of receiving a UTT at delivery compared with White patients and other racial groups. However, Black patients did not have a higher probability of a positive test result than other racial groups. Limitations of the study include a lack of a sufficient sample size to investigate other racial and ethnic minoritized groups, such as Alaska Native and American Indian patients, and that data were from a single geographical area and may not generalize nationally. To address racial biases, health care systems should examine drug testing practices and adhere to evidence-based practices.

Accepted for Publication: February 4, 2023.

Published: April 14, 2023. doi:10.1001/jamahealthforum.2023.0441

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Jarlenski M et al. JAMA Health Forum .

Corresponding Author: Marian Jarlenski, PhD, MPH, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, Pittsburgh, PA 15261 ( [email protected] ).

Author Contributions: Dr Jarlenski and Mr Shroff had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jarlenski, Terplan, Krans.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jarlenski, Krans.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Shroff, Terplan, Brown-Podgorski, Krans.

Obtained funding: Jarlenski, Krans.

Administrative, technical, or material support: Krans.

Supervision: Jarlenski, Krans.

Conflict of Interest Disclosures: Dr Roberts reported receiving grants from the Foundation for Opioid Response Efforts and the University of California, San Francisco CSF Bixby Center for Global Reproductive Health and National Center of Excellence in Women's Health outside the submitted work. Dr Krans reported receiving grants from the National Institutes of Health, Merck, and Gilead outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grant R01DA049759 from the National Institute on Drug Abuse (Dr Jarlenski and Krans).

Role of the Funder/Sponsor: The National Institute on Drug Abuse had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Elsevier - PMC COVID-19 Collection

Tourism and COVID-19: Impacts and implications for advancing and resetting industry and research

The paper aims to critically review past and emerging literature to help professionals and researchers alike to better understand, manage and valorize both the tourism impacts and transformational affordance of COVID-19. To achieve this, first, the paper discusses why and how the COVID-19 can be a transformational opportunity by discussing the circumstances and the questions raised by the pandemic. By doing this, the paper identifies the fundamental values, institutions and pre-assumptions that the tourism industry and academia should challenge and break through to advance and reset the research and practice frontiers. The paper continues by discussing the major impacts, behaviours and experiences that three major tourism stakeholders (namely tourism demand, supply and destination management organisations and policy makers) are experiencing during three COVID-19 stages (response, recovery and reset). This provides an overview of the type and scale of the COVID-19 tourism impacts and implications for tourism research.

1. Introduction: Setting the necessity and parameters for tourism COVID-19 research

The COVID-19 (declared as a pandemic by WHO, 12 March 2020) of significantly impacts the global economic, political, socio-cultural systems. Health communication strategies and measures (e.g. social distancing, travel and mobility bans, community lockdowns, stay at home campaigns, self- or mandatory-quarantine, curbs on crowding) have halted global travel, tourism and leisure. Being a highly vulnerable industry to numerous environmental, political, socio-economic risks, tourism is used to and has become resilient in bouncing back ( Novelli, Gussing Burgess, Jones, & Ritchie, 2018 ) from various crises and outbreaks (e.g. terrorism, earthquakes, Ebola, SARS, Zika). However, the nature, the unprecedented circumstances and impacts of the COVID-19, demonstrate signs that this crisis is not only different, but it can have profound and long-term structural and transformational changes to tourism as socio-economic activity and industry. Indeed, the global and huge scale, the multidimensional and interconnected impacts challenging current values and systems and leading to a worldwide recession and depression are the most distinctive characteristics of this pandemic.

COVID-19 tourism impacts will be uneven in space and time, and apart from the human tool, estimates show an enormous and international economic impact: international tourist arrivals are estimated to drop to 78% causing a loss of US$ 1.2 trillion in export revenues from tourism and 120 million direct tourism job cuts representing seven times the impact of September 11, and the largest decline in the history ( UNWTO, 2020 ). Being one of the most important global employer (1 in 10 jobs are directly related to tourism, UNWTO, 2020 ) and the major GDP contributor for several countries, tourism and COVID-19 are the epicenter of all international discussions and economies.

Within the burgeoning industry discussions and research about tourism and COVID-19, there is an unanimous call to see and use the pandemic as a transformative opportunity ( Mair, 2020 ). Industry should not only recover but also reimagine and reform the next normal and economic order ( McKinsey, 2020 ), while researchers should not solely use COVID-19 as another context to replicate existing knowledge for measuring and predicting tourism impacts ( Gössling et al., 2020 , Hall et al., 2020 ). Although such studies are important for managing the pandemic, they do not advance knowledge and/or guide the industry to a step beyond. Moreover, because of the interlinked socio-cultural, economic, psychological and political impacts of COVID-19 of this magnitude, unforeseen trajectories instead of historical trends are expected and the predictive power of ‘old’ explanatory models may not work. Moreover, there is enough evidence to claim that both the tourism industry and research have matured to a good extent providing sufficient knowledge about how to study and effectively: (1) design and implement crisis recovery and response strategies (e.g. McKercher & Chon, 2004 ); (2) build resilience to address future crises ( Hall, Prayag, & Amore, 2017 ). What is still lacking is knowledge about how crisis can foster industry change, how companies can convert this crisis disruption into transformative innovation and how to conduct research that can enable, inform and shape the rethinking and resetting of a next normal.

Crises can be a change trigger, but none crisis has been so far a significant transition event in tourism ( Hall et al., 2020 ). Crises have also been used as a political tool to stabilize existing structures and diminish the possibility of collective mobilization ( Masco, 2017 ). As change can be selective and/or optional for the tourism stakeholders (e.g. tourists, operators, destination organisations, policy makers, local communities, employees), the nature and degree of crises-led transformations depend on whether and how these stakeholders are affected by, respond to, recover and reflect on crises. Consequently, to better understand, predict but also inform and shape change, tourism COVID-19 research should provide a deeper examination and understanding of the tourism stakeholders’ (behavioural, cognitive, emotional, psychological and even ideological) drivers, actions and reactions to their COVID-19 impacts. Research should also examine and understand the stakeholders’ lived and perceived COVID-19 experiences as well as their consciousness, mindfulness, capabilities and willingness to understand and act (pro-actively and re-actively) to the pandemic, as all these can equally influence their attitudes, behaviours and change potential.

COVID-19 tourism research should also advance our knowledge for informing, fostering, shaping or even leading such crises-enabled transformations. Otherwise, we will simply experience one crisis after the other ( Lew, 2020 ). Responding to the mushrooming euphoria of COVID-19 tourism related research, Gretzel et al. (2020) also plead for transformative e-tourism research that can shape tourism futures by making value systems, institutional logics, scientific paradigms and technology notions visible and transformable. To achieve scientific paradigm shifts, e-tourism research should embrace historicity, reflexivity, transparency, equity, plurality and creativity ( Gretzel et al., 2020 ). To avoid the bubble of the COVID-19 research orgasm and advance tourism research, others have also suggested to adopt inter-disciplinary ( Wen, Wang, Kozak, Liu, & Hou, 2020 ), multi-disciplinary ( Gössling et al., 2020 , Hall et al., 2020 ) or even anti-disciplinary ( Sigala, 2018 ) research to enable out-of-the-box, creative and flexible thinking that challenges and goes beyond existing pre-assumptions and mindsets.

To address these needs and gaps, this paper aims to critically review past and emerging literature to help professionals and researchers alike to better understand, manage and valorize both the tourism impacts and transformational affordance of COVID-19. To achieve this, first, the paper discusses why and how the COVID-19 can be a transformational opportunity by discussing the circumstances and the questions raised by the pandemic. By doing this, the paper identifies the fundamental values, institutions and pre-assumptions that the tourism industry and academia should challenge and break through to advance and reset the research and practice frontiers. The paper continues by discussing the major impacts, behaviours and experiences that three major tourism stakeholders (namely tourism demand, supply and destination management organisations and policy makers) are experiencing during three COVID-19 stages (response, recovery and reset). This analysis is useful because it provides an overview and understanding of the type and scale of the COVID-19 tourism impacts, while it also demonstrates that the way in which stakeholders and researchers understand, react and behave in each stage may form and set the next (new) normal in the post COVID-19 era. Responding to the call for transformative research, discussions are developed based on the rational that tourism research should go beyond replicating and reconfirming existing knowledge within the COVID-19 context; instead tourism COVID-19 research should see new things and see them differently to inform and guide tourism futures. Hence, the paper suggests potential new research areas and theoretical lenses that can be used for advancing and resetting industry practice and research. The paper does not aim to provide a fully comprehensive and inclusive analysis of all the impacts, theories, topics and tourism stakeholders that COVID-19 tourism research can examine. Instead, it aims to provide practical and theoretical implications on how to better research, understand, manage and transformative valorize COVID-19 tourism impacts.

