ANALYSIS: May heads into Syria as junior partner to trigger-happy Trump

Theresa May seeks cabinet approval for attacks on Syria - but questions remain over their legality and how meaningful UK action will be

A Royal Navy Astute-class submarine and a Type-45 destroyer on exercise (BAE Systems)

Jamie Merrill, Diplomatic Editor

Thursday 12 April 2018

Theresa May is facing questions over the legality of committing UK forces to any US-led attack on Syria, even as Royal Navy submarines and RAF jets prepare for the UK's first military action against another government since the 2011 Libya campaign.

May's national security team will call for strikes and present new evidence blaming Bashar al-Assad for the "barbaric" attack at a cabinet meeting on Thursday afternoon, despite warnings from legal experts that UK air strikes would not be clearly supported by a "right of humanitarian intervention" under international law.

Nevertheless, the British government is firmly behind the US president, Donald Trump, who has already told the Syrians and Russians that missiles "are coming".

May is also facing opposition from the Labour Party, amid questions over whether UK forces will be able to make a meaningful contribution to the air campaign.

The former head of the Royal Navy has told MEE that UK involvement in the initial stage of any intervention would likely be limited to submarine-launched cruise missiles and intelligence assets.

Lord Sir Alan West, a former first sea lord and Labour security minister, said: "If we have absolute certainty the Assad regime carried out this attack, we have to decide whether to give him a wrap across the knuckles or really make his eyes water, in which case it will require a three to four day air campaign to take out his integrated air defences, chemical weapons sites and his means to deliver them."

The safest, and most cautious, point of view is that the intervention would not be legal as there is no right of humanitarian intervention

- James Sweeney, law professor

West said this sort of air campaign risked hitting Russian forces who work alongside Syrian forces at Assad's air defence sites.

He added: "Clearly the US can do this alone, but there is a lot of merit for them and us, in involving the UK. They find us extremely valuable in a diplomatic sense, and we can also bring something to the party in the form of submarine-launched TacToms [Tomahawk cruise missiles]."

MEE understands that one or more Royal Navy submarines, armed with Tomahawk cruise missiles, will be in range of Syrian targets by Thursday evening, while Type-45 destroyer HMS Duncan, armed with an advanced air defence missile system, is on routine operations in the central Mediterranean and is likely to be manoeuvred to operate alongside US vessels or to provide defence for the Royal Air Force (RAF) base at Akrotiri in Cyprus.

At Akrotiri, RAF fast jets are also ready for action, including Tornado bombers armed with Storm Shadow missiles, which can be launched from outside Syrian airspace. Typhoon jets are standing by for air defence and possible ground-attack missions on chemical weapons sites.

US forces will dominate 

But, West said that the initial stages of any air campaign will be dominated by US stealth aircraft and cruise missiles, with only a minimal deployment of UK forces. France has 10 cruise-missile equipped jets based in the Gulf, and has the capacity to launch around 50 cruise missiles. 

Neither the UK or France has an aircraft carrier available to deploy to the region.

West said the next stage of the air campaign would see US electronic warfare aircraft acting as "capability enablers" to blind Syrian defences and allow US, French and UK jets to take out additional anti-aircraft sites and chemical weapons stockpiles.

"To pretend that this attack will not be dominated by US forces is stupid, but they will be keen to have additional UK assets and capabilities," he said.

"RAF Tornado and Typhoon jets are very practised at flying over Syria and have very advanced precision weapons. We also own very serious intelligence assets, especially those based in Cyprus."

There are fears though that any sustained air campaign in Syria will risk hitting Russian troops who operate Syrian air defence sites and radar installations, West warned. "And when it comes to Russia hitting back, they couldn't feasibly hit a submarine or a US carrier - it would be too difficult for them - but they could launch cruise missiles at the RAF base in Cyprus."

An analysis of Syria's air defence by experts at the Royal United Services Institute (RUSI) has also warned that the linking of the advanced Russian S-400 system to Syria's air defence network will leave US, French and UK warplanes with "restricted options".

A man recieves medical attention after the suspected chemical weapon attack in Douma on Saturay (AFP)

Justin Bonk, a research fellow at RUSI specialising in airpower, said: "It also means a greater and more open presence of Russian specialists embedded within the Syrian surface-to-air missile batteries, radar sites and command centres – all essential targets for suppression as part of any concerted US air effort against the regime's forces."

'Have we forgotten the lessons of Iraq?'

Warnings over the risk of Russian casualties came as Labour leader Jeremy Corbyn said that US-led intervention in the country could "escalate the conflict beyond belief" and that "more bombing, more killing, more war will not save life".