2. COVID-19 circumstances and tourism: Shifting the research focus to challenge, reset and contradict institutional logics, systems and assumptions

Research investigating, measuring and predicting the COVID-19 tourism impacts is important in order to eliminate ‘casualties’, draft, monitor and improve response strategies (i.e. you cannot manage what you cannot measure). However, research focusing on the features and impacts of crises instead of their structural roots tends to conceal and stabilize the conditions and corollary social structures through which crises are produced ( Barrios, 2017: 151 ). Investigating the real roots of COVID-19 may go beyond the boundaries and scope of tourism research. Yet, the latter needs to look into and challenge the tourism ‘circumstances’ and structures that have enabled and sometimes accelerated the global spread and impact of COVID-19. Unfortunately, the economists downplay the pandemic as a purely natural event originating and operating outside of the economic system ( Nowlin, 2017 ). But, treating COVID-19 as an exogenous shock and phenomenon that has nothing to do with socio-economic structures and values, can perpetuate and strengthen the pandemic roots during the post COVID-era as well as constrain change and transformational processes.

COVID-19 is a crisis of the economized societies rooted in the growth-paradigm ( Ötsch, 2020 ). COVID-19 is also a result of the intersection of broader processes of urbanisation, globalisation, environmental change, agribusiness and contemporary capitalism ( Allen et al., 2017 ). The nature of tourism (requiring traveling) and its evolution and growth paradigms are a significant contributor to such circumstances and the current socio-economic system accelerating the spread and impact of this contagious and infectious virus. Tourism is a result but also responsible for: our highly interconnected and global world; pollution, waste and climate change; global, national and regional economic development and growth; superiority of capitalism values in people’s and business decision-making but also policy and politics formulations. As climate change increases the frequency of pandemics and outbreaks, pandemics are expected to become more common in the future ( World Economic Forum (2019) (2019), 2019 ), which in turn highlights the interwoven nature and vicious circle forces between the biological, physical and socio-economic systems.

Moreover, the economic system and mindset contributing to the COVID-19 has also been guiding and shaping the COVID-19 response and recovery strategies of governments, institutions, businesses and people alike. This can significantly perpetuate and repeat crises as we are treating their symptoms and not their roots. For example, economic priorities for maintaining business continuity and jobs, resume and recovering to the old ‘economic success growth’, have been driving governments’ policies and practices such as: economic support (e.g. subsidies, tax reliefs) to tourism businesses and employees; debates for relaxation of restrictions for re-opening and re-starting economies at the expense of a second way and human lives. Similarly, people have engaged in panic buying and (over)-consumption of online experiences (e.g. virtual entertainment, dining, drinking, traveling) during lock-downs, that demonstrate their persistence, preference and fear of loosing to their ‘consumerism’ traditional lifestyles deemed essential for their success and happiness. Early COVID-19 tourism research also reinforces a similar mindset, e.g. many studies trying to measure the economic impacts of COVID-19 trading them off to socio-cultural and biological impacts, studies aiming to predict and measure when tourists will start traveling again and when we can reach the old tourism targets. As governments race to minimise economic losses, and be the first to reopen borders and (tourism) businesses, and financial markets, investors, cash liquidity and financial survival are equally pressing multinational and small tourism enterprises, they are all also looking for tourism research that can ‘feed’ and ‘reconfirm’ their mindset and help them resume operations based on the old paradigms and business models they are founded. Debates and research are based on trading between economic benefits and losses in exchange of human rights, lives, morals and ethics. There is no discussion why trade-offs are the best methodology and mindset to decide, no one has re-imagined ‘solutions’ enabling co-existence or regenerative forces between these concepts.

Overall, research, education and our socio-economic and political system (which they shape and are shaped by each other), have all framed our mindset on how we research, measure, understand, respond and aim to recover from the COVID-19. Consequently, we have converted COVID-19 from a biological virus contagion to a financial crisis contagion and recently, an economic race to re-build our old financial competitiveness. To avoid such perpetuations, tourism research should assume more responsibility in informing, driving and leading sustainable futures. To that end, COVID-19 tourism research should not be solely seen, conducted and used as a useful tool to help resume old states. Instead, COVID-19 tourism research should also challenge our growth-paradigms and assumptions that have led to the current situation and enable us to reimagine and reset tourism (e.g. Ioannides and Gyimóthy, 2020 , Gössling et al., 2020 , Hall et al., 2020 , Higgins-Desbiolles, 2020 ). To achieve this, COVID-19 tourism research should criticize ontological and epistemological foundations and assumptions that underpin the current science and growth paradigms ( Brodbeck, 2019 ). It should also deconstruct and challenge the mechanisms and systems that sustain the deleterious unsustainable tourism evolution ( Higgins-Desbiolles, 2020 ). But to regenerate and transform tourism and its socio-economic system, tourism research should not only support new ways and perspectives of researching, knowing and evolving. COVID-19 tourism research should also inspire, motivate and inform all tourism stakeholders alike to adopt new ways of being, doing and politicising. For example:

At a macro-level, COVID-19 tourism research should generate dethinking, rethinking and unthinking of pre-assumptions and mindsets including ( Higgins-Desbiolles, 2020 ): globalisation as an unstoppable force; neoliberal capitalism as the best system and decision-making tool for organizing and allocating resources; growth as the sole way for development and success. It should also challenge the ‘surveillance capitalism’, whose institutionalisation and normalisation is perceived as inevitable and unstoppable because of forces including ( Zuboff, 2015 ): institutionalised facts (e.g. data collection, analytics and mining); leading tech and disrupting companies being respected and treated as emissaries of a better future solving the “faults of capitalism” (e.g. sharing economy platforms ‘democraticing’ micro-entrepreneurship); and people seeing technologies as a necessity requirement for social and civic participation, securing employment and addressing the increasingly stressful, competitive, and stratified struggle for effective life. The COVID-19 is accelerating the institutionalisation and acceptance of this algorithmic governance, management and society, previously contested as violations of human rights, privacy and laws ( Zysman, 2006 ), but now becoming normalised in the name of health and common good.

Technology is at the core of solutions for combating the COVID-19 and re-opening tourism and the economy (e.g. mobility tracing apps, robotised-AI touchless service delivery, digital health passports and identity controls, social distancing and crowding control technologies, big data for fast and real time decision-making, humanoid robots delivering materials, disinfecting and sterilizing public spaces, detecting or measuring body temperature, providing safety or security), while technology is seen as a panacea to our COVID-19 driven-needs to normalise surveillance, to ensure health and safety, to collect and analyse personal data for fast decision-making. Although COVID-19 tourism research cannot stop these technological advances, it should fight this digital trojan horse from the inside by questioning and resetting their purposes, designs and affordances, interpretations and application ethics. Technologies are constituted by unique affordances, whose development and expression are shaped by the institutional logics in which technologies are designed, implemented, and used ( Zuboff, 2015 ). COVID-19 tourism research could simply investigate and advance our information and technological capabilities to collect, analyse and use (big) data for better knowing, predicting, controlling, and modifying human behavior (e.g. tourists and employees behaviour) as a means to produce revenue and market control ( Zuboff, 2015 ). But such research will simply further support the making of everydayness qua data imprints an intrinsic component of organizational and institutional life and a primary target of commercialization strategies ( Constantiou & Kallinikos, 2015 ). Technologies have always been an enabler, a catalyst of innovation and change, a disruptor of tourism, as well as a tool to build tourism resilience in crisis ( Hall et al., 2017 ). The COVID-19 has further enhanced the role of technologies in the recovery and reimagination of tourism, while it reinforces existing paradigms in the e-tourism evolution. Developmental trends and adoption of smart destinations and tourism services, AI, robotics and other digital advances are now accelerated to combat the COVID-19 tourism implications. COVID-19 tourism research should reimagine and re-shape the purposes, usage and means of such technological advances that significantly form how our societies and economies are being transformed, how tourism is being practiced, managed and evolves with the help and/or because of the COVID-19.

At a micro-level, COVID-19 tourism research should question and reset why tourism is viewed, practiced and managed as a way to ‘escape’, ‘relax’, ‘socialise’, ‘construct identities/status’, ‘learn’ and reward themselves from a routine, unpleasant and meaningless life. Why tourism should be researched and practiced as an escape from a boring life, instead of life being rewarding and meaningful itself? Why people have to travel thousands of miles away from home to ‘learn’ and ‘be happy’? Why companies have to commercialize and commoditize communities, people and their tangible and intangible resources as tourism attractions ‘please’ the tourists’ needs and drive economic development? Tourism paradigms and mindsets like this, have led and intensified crises like COVID-19 and this cannot be sustainable for much longer. Consumerism and tourism should not be seen as the sole way to achieve happiness, self-expression, and (economic) development. COVID-19 tourism research should inspire tourists, businesses and destinations alike to re-imagine and reset new mindsets, frontiers and behaviours such as: how to use and develop tourism to valorize and not consume tourism resources, to generate well-being, sustainability and transformational learning; how to study and practice environmental/sustainable management not as a legal necessity for lobbying and formulating policies, not as marketing tool to build brands’ and people’s identities, not as an expense to be minimized, but as a mindful business investment and personal lifestyle for a responsible future.

Overall, COVID-19 tourism research should not only be the mean to overcome the crisis and resume previously chartered economic growth trajectories. It should lead the refocusing, repurposing, reframing and re-interpretation of research questions, methodologies and outcomes, so that tourism stakeholders can in turn re-direct their actioning, conduct and evolution. To that end, COVID-19 tourism research will be benefited by embedding, adapting, reflecting and expanding the theoretical lenses and perspectives of a much greater plurality of disciplines and constructs to guide and implement research. Transformative (service) research, philosophy, criminology, ethics, law, anthropology, behavioural and religious studies, political science and diplomacy, governance, bioethics, rhetoric. Researching within unchartered waters, COVID-19 tourism research may also need to apply new methodological approaches and tools that are capable to combat roots and not symptoms of tourism crises and use the latter as transformational opportunity to reset research agendas and re-imagine and re-shape unthinkable tourism futures. Due to the newness of the field qualitative approaches such as (cyber)ethnography and the need for urgent, fast and real-time research processes and outcomes, COVID-19 tourism research may also need to intensify and advance “new” methods of (big) data collection, analysis and interpretation/visualization, such as participatory sensing (i.e. using tourists as sensors for data collection).

Paradox research, as a meta-theory and/or methodology, can also be very instrumental for informing and supporting COVID-19 tourism research. Originating in philosophy and psychology (e.g. Aristotle, Confucius, Freud), paradox research (also frequently requiring multi-disciplinarity) has helped to inform, advance and transform management science research ( Schad, Lewis, Raisch, & Smith, 2016 ) and organisations ( Cameron & Quinn, 1988 ) alike. As a meta-theory, paradox research offers a powerful lens for enriching extant theories and fostering theorizing processes in management science, because it provides deeper understanding and conceptualisation of constructs, relationships, and dynamics surrounding organizational tensions. By investigating contradictions between interdependent elements that are seemingly distinct and oppositional, one can better unravel how one element actually informs and defines the another, tied in a web of eternal mutuality. As a methodology, the paradox lens encourages researchers to approach organizational paradoxes paradoxically ( Cameron & Quinn, 1988 ). Incorporating paradox research into COVID-19 research may also be inevitable, as the COVID-19 circumstances, impacts and debates have uncovered and intensified existing paradoxes, but also generated new ones. Paradox research is also paramount to COVID-19 tourism research, if the latter is to become innovative and transformative. These are because (adapted by Schad et al., 2016 ):

• • Interruptions in socio-economic life can reveal structural contradictions and paradoxes, and by studying and understanding them, one can make the crisis positive and transformative
• • paradoxes intensify, grow and intensify, as contemporary organizations and their environments become increasingly global, fast-paced, and complex; the evolution and circumstances of tourism and COVID-19 are a strong evidence of a highly interconnected, fast paced and complex world
• • paradox is a powerful meta-theorizing tool: opposing theoretical views may enable vital insights into persistent and interdependent contradictions, fostering richer, more creative, and more relevant theorizing
• • paradox identifies and challenges our pre-assumptions: as antinomies, theoretical paradoxes remain perplexing, even paralyzing, when researchers are confined by the past and/or assumptions
• • paradox help us think creatively and out-of-the box, because contradictions provoke established certainties and tempts untapped creativity

Paradox research is limitedly used within tourism research, but its applicability, versatility and value are shown already in investigating: macro-level tourism and destination management issues ( Williams & Ponsford, 2009 ); business operations ( Sigala, Airey, Jones, & Lockwood, 2004 ) and tourism demand ( Mawby, 2000 ). However, as the present and post COVID-19 era is a fertile ground of persistent and new paradoxes in tourism, tourism researchers should seriously consider adopting a paradox lense. For example, the circumstances of COVID-19 (e.g. stay at home lockdowns, social distancing) have necessitated and accelerated the use of technologies by both tourists (e.g. information about travel restrictions, online crisis communication, online COVID-19 alerts and hygiene measures) and businesses (e.g. online food delivery, virtual dining, virtual wine experiences, festivals/events, virtual visits of museums, destinations). However, persistent ‘paradoxes’ (e.g. increase use of social media and loneliness, democratisation of information accessibility and information darkness, technology and (small) business empowerment/equalizing competition rules) are questioning the effectiveness of such technology solutions and have fuelled debates on whether they are a ‘cure’ or a ‘fertiliser’ and “diffuser’ of the pandemic. Not everyone has access to technology and those that they have do not necessarily have the capabilities and knowledge to effectively use the technology tools and information. The persistent digital divide found in consumers and businesses (which mainly represents a socio-economic divide of citizens and size of businesses), has converted the pandemic to an infodemic (e.g. lack or mis-information, diffusion of fake COVID-19 news and advices, emotional contagion of global depression and mental health) and a tool deepening the economic divide and competitive gap between larger and smaller tourism operators. Digital inequalities in tourists potentiated their vulnerability to COVID-19 (e.g. putting themselves and their loved one in health risk while traveling or willing to travel during and after the COVID-19), while COVID-19 vulnerability potentiate to enlarge the digital inequalities [e.g. those who have the tools and means to easier go through the COVID-19 impacts will also be the only ones who can pay and access virtual tourism experiences, who will be well informed on how, where and when travel and who will be able to afford to travel in the future, as increased (hygiene and technology) operating costs and transportation oligopolies may increase costs of tourism]. Similarly, digital inequalities in tourism businesses potentiate COVID-19 vulnerability (as larger operators that were technology ready and ‘inherited’ by size resilience, were the first and maybe the only ones to be able to virtualise operations and experiences for maintaining business liquidity, surviving, re-opening and recovering post COVID-19), while COVID-19 vulnerability increases digital and economic inequalities in the tourism competitive landscape (e.g. larger companies/destinations which are characterised by greater cash liquidity, know-how, technology readiness and resilience and so, have lower COVID-19 vulnerability, will be the ones to survive and thrive post COVID-19). Paradox research that can investigate such contradictions between the abovementioned distinct and oppositional, but also elements interdependent elements can better define, understand, manage and address their concepts and the dynamics of their web of eternal mutuality.

The COVID-19 fortified and generated many other paradoxes, which are also identifiable at all tourism management levels (macro, meso and micro) and COVID-19 tourism research can investigate for advancing and transforming research. Table 1 provides some ideas for applying such paradoxes in COVID-19 tourism research.

Paradox Research: advancing and transforming COVID-19 tourism research.

3. COVID19: Dismantling and re-mantling tourism in three stages

It is widely accepted that crisis management needs to be implemented before, during and after a crisis. Table 2 provides an overview of the impacts and implications of COVID-19 on three major stakeholders (tourism demand, tourism operators, destinations and policy makers) under three stages (representing the respond, recovery and restart stage from the pandemic) to incorporate a transformational stage envisioned in the post COVID-19 era. COVID-19 tourism research does not have to address issues in the last stage in order to be transformative. It can equally be transformative if it re-examines ‘existing’ issues and relations but through new theoretical lenses and/or methodological approaches by embedding a plurality of ‘new’ disciplines into the research designs. By doing this, one can significantly unravel unknown issues and dynamics, provide a better explanatory power and understanding of concepts and relations as well as identify and test new ‘remedies’.

COVID-19 and tourism in three stages: major impacts and some ideas for future research.