He said: "Just imagine the scenario if an American missile shoots down a Russian plane or vice versa. Where do we go from there?

"Parliament must be consulted on this. Surely the lessons of Iraq… are that there's got to be, there has to be a proper process of consultation."

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Theresa May seeks cabinet backing for Syria strikes

Corbyn's intervention came as there was increasing discussion in Westminster over the role of parliament in authorising action, and whether any US-led air strikes would be legal under international law.

James Sweeney, professor at Lancaster Law School, told MEE that military action has not been authorised by the United Nations Security Council and that the US, France and the UK could not claim to be acting in self-defence under international law.

"The safest, and most cautious, point of law is that the intervention would not be legal as there is no right of humanitarian intervention, and this obviously doesn't involve the UK's right to self-defence," he said.

However, he that government lawyers "might argue" that an "emerging customary international legal norm" allows for the use of force to prevent the use of chemical weapons and punish states that use them, following the use of force for humanitarian reasons in Kosovo and Libya.

"The Chemical Weapons Convention absolutely does not mention using force in a case like this, but emerging customary international legal norms are a big deal. It is one of the main sources of law, and if I were the UK attorney general I would argue that we are witnessing the evolution of the law around the use of force," he said.

Sweeney also said there was a "live debate" over the evolving right of the use of force in humanitarian interventions.

'A very delicate situation' 

May appears to have the support of key cabinet colleagues and looks likely, initially at least, to defy calls from Corbyn to follow recent convention and allow MPs a vote over military action.

Speaking in London on Thursday morning, Brexit Secretary David Davis, who voted against intervention in Syria in 2013, said the situation was horrific and the international community must act to prevent the use of chemical weapons.

He said: "But also it is a very, very delicate circumstance, and we've got to make this judgment on a very careful, very deliberate, very well thought-through basis, knowing exactly ... how strong the evidence is."

He said he had been "assured" that government would provide clear "evidence and intelligence" linking the attack to Assad and that there was a "proper plan".

Guided missile destroyer USS Donald Cook launching cruise missiles in 2003. Reports say it is currently sailing for Syrian coast (Creative Commons)

Discussions in London came as French President Emmanuel Macron said that France has proof that chemical weapons were used by the Syrian government. 

May will have welcomed Macron's comments and was also given the backing of key backbenchers on Thursday.

Tom Tugendhat MP, chair of the influential Foreign Affairs Select Committee, told BBC Radio 4's Today programme that the government does not need a Commons mandate to take part in air strikes.

He said: "What we're doing is dealing with a violation of the 1925 Geneva gas protocol, and exercising the 2005 responsibility to protect."

Fellow Tory Crispin Blunt MP, who recently co-authored a report on how the UK should respond to chemical attacks, said: "The British government is free to exercise its Royal Prerogative concerning any action in Syria, It must expect to make its case in arrears to Parliament. This could have been avoided with a preauthorisation resolution."

Sweeney added that May did not require parliamentary approval to launch air strikes. "The convention for consulting parliament on the use of force is a fairly new one, and I doubt its strength. I don't think there would be a constitutional crisis if Prime Minister May were to ignore it. Whereas it is unlikely she would survive if she lost a vote over action."

The political row came as a poll for The Times newspaper showed that only a fifth of British would support military strikes against Syrian military targets. More than two fifths oppose action, while the remainder were undecided.

Lindsey German, founder of Stop the War, said: "No one knows where this is going to end. You can see how this could spread very, very dangerously indeed."

National Enquirer paid second source with embarrassing Trump rumor

A former Trump Tower doorman offering a salacious tale about President Trump was paid $30,000 by the parent company of the National Enquirer in late 2015. (Ricky Carioti/The Washington Post)

By Carol D. Leonnig April 12 at 1:34 PM

The owner of the National Enquirer paid $30,000 in late 2015 to a onetime Trump Tower doorman who was offering an embarrassing story about then-presidential candidate Donald Trump but never published it, according to a person familiar with the payment.

A spokesman for the Trump Organization on Thursday denied the story that doorman Dino Sajudin told the tabloid: that Trump fathered a child out of wedlock in the late 1980s and that top executives of the Trump Organization, including longtime security chief Matt Calamari, knew about it.

“Mr. Sajudin’s claims are completely false,” the Trump Organization said in a statement. A spokesman added that Calamari never made such a statement and accused Sajudin of having a history of peddling false stories.

In an interview with The Washington Post on Thursday, Sajudin dismissed claims that he had made anything up.

“You know I took a polygraph test,” he said, adding that he believes his story was buried as part of a larger strategy by the tabloid to quash negative articles about Trump.