3.1. Tourism demand

Tourists have experienced themselves, through their loved ones and/or through the shared experiences of others (e.g. user-generated-content) significant disruptions and health-risks in their travel and bookings plans. The tourists’ experiences and/or exposure to others’ experiences (that are also magnified through the emotional contagion and information diffusion of the social media) can have a significant impact on their travel attitudes, intentions and future behaviours. Psychiatric research investigating the impact of traumatic experiences on people’s life, behaviours and experiences of places and services (e.g. Baxter & Diehl, 1998 ) can provide a useful theoretical lenses for understanding the travel behavior and attitudes of tourists that have been exposed to own or others’ COVID-19 travel trauma. Tourism research has mainly focused on studying how tourists develop their perceived risk and the impacts of the latter on tourists’ decision-making processes, future intentions and segmentation profiles (e.g. Dolnicar, 2005 , Aliperti and Cruz, 2019 , Araña and León, 2008 ). Others have also examined the impact of the tourists’ perception of crisis management preparedness certification on their travel intentions (e.g. Pennington-Gray, Schroeder, Wu, Donohoe, & Cahyanto, 2014 ). Such research is important, as risk perceptions are important for predicting future tourism demand and drafting appropriate recovery strategies ( Rittichainuwat & Chakraborty, 2009 ). It is also relevant for COVID-19 tourism research because of the new COVID-19 standards and certification rules that companies are now required to adopt. Research has shown that perceptions of risks may differ between tourists with different origin-country, final destination, age, sex and the typology of travel ( Rittichainuwat & Chakraborty, 2009 ). However, the impact of crisis communication and social media on perceived risk has been totally ignored. Some research is done for examining the impact of social media use on tourists’ mental health ( Zheng, Goh, & Wen, 2020 ) and crisis information systems and communication – social media ( Sigala, 2012 , Yu et al., 2020 ), however, given the increasing role and impact of social media on crisis communication and people’s health and risks perceptions, this is an area where more research is granted. As a vaccine for COVID-19 may take long to be developed and travelers may need to live with it, tourism research might benefit from medical and health research investigating how people behave, live and cope with chronic and lifestyle-related diseases (e.g. AIDS).

During lockdowns, people have experienced and become familiar with virtual services and tourism experiences. Research in technology adoption would claim that increased technology familiarity and trialability will increase its adoption. But will this apply for the controversial technologies introduced by COVID-19? Political economy and law research explaining how people react and accept human rights ‘violations’ (e.g. surveillance measures, freedom of speech, lockdowns) under conditions of ‘state of exception’ like terrorism or the COVID-19 ( Carriere, 2019 , Bozzoli and Müller, 2011 , Scheppele, 2003 ) can provide a new lenses for studying adoption of the COVID-19 controversial technologies and restrictions Research on political ideologies could further enlighten why people’s ideologies and political values may further perplex their reactions and behaviours to such interventions in their human rights.

It is claimed that while experiencing low pace, new lifestyles and working patterns, people are reflecting and recalibrating their priorities and social values. Is that true in relation to their travel behavior? Would people require and expect greater responsibility and sustainability from tourism operators and destinations? Would they be motivated to travel more but for a meaningful purpose? Or would people go back to their previous travel behaviours and preferences? Past research ( Pieters, 2013 ) has shown that consumers face a “material trap” in which materialism fosters social isolation and which in turn reinforces materialism. This might explain why during lockdowns people increased their online shopping and consumption of virtual entertainment and probably they might not have reflected and reset their values. Is that true and what is its impact on tourists’ behaviours? Consumer psychology and behavioural science explaining how people wish to align the time they spend with their values (congruence theory) can provide useful insights into such investigations. In addition, religion and spirituality studies can further enlighten the impact of COVID-19’s living conditions on tourists’ tourism sustainability preferences and attitudes as well as responses to tourism operators’ and destination sustainability practices and communications. This is because religion and spirituality is found to play an important role in influencing individuals’ thoughts and behaviors ( Laurin, Kay, & Fitzsimons, 2012 ).

Social distancing imposed by COVID-19 includes actions such as, reducing social contact, avoiding crowded places, or minimizing travel. Social distancing can significantly impact how people experience and evaluate leisure and travel activities like hiking, outdoor activities and nature-based tourism or even personal services like spas, dining, concierge services. Social distancing or better physical distancing may influence tourists’ perceptions of health hazards, insecurity and unpleasant tourism experiences. But how ‘far’ away is enough for tourism employees and other customers to be from each other without compromising sociality, personal service and perceptions of social distancing measures? Social distancing has not been studied before in service provision, while law and criminology research on ‘sexual’ consent may provide a different perspective on how people define social space and the ‘invasion’ or not of others into it.

Tourism is heavily a hedonic and sensorial experience. Servicescape design plays a major role in tourism experience by influencing customers’ emotions, behaviors, attitudes and service evaluations. However, COVID-19 operating standards require servicescapes to be redesigned eliminating or inhibiting sensorial elements and ‘changing’ tourism experiences, e.g.: smell of cleanliness instead of fragrance; social distancing and number of co-presence of clients in restaurants, festivals and other tourism settings will influence new standards of psychological comfort and acceptable levels of perceived crowdness; raised voices may generate a wider “moist breath zone” increasing viral spread; warmer temperatures create relaxing environments encouraging customers to stay and spend more, but poorly ventilated or air-conditioned indoor spaces may spread COVID-19. Would tourists and tourism firms change their behaviour and attitudes towards these new COVID-19 servicescapes? What new service etiquettes, customer expectations, behaviours and experiences would COVID-19 determined servicescapes and operational procedures may generate?

These and many other fields of research have been raised due to COVID-19 conditions, and as explained a plurality of theoretical lenses can be beneficial to provide a better understanding of these new concepts introduced in tourism research.

3.2. Tourism supply – Businesses

Tourism businesses have been racing to ensure the safety of their employees, customers, brand image and cash liquidity. To re-start, tourism companies are re-designing experiences (e.g. winery experiences, museum visits, tours, sports events, in-room dining and entertainment instead of hotel facilities) to feature smaller groups of tourists, outdoor activities and/or private experiences complying with social distancing and gathering restrictions and travellers’ expectations. Tourism companies have already upgraded their cleaning procedures by adopting new standards and restraining staff. Many of companies promote their hygiene certifications accredited by health expert associations. Tourism professionals are being trained to become ‘contact tracers’ obtaining relevant certifications confirming their skills to identify cases, build rapport and community with cases, identify their contact and stop community transmission. Restaurants, hotels, airports, public spaces are re-engineering their operations to make them contact-free or contactless. Mobile apps (for check-in, check-out, room keys, mobile payments, bookings-purchases), self-service kiosks, in-room technologies for entertainment and destination e-shopping (e.g. virtual reality for destination virtual visits to museums, attractions and destinations, movies), robots (for reception and concierge services, food delivery museum guides), artificial intelligence enabled websites and chatbox for customer communication and services, digital payments (e.g. digital wallets, paypal, credit cards). In addition, the new operating environment enforced by COVID-19 measures require firms to adopt new technologies and applications to ensure management of crowds and number of people gathered in public spaces (e.g. airports, shopping malls, museums, restaurants, hotels), human disinfectors and hand sanitiser equipment, applications identifying and managing people’s health identity and profiles.

Research can conduct a reality check and benchmarking of the effectiveness of the various respond and recovery strategies adopted by tourism operators. Research can also investigate the role and the way to build resilience to fast develop and implement such strategies. However, such research is useful and important but probably not enough for investigating the resetting of the next tourism industry normal. Transformative COVID-19 research should help industry to reimagine and implement an operating environment that is human-centred and responsible to sustainability and well-being values.

3.3. Destination management organisations and policy makers

Governments and destinations have been providing stimulus packages and interventions (e.g. tax reliefs, subsidies, deferrals of payments) to ensure the viability and continuity of tourism firms and jobs. Governments have intervened in mobility restriction and closures of businesses. Because of these, COVID-19 has resulted in a greater intervention of governments in the functioning and operations of the tourism industry. The government has also become a much bigger actor in the tourism economy (e.g. re-nationalisation of airlines and other tourism firms and tourism infrastructure like airports). This is very unique for COVID-19, as previous crises have generated research and institutional interest, but they did not have policy impact, specifically in tourism ( Hall et al., 2020 ). Would such government interventions and role sustain in the future? How will this influence the structure and functioning of the industry at a national and global level? Debates have already started questioning the effectiveness of such interventions, their fairness and equal distribution amongst tourism stakeholders ( Higgins-Desbiolles, 2020 ), their long-term impacts in terms of austerity and cuts of public expenditures. Future research looing into these issues is highly warrantied. In their CIVID-19 reactions and responses governments and destinations seem to have acted individually and nationalistic and recently selectively (e.g. bilateral and multilateral agreements amongst tourism bubbles). However, systems theory and crisis management, would argue that crises need to be addressed collectively. What would be the impact of such governmental behaviours on the future of tourism and destinations tourism policy making and strategies? As it seems, COVID-19 has raised political, geopolitical and governance issues that frameworks and concepts from these disciplines would need to be used to enlighten such research.

4. Conclusions: What is more and what is next

COVID-19 resulted in numerous socio-cultural, economic and psychological impacts on various tourism stakeholders, some of them for years to stay. Consequently, the pandemic has created a ‘fertile’ new context whereby tourism researchers can conduct research with valuable end-user benefits. However, COVID-19 tourism research should try to avoid the ‘publish or perish’ old mantra that has been driving and mushrooming tourism research ( Hall, 2011 ). Although studies conducting a reality check of impacts, predicting tourism demand, and benchmarking good and best practices are very useful and contextually interesting to assess COVID-19 impacts on various geographies sectors and stakeholders, they potentially offer limited scope to advance our knowledge on crisis management as well as to potentiate the pandemic’s affordance to reset our research agendas and expand the contribution and frontiers of tourism research and industry. It is the aim of this paper to inspire tourism scholars to view and use the COVID-19 as a transformational opportunity for reforming their mindsets in designing and conducting research and for the tourism institutions to reset their standards and metrics for motivating and evaluating the purpose, role and impact of tourism research. In addition, crises also accelerate technology innovation and change ( Colombo, Piva, Quas, & Rossi-Lamastra, 2016 ). However, these should not be viewed as inevitable, unquestionable and impossible to re-shape and re-adjust to serve real needs and meaningful values. It is the responsibility scholars to ensure that COVID-19 tourism research can ensure the latter.

The present analysis is not exhaustive in terms of the COVID-19 impacts, while impacts may not be uniform across all the actors of the same tourism stakeholder group. For example, the COVID-19 has different impacts on tourism operators based on their characteristics such as, the nature of the tourism sector (intermediaries, event organizers transportation, type of accommodation or attraction provider), their size, location, management and ownership style. Similarly, the highly heterogenous tourism demand (e.g. leisure and business travelers, group and independent tourists, special interest tourists such as religious, gay & lesbian, corporate travelers) also means that different COVID-19 impacts and implications are anticipated and worthy to be investigated for different market segments. COVID-19 tourism research should not only disclose such differentiated COVID-19 impacts, but it should also provide an enriched explanatory power about the roots of such disparities with the scope to envision and/or test any suggestions on how to address any inequalities and disadvantages that they may cause to various groups of tourism stakeholders. The analysis did not also include other major tourism stakeholders such as tourism employees, local communities, tourism entrepreneurs and tourism education (scholars, students and institutions alike). Recent developments and pressures faced by some of these tourism stakeholders were further strengthen by the COVID-19, which in turn place them in a more disadvantaged situation. COVID-19 research related to these stakeholders is equally important.

For example, COVID-19 has worsen the already difficult situation (e.g. high labour flexibility but at the expense of low salaries, lack of job security, insurance and other benefits) faced by an increasing number of tourism micro-entrepreneurs (e.g. food delivery people, ‘Uber taxi drivers’, “Airbnb hoteliers”) ( Sigala & Dolnicar, 2017 ). Algorithmic management, increased pressure and work stress are some of the negative impacts of the gig economy, which become more evident and fortified due to the COVID-19 (e.g. food delivery employees have no health insurance or coverage of lost salaries in case they get infected while working; ‘micro-hoteliers’ risk loosing their homes, as they cannot collect ‘accommodation fees’ to pay off home mortgages). Being an unofficial and sometime black economy/employment, gig tourism workers may not even be entitled to governmental subsidies provided to COVID-19 vulnerable employees or businesses. As the COVID-19 is expected to continue and reinforce contemporary paradigms and trends of this ‘causalisation’ of tourism employment (due to the upcoming economic recession and greater operating costs of tourism firms), COVID-19 tourism research needs to urgently investigate issues of employee psychological, mental and physical health, engagement, working conditions (e.g. remote working, virtual teams and virtual leadership) and other human resource issues within the COVID-19 setting. For example, traditional leadership, recruitment, management, and motivational incentives may not inspire, engage, motivate, and attract employees who have recalibrated their personal values and priorities during the COVID-19 lockdown and remote working.

The COVID-19 impacts on tourism employment create further pressures on tourism education that has severely affected by the pandemic. Apart from the virtualization of teaching and learning processes, tourism students and graduates have to also address the halt of industry interships, recruitment and questionable career paths. Tourism programs and universities are faced with reduced students’ intakes, industry and government sponsorship and research funding. Tourism researchers need to find new ways and sources for conducting research addressing social distancing, respecting the mental health and privacy issues of COVID-19 affected stakeholders. Investigating pedagogical issues such as how to make the design and delivery of tourism curricula more ‘resilient’, agile and updated to develop graduates with flexible and transferable skills to other industries is also equally important. For example, new online and offline courses and certifications have already emerged training graduates to become professional ‘contact tracer’ possessing the technical, emotional/social and ethical skills to manage customers and employees in situations of contact tracing, isolation, and quarantine (e.g. how contact tracing is done, how to build rapport with cases, identify their contacts, and support both cases and their contacts to stop transmission in their communities ( https://uh.edu/medicine/education/contact-tracer/ , https://www.coursera.org/learn/covid-19-contact-tracing?edocomorp=covid-19-contact-tracing , https://sph.uth.edu/news/story/trace ). However, is that just an opportunistic educational offering and/or a new ‘skill and qualification standard’ that tourism industry and demand would expect alike?

Many other specialized topics also warrant research within the domain of COVID-19. For example, the social entrepreneurship has been booming in tourism during the last decade ( Sigala, 2019 ) for several reasons including the 2008 economic recession. COVID-19 has boosted such tourism social ventures aiming to create social value, solve social problems created by the COVID-19 and provide help to people in need (e.g. marketplaces enabling the repurposing of various tourism unutilized resources such as labour, hotel and function space, food, cleaning material, e.g. HospitalityHelps.org ). The mushrooming of COVID-19 related tourism social ventures provides many opportunities to study and better understand this phenomenon within new and various ecosystems, stakeholders and circumstances.

Marianna Sigala is Professor at the University of South Australia and Director of the Centre for Tourism & Leisure Management. She is an international authority in the field of technological advances and applications in tourism with numerous awarded publications, research projects, keynote presentations in international conferences. In 2016, she has been awarded the prestigious EuroCHRIE Presidents’ Award for her lifetime contributions and achievements to tourism and hospitality education. She is the co-editor of the Journal of Service Theory & Practice, and the Editor-In-Chief of the Journal of Hospitality & Tourism Management. Professor Sigala was also appointed as CAUTHE Fellow in 2020.

• Aliperti G., Cruz A.M. Investigating tourists' risk information processing. Annals of Tourism Research. 2019; 79 :1–18. [ Google Scholar ]
• Allen T., Murray K.A., Zambrana-Torrelio C., Morse S.S., Rondinini C., Di Marco M., Breit N., Olival K.J., Daszak P. Global hotspots and correlates of emerging zoonotic diseases. Nature Communications. 2017; 8 (1) doi: 10.1038/s41467-017-00923-8. http://www.nature.com/articles/s41467-017-00923-8 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Araña J.E., León C.J. The impact of terrorism on tourism demand. Annals of Tourism Research. 2008; 35 (2):299–315. https://linkinghub.elsevier.com/retrieve/pii/S0160738307001120 [ Google Scholar ]
• Barrios R.E. What does catastrophe reveal for whom? The anthropology of crises and disasters in a 'Post-Truth' world. Annual Review of Anthropology. 2017; 46 (1) [ Google Scholar ]
• Baxter E.A., Diehl S. Emotional stages: Consumers and family members recovering from the trauma of mental illness. Psychiatric Rehabilitation Journal. 1998; 21 (4):349. [ Google Scholar ]
• Bozzoli C., Müller C. Perceptions and attitudes following a terrorist shock: Evidence from the UK. European Journal of Political Economy. 2011; 27 :S89–S106. https://linkinghub.elsevier.com/retrieve/pii/S0176268011000681 [ Google Scholar ]
• Brodbeck, K. H. (2019) Die Illusion der Identität und die Krise der Wissenschaften, Working Paper Serie der Institute für Ökonomie und für Philosophie, Cusanus Hochschule. No. 47, 03 2019.
• Cameron K.S., Quinn R.E. In: Paradox and transformation: Toward a theory of change in organization and management. Quinn R.E., Cameron K.S., editors. Ballinger; Cambridge, MA: 1988. Organizational paradox and transformation; pp. 1–18. [ Google Scholar ]
• Carriere K.R. Threats to human rights: A general review. Journal of Social and Political Psychology. 2019; 7 (1):8–32. [ Google Scholar ]
• Colombo M.G., Piva E., Quas A., Rossi-Lamastra C. How high-tech entrepreneurial ventures cope with the global crisis: Changes in product innovation and internationalization strategies. Industry and Innovation. 2016; 23 (7):647–671. [ Google Scholar ]
• Constantiou I.D., Kallinikos J. New Games, New Rules: Big Data and the Changing Context of Strategy. Journal of Information Technology. 2015; 30 (1):44–57. [ Google Scholar ]
• Dolnicar S. Understanding barriers to leisure travel, tourists fears as marketing basis. Journal of Vacation Marketing. 2005; 11 :197–208. [ Google Scholar ]
• Higgins-Desbiolles F. Socialising tourism for social and ecological justice after COVID-19. Tourism Geographies. 2020 [ Google Scholar ]
• Gössling S., Scott D., Hall C.M. Pandemics, tourism and global change: A rapid assessment of COVID-19. Journal of Sustainable Tourism. 2020 doi: 10.1080/09669582.2020.1758708. [ CrossRef ] [ Google Scholar ]
• Gretzel U., Fuchs M., Baggio R., Hoepken W., Law R., Neidhardt J., Pesonen J., Zanker M., Xiang Z. e-Tourism beyond COVID-19: A call for transformative research. Journal of Information Technology & Tourism. 2020; 22 (2):187–203. http://link.springer.com/10.1007/s40558-020-00181-3 [ Google Scholar ]
• Hall C.M. Publish and perish? Bibliometric analysis, journal ranking and the assessment of research quality in tourism. Tourism Management. 2011; 32 (1):16–27. https://linkinghub.elsevier.com/retrieve/pii/S0261517710001469 [ Google Scholar ]
• Hall C.M., Prayag G., Amore A. Channel View Publications; Blue Ridge Summit, PA: 2017. Tourism and resilience: Individual, organisational and destination perspectives. [ Google Scholar ]
• Hall C.M., Scott D., Gössling S. Pandemics, transformations and tourism: Be careful what you wish for. Tourism Geographies. 2020 doi: 10.1080/14616688.2020.1759131. [ CrossRef ] [ Google Scholar ]
• Ioannides D., Gyimóthy S. The COVID-19 crisis as an opportunity for escaping the unsustainable global tourism path. Tourism Geographies. 2020 [ Google Scholar ]
• Laurin K., Kay A.C., Fitzsimons G.M. Divergent effects of activating thoughts of God on self-regulation. Journal of Personality and Social Psychology. 2012; 102 (1):4. [ PubMed ] [ Google Scholar ]
• Lew, A. (2020). How to Create a Better Post-COVID-19 World. March 15, 2020. Medium. https://medium.com/@alanalew/creating-a-better-post-covid-19-world-36b2b3e8a7ae .
• Mair, S. (2020, March 30). What will the world be like after coronavirus? Four possible futures. The Conversation. https://theconversation.com/what-will-the-world-be-like-after…d=IwAR2wr9pzssSdBSxjaHaWba9-iHSF3flYgZ9BVI1jAx_Y4YlXVAImcJcNdjM .
• Masco J. The Crisis in Crisis. Current Anthropology. 2017; 58 (S15):S65–S76. [ Google Scholar ]
• Mawby R.I. Tourists' Perceptions of Security: The Risk—Fear Paradox. Tourism Economics. 2000; 6 (2):109–121. [ Google Scholar ]
• McKercher B., Chon K. The Over-Reaction to SARS and the Collapse of Asian Tourism. Annals of Tourism Research. 2004; 31 (3):716–719. https://linkinghub.elsevier.com/retrieve/pii/S0160738304000283 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• McKinsey & Company. (2020). Beyond coronavirus: The path to the next normal. https://www.mckinsey.com/_/media/McKinsey/Industries/Healthcare%20Systems%20and%20Services/Our%20Insights/Beyond%20coronavirus%20The%20path%20to%20the%20next%20normal/Beyondcoronavirus-The-path-to-the-next-normal.ashx .
• Novelli M., Gussing Burgess L., Jones A., Ritchie B.W. ‘No Ebola…still doomed’ – The Ebola-induced tourism crisis. Annals of Tourism Research. 2018; 70 :76–87. https://linkinghub.elsevier.com/retrieve/pii/S0160738318300306 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Nowlin C. Understanding and undermining the growth paradigm. Dialogue. 2017; 56 :559–593. [ Google Scholar ]
• Ötsch, W. (2020). What type of crisis is this? The coronavirus crisis is a crisis of the economized society. Lecture at the topical lecture series of Cusanus Hochchule für Gesellschaftsgstaltung, 9 April 2020.
• Pennington-Gray L., Schroeder A., Wu B., Donohoe H., Cahyanto I. Travelers’ Perceptions of Crisis Preparedness Certification in the United States. Journal of Travel Research. 2014; 53 (3):353–365. [ Google Scholar ]
• Pieters R. Bidirectional Dynamics of Materialism and Loneliness: Not Just a Vicious Cycle. J Consum Res. 2013; 40 (4):615–631. [ Google Scholar ]
• Rittichainuwat B.N., Chakraborty G. Perceived travel risks regarding terrorism and disease: The case of Thailand. Tourism Management. 2009; 30 (3):410–418. https://linkinghub.elsevier.com/retrieve/pii/S0261517708001222 [ Google Scholar ]
• Schad J., Lewis M.W., Raisch S., Smith W.K. Paradox Research in Management Science: Looking Back to Move Forward. ANNALS. 2016; 10 (1):5–64. [ Google Scholar ]
• Scheppele, K. L. (2003). Law in a Time of Emergency: States of Exception and the Temptations of 9/11. U. Pa. J. Const. L., 6, 1001. Faculty Scholarship at Penn Law. 53. https://scholarship.law.upenn.edu/faculty_scholarship/53 .
• Sigala M. A market approach to social value co-creation: Findings and implications from “Mageires” the social restaurant. Marketing Theory. 2019; 19 (1):27–45. [ Google Scholar ]
• Sigala M., Airey D., Jones P., Lockwood A. ICT Paradox lost? A stepwise Data Envelopment Analysis methodology. Journal of Travel Research. 2004; 43 :180–192. [ Google Scholar ]
• Sigala M., Dolnicar S. In: Peer-to-Peer Accommodation Networks. Dolnicar S., editor. Goodfellow Publishers; Oxford, UK: 2017. Entrepreneurship Opportunities. https://www.goodfellowpublishers.com/academic-publishing.php?content=doi&doi=10.23912/9781911396512-3605 [ CrossRef ] [ Google Scholar ]
• Sigala M. New technologies in Tourism: From multi-disciplinary to anti-disciplinary advances and trajectories. Tourism Management Perspectives. 2018; 21 :151–155. [ Google Scholar ]
• Sigala M. Social media and crisis management in tourism: applications and implications for research. Information Technology and Tourism. 2012; 13 (4):269–283. [ Google Scholar ]
• UNWTO . UNWTO; Madrid, Spain: 2020. UNWTO World Tourism Barometer (Vol. 18, Issue 2, May 2020) [ Google Scholar ]
• Wen J., Wang W., Kozak M., Liu X., Hou H. Many brains are better than one: The importance of interdisciplinary studies on COVID-19 in and beyond tourism. Tourism Recreation Research. 2020 [ Google Scholar ]
• Williams P.W., Ponsford I.F. Confronting tourism's environmental paradox: Transitioning for sustainable tourism. Futures. 2009; 41 (6):396–404. https://linkinghub.elsevier.com/retrieve/pii/S0016328708002164 [ Google Scholar ]
• World Economic Forum (2019). Outbreak readiness and business impact protecting lives and livelihoods across the global economy. Retrieved April 24, 2020, from http://www3.weforum.org/docs/WEF HGHI_Outbreak_Readiness_Business_Impact.pdf .
• Yu M., Li Z., Yu Z., He J., Zhou J. Communication related health crisis on social media: a case of COVID-19 outbreak. Current Issues in Tourism. 2020 [ Google Scholar ]
• Zheng Y., Goh E., Wen J. The effects of misleading media reports about COVID-19 on Chinese tourists’ mental health: A perspective article. Anatolia. 2020; 31 (2):337–340. [ Google Scholar ]
• Zuboff S. Big other: Surveillance Capitalism and the Prospects of an Information Civilization. Journal of Information Technology. 2015; 30 (1):75–89. [ Google Scholar ]
• Zysman J. Berkeley Roundtable on the International Economy; 2006. The 4th service transformation: The algorithmic revolution. [ Google Scholar ]

Harvey Cushing/John Hay Whitney Medical Library

Sharing libraries and collaborating on research papers, ways to share endnote desktop library, 1. endnote   group sharing.

You can share your EndNote library (or groups) through EndNote Desktop

• Pros : Read/write access, easy
• Cons : The sharer can only share (sync) one library, the share-ee can have multiple libraries shared with them, make sure to finish syncing before closing the library, everyone needs to have an EndNote online account  

2. Compress and send an EndNote library (or group) through email or Box

Compress and send your library

How to: File > Compressed Library (.enlx)

• Pros : PDFs can be included in the EndNote library
• Cons : X9.3 isn't backward compatible. If this happens send an RIS file but note, all Groups and Group Sets will be lost, changes made by one user won’t be reflected in other users’ files.  

3. Send your EndNote library embedded within the Word Document you've been editing with EndNote.

Your Word document contains a "Traveling Library" comprising all references cited using EndNote. This enables you to collaborate with your colleagues on the same document without having to have the same EndNote library.

• Pros : Easy
• Cons : No pdfs, metadata incomplete, required that everyone has EndNote Desktop  

Ways to Collaborate on a Paper (Pros and Cons)

1. microsoft word or google docs.

One person makes the edits. One person has access to the EndNote library and has control over the master document.  All others collaborate on the manuscript, editing and marking where a reference goes (use author, year). The person with the master document uses the edited document to add the new references to EndNote and then references into the master document.

• Pros : less prone to error
• Cons : complicated  

2. Google Docs Method

There is no EndNote Cite While You Write tool available for Google Docs.

• Pros : Highly collaborative
• Cons : Complicated

Directions :

• Highlight the references in EndNote
• Drag and drop the references into your Google Doc. This will create an unformatted citation, (it will have curly brackets { }).
• Alternatively, manually insert unformatted citations in the format {first authors surname, year #record number}. To see the record number, in EndNote, right click on the display fields shown in the middle panel and tick Record Number to add it to the display.
• When the manuscript is completed, download the Google Doc as a .docx file
• Open in Word
• Make sure you have a completed EndNote library from which the Word document will pull the references from. If you have people contributing from personal EndNote libraries, the library at the end needs to have all the references in it. If you don't have a copy, ask the person (people) to compress and email their citations.
• Turn on Instant Formatting. If the reference number don't match, Word will prompt you to clarify which reference you mean.

Training and Support

Cushing/whitney medical library.

• Contact your librarian
• WebEx trainings
• EndNote Guide

Hotels.com Rewards is now One Key™

Rainbow house hostel, choose dates to view prices, photo gallery for rainbow house hostel.

Exceptional

Popular amenities.

• Free parking Free parking Free parking
• Free WiFi Free WiFi Free WiFi
• Laundry facilities Laundry facilities Laundry facilities
• 24/7 front desk 24/7 front desk 24/7 front desk
• Non-smoking Non-smoking Non-smoking

Main amenities

• Daily housekeeping
• Breakfast available
• 24-hour front desk
• Snack bar/deli
• ATM/banking services
• Laundry service
• Self-serve laundry
• Free newspapers in the lobby
• Luggage storage
• Lockers available

Feel at home

• Separate dining area
• Separate sitting area
• Laundry facilities
• Microwave (on request)
• Free self parking

Check out the area

• Popular Location Globy Park 13 min walk
• Popular Location Karl Marx Prospect 17 min walk
• Popular Location Dnipro Arena 3 min drive
• Airport Dnepropetrovsk (DNK-Dnepropetrovsk Intl.) 30 min drive

Most relevant reviews

Experimentalcarousel, 20/10 exceptional, room options, view all photos for comfort shared dormitory, women only (8 beds).

Comfort Shared Dormitory, Women only (8 beds)

• 4 Large Twin Bunk Beds

View all photos for Comfort Shared Dormitory (8 beds)

Comfort Shared Dormitory (8 beds)

View all photos for Deluxe Shared Dormitory, Mixed Dorm (4 beds)

Deluxe Shared Dormitory, Mixed Dorm (4 beds)

• 2 Large Twin Bunk Beds

View all photos for Basic Shared Dormitory, Men only (8 beds)

Basic shared dormitory, men only (8 beds), view all photos for comfort shared dormitory, men only (8 beds), comfort shared dormitory, men only (8 beds), view all photos for basic shared dormitory, women only (8 beds).

Basic Shared Dormitory, Women only (8 beds)

Similar properties.

Hotel European

About the neighborhood, what's nearby.

• Globy Park - 13 min walk
• Karl Marx Prospect - 17 min walk
• Dnipro Arena - 3 min drive
• National History Museum - 5 min drive
• Oles Honchar Dnipro National University - 8 min drive

Getting around

• Dnepropetrovsk (DNK-Dnepropetrovsk Intl.) - 32 min drive
• Diivka Station - 25 min drive
• Kulebivka Station - 38 min drive

About this property

At a glance, arriving/leaving.

• Check-in start time: noon; Check-in end time: midnight
• Minimum check-in age: 15
• Check-out time is 11:00 AM

Restrictions related to your trip

• Check COVID-19 restrictions.

Special check-in instructions

• Front desk staff will greet guests on arrival

Required at check-in

• Credit card, debit card, or cash deposit required for incidental charges
• Government-issued photo ID may be required
• Minimum check-in age is 15
• If you require a visa to enter the country, your property may be able to help with the supporting documents needed to obtain one*
• Pets not allowed
• Free WiFi in public areas
• Free WiFi in rooms
• Free onsite self parking

Other information

• Smoke-free property

Property amenities

Food and drink.

• Continental breakfast each morning (surcharge)
• Dry cleaning/laundry services
• Free newspapers in lobby
• ATM/banking

Room amenities

Home comfort.

• Iron/ironing board (on request)
• Soundproofed rooms

What to enjoy

• Shower only
• Free toiletries
• Toilet paper

Stay connected

Fees & policies, mandatory fees.

• A tax is imposed by the city: UAH 106.50 per person, per night

Optional extras

• Continental breakfast is offered for an extra charge of approximately UAH 50 for adults and UAH 50 for children

Also known as

Frequently asked questions.

All reviews shown are from real guest experiences. Only travelers who have booked a stay with us can submit a review. We verify reviews according to our guidelines and publish all reviews, positive or negative. More information Opens in a new window

10/10 Exceptional

Sylvester junior, most popular destinations.

• Share full article

Advertisement

Supported by

Study Suggests Genetics as a Cause, Not Just a Risk, for Some Alzheimer’s

People with two copies of the gene variant APOE4 are almost certain to get Alzheimer’s, say researchers, who proposed a framework under which such patients could be diagnosed years before symptoms.

By Pam Belluck

Scientists are proposing a new way of understanding the genetics of Alzheimer’s that would mean that up to a fifth of patients would be considered to have a genetically caused form of the disease.

Currently, the vast majority of Alzheimer’s cases do not have a clearly identified cause. The new designation, proposed in a study published Monday, could broaden the scope of efforts to develop treatments, including gene therapy, and affect the design of clinical trials.

It could also mean that hundreds of thousands of people in the United States alone could, if they chose, receive a diagnosis of Alzheimer’s before developing any symptoms of cognitive decline, although there currently are no treatments for people at that stage.

The new classification would make this type of Alzheimer’s one of the most common genetic disorders in the world, medical experts said.

“This reconceptualization that we’re proposing affects not a small minority of people,” said Dr. Juan Fortea, an author of the study and the director of the Sant Pau Memory Unit in Barcelona, Spain. “Sometimes we say that we don’t know the cause of Alzheimer’s disease,” but, he said, this would mean that about 15 to 20 percent of cases “can be tracked back to a cause, and the cause is in the genes.”

The idea involves a gene variant called APOE4. Scientists have long known that inheriting one copy of the variant increases the risk of developing Alzheimer’s, and that people with two copies, inherited from each parent, have vastly increased risk.

The new study , published in the journal Nature Medicine, analyzed data from over 500 people with two copies of APOE4, a significantly larger pool than in previous studies. The researchers found that almost all of those patients developed the biological pathology of Alzheimer’s, and the authors say that two copies of APOE4 should now be considered a cause of Alzheimer’s — not simply a risk factor.

The patients also developed Alzheimer’s pathology relatively young, the study found. By age 55, over 95 percent had biological markers associated with the disease. By 65, almost all had abnormal levels of a protein called amyloid that forms plaques in the brain, a hallmark of Alzheimer’s. And many started developing symptoms of cognitive decline at age 65, younger than most people without the APOE4 variant.

“The critical thing is that these individuals are often symptomatic 10 years earlier than other forms of Alzheimer’s disease,” said Dr. Reisa Sperling, a neurologist at Mass General Brigham in Boston and an author of the study.

She added, “By the time they are picked up and clinically diagnosed, because they’re often younger, they have more pathology.”

People with two copies, known as APOE4 homozygotes, make up 2 to 3 percent of the general population, but are an estimated 15 to 20 percent of people with Alzheimer’s dementia, experts said. People with one copy make up about 15 to 25 percent of the general population, and about 50 percent of Alzheimer’s dementia patients.

The most common variant is called APOE3, which seems to have a neutral effect on Alzheimer’s risk. About 75 percent of the general population has one copy of APOE3, and more than half of the general population has two copies.

Alzheimer’s experts not involved in the study said classifying the two-copy condition as genetically determined Alzheimer’s could have significant implications, including encouraging drug development beyond the field’s recent major focus on treatments that target and reduce amyloid.

Dr. Samuel Gandy, an Alzheimer’s researcher at Mount Sinai in New York, who was not involved in the study, said that patients with two copies of APOE4 faced much higher safety risks from anti-amyloid drugs.

When the Food and Drug Administration approved the anti-amyloid drug Leqembi last year, it required a black-box warning on the label saying that the medication can cause “serious and life-threatening events” such as swelling and bleeding in the brain, especially for people with two copies of APOE4. Some treatment centers decided not to offer Leqembi, an intravenous infusion, to such patients.

Dr. Gandy and other experts said that classifying these patients as having a distinct genetic form of Alzheimer’s would galvanize interest in developing drugs that are safe and effective for them and add urgency to current efforts to prevent cognitive decline in people who do not yet have symptoms.

“Rather than say we have nothing for you, let’s look for a trial,” Dr. Gandy said, adding that such patients should be included in trials at younger ages, given how early their pathology starts.

Besides trying to develop drugs, some researchers are exploring gene editing to transform APOE4 into a variant called APOE2, which appears to protect against Alzheimer’s. Another gene-therapy approach being studied involves injecting APOE2 into patients’ brains.

The new study had some limitations, including a lack of diversity that might make the findings less generalizable. Most patients in the study had European ancestry. While two copies of APOE4 also greatly increase Alzheimer’s risk in other ethnicities, the risk levels differ, said Dr. Michael Greicius, a neurologist at Stanford University School of Medicine who was not involved in the research.

“One important argument against their interpretation is that the risk of Alzheimer’s disease in APOE4 homozygotes varies substantially across different genetic ancestries,” said Dr. Greicius, who cowrote a study that found that white people with two copies of APOE4 had 13 times the risk of white people with two copies of APOE3, while Black people with two copies of APOE4 had 6.5 times the risk of Black people with two copies of APOE3.

“This has critical implications when counseling patients about their ancestry-informed genetic risk for Alzheimer’s disease,” he said, “and it also speaks to some yet-to-be-discovered genetics and biology that presumably drive this massive difference in risk.”

Under the current genetic understanding of Alzheimer’s, less than 2 percent of cases are considered genetically caused. Some of those patients inherited a mutation in one of three genes and can develop symptoms as early as their 30s or 40s. Others are people with Down syndrome, who have three copies of a chromosome containing a protein that often leads to what is called Down syndrome-associated Alzheimer’s disease .

Dr. Sperling said the genetic alterations in those cases are believed to fuel buildup of amyloid, while APOE4 is believed to interfere with clearing amyloid buildup.

Under the researchers’ proposal, having one copy of APOE4 would continue to be considered a risk factor, not enough to cause Alzheimer’s, Dr. Fortea said. It is unusual for diseases to follow that genetic pattern, called “semidominance,” with two copies of a variant causing the disease, but one copy only increasing risk, experts said.

The new recommendation will prompt questions about whether people should get tested to determine if they have the APOE4 variant.

Dr. Greicius said that until there were treatments for people with two copies of APOE4 or trials of therapies to prevent them from developing dementia, “My recommendation is if you don’t have symptoms, you should definitely not figure out your APOE status.”

He added, “It will only cause grief at this point.”

Finding ways to help these patients cannot come soon enough, Dr. Sperling said, adding, “These individuals are desperate, they’ve seen it in both of their parents often and really need therapies.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck

The Fight Against Alzheimer’s Disease

Alzheimer’s is the most common form of dementia, but much remains unknown about this daunting disease..

How is Alzheimer’s diagnosed? What causes Alzheimer’s? We answered some common questions .

A study suggests that genetics can be a cause of Alzheimer’s , not just a risk, raising the prospect of diagnosis years before symptoms appear.

Determining whether someone has Alzheimer’s usually requires an extended diagnostic process . But new criteria could lead to a diagnosis on the basis of a simple blood test .

The F.D.A. has given full approval to the Alzheimer’s drug Leqembi. Here is what to know about i t.

Alzheimer’s can make communicating difficult. We asked experts for tips on how to talk to someone with the disease .

Alabama’s Black Belt tourism booming due to hunting and fishing, according to report

A labama’s Black Belt region that encompasses 23 counties through the central and southern portions of the state has long been maligned by tales of poverty, environmental hazards, limited economic opportunities and health care.

But the vast rural region is also home to a growing appeal as a hunting and fishing getaway, and it’s historic and cultural attractions are bringing in tourists, according to a new report released Saturday by the Alabama Black Belt Adventures Association (ALBBAA) , a nonprofit organization committed to promoting outdoor recreation and tourism opportunities within the region.

The report, titled “The Economic Impact of Tourism in Alabama’s Black Belt Region,” shows the region generating an annual economic impact of $3.8 billion in 2023 and accounting for 45,500 jobs. The 2023 growth rate is 9% over the 2022 estimate.

The most impactful attraction in the region is from hunting and fishing, which attributes $1.7 billion or 45% of the overall economic impact on tourism within the Black Belt.

The report was produced by Keivan Deravi of Montgomery-based Economics Research Services Inc.

“Tourism is a key factor in Alabama’s growing economy,” Alabama Gov. Kay Ivey said in a statement. “Having grown up in the heart of the Black Belt in Wilcox County, I understand this region has so much to offer — from outdoor recreation like hunting and fishing to world changing cultural events, talented artisans and crafters and historic sites. I’m excited to see the growth of the tourism industry in the Black Belt.”

The Black Belt’s tourism growth follows a similar path as the entire state, which saw continued increases in tourism expenditures to $23.5 billion in 2023, up from $22.4 billion in 2022. The state saw 28.8 million visitors, according to an annual report released by the Alabama Tourism Department, up from 28.6 million in 2022.

Deravi’s report shows that all 23 Black Belt counties have experienced tourism growth since the onset of the pandemic in 2020.

“Those of us who live in the Black Belt have long recognized the bountiful recreational and cultural activities available here, and it’s clear people from all over the country and all over the globe have now noticed,” said Greenville Mayor Dexter McLendon, a member of the ALBBAA board of directors. “I know I’ve seen people visiting Greenville from so many different places that it’s hard to remember them all, and this report shows the immense economic benefits that tourism is having for our entire region.”

The Black Belt includes the following 23 counties: Barbour, Bullock, Butler, Choctaw, Clarke, Conecuh, Crenshaw, Dallas, Greene, Hale, Lee, Lowndes, Macon, Marengo, Monroe, Montgomery, Perry, Pickens, Pike, Russell, Sumter, Tuscaloosa and Wilcox.

Montgomery County, with the largest city within the Black Belt region, had the largest economic impact for the year at $1.2 billion, accounting for 32% of the tourism activity within the region. Tuscaloosa County’s impact is at $999.6 million, followed by Lee County at $800.6 million.

©2024 Advance Local Media LLC. Visit al.com. Distributed by Tribune Content Agency, LLC.