Three women, Stormy Daniels, Karen McDougal and Summer Zervos, are suing so they can speak out about their alleged encounters with President Trump. (Joyce Koh/The Washington Post)

“It seems like the writing is on the wall about that, it’s pretty clear,” Sajudin said. He said the story “had to come out,” and he referred further questions to his lawyer.

Sajudin’s contract with America Media Inc., the Enquirer’s parent company, was first reported by the New Yorker and the Associated Press.

The news about the payment he received comes as federal investigators in New York are examining efforts by Trump’s personal attorney Michael D. Cohen to tamp down negative stories about the longtime real estate mogul as he ran for president.

[Federal investigators sought Trump’s communications with his lawyer about ‘Access Hollywood’ tape]

One focus of the inquiry is Cohen’s relationship with David Pecker, AMI’s chief executive and chairman, according to people familiar with the investigators’ work. Pecker and Cohen are longtime friends who strategized throughout the campaign about how to assist Trump’s bid and counter salacious rumors that might surface about him, according to two people with knowledge of their relationship.

An FBI raid executed Monday on Cohen’s office and residences sought all of the lawyer’s records of communications with AMI, Pecker and National Enquirer executive Dylan Howard regarding two women who claimed to have had affairs with Trump while he was married, according to three people familiar with the investigation.

In a statement, AMI denied “that Donald Trump or Michael Cohen had anything to do with its decision not to pursue a story about a ‘love child’ that it determined was not credible.

“The suggestion that David Pecker has ever used company funds to ‘shut down’ this or any investigation is not true,” the company said. “In addition, AMI and Mr. Pecker emphatically deny any suggestion that there might have been any ‘partnership’ created which might influence any business ties in regard to AMI. These claims are reckless, unsubstantiated, and false.”

It is unclear whether federal investigators are scrutinizing the AMI payment to Sajudin.
A person familiar with the contract with the former doorman said that the company agreed to pay Sajudin $30,000 for his story in late 2015 and that he passed a lie-detector test when making his claims. Under his deal, he gave the Enquirer exclusive rights to the story.

Such a story would have been a “huge scoop” for the tabloid, which broke a similar story about then-presidential candidate John Edwards in 2008, the person noted.

But at some point, the editors determined that Sajudin’s story was not credible and decided not to publish it, the person said, adding that AMI released the doorman from his contract in late 2016. The person was not aware of any information indicating that Pecker shelved the story to help Trump.
“When we realized we would be unable to publish, and other media outlets approached the source about his tale, we released Sajudin from the exclusivity clause that had accompanied his $30,000 payment, freeing him to tell his story to whomever he wanted,” Howard told RadarOnline.com, a sister publication of the Enquirer.

Cohen told the Associated Press that he had discussed Sajudin’s story with the Enquirer as a Trump spokesman when the tabloid was looking into the account, but denied that he had been involved in the payment to the former doorman.

Cohen and his attorney, Stephen Ryan, did not respond to requests for comment.

Howard said that claims that the National Enquirer had shelved the story to help Trump are false.
“AMI categorically denies that Donald Trump or Michael Cohen had anything to do with its decision not to pursue a story about a “love child” that it determined was not credible. The suggestion that David Pecker has ever used company funds to ‘shut down’ this or any investigation is not true. In addition, AMI and Mr. Pecker emphatically deny any suggestion that there might have been be any ‘partnership’ created which might influence any business ties in regard to AMI. These claims are reckless, unsubstantiated, and false.”

The search warrant served on Cohen sought all communications he had with Trump and the Trump campaign about any “negative publicity” that might arise during the presidential campaign, according to a person familiar with investigators’ work. It also sought all his communication about an embarrassing “Access Hollywood” tape that surfaced in October 2016, weeks before the election.

Federal prosecutors who are investigating Cohen also have sought records relating to another AMI payment for a story that could have been damaging to Trump’s campaign.

Karen McDougal, a health and fitness model and former Playboy centerfold, claims that she had a 10-month affair with Trump in 2006 and 2007, meeting him dozens of times at various Trump properties and elsewhere.

She met AMI executives through Keith Davidson, her attorney at the time, in the summer of 2016 and signed a contract with them that August. The tabloid company gave her $150,000 and an opportunity to publish fitness columns in AMI magazines. In return, she gave up the rights to her “life story,” including the story of her relationship with “any then-married man,” according to lawsuit she filed against AMI last month in Los Angeles Superior Court.

According to her suit, McDougal said she understood that the company was buying her story not to publish it but to suppress it. She is suing to break the contract so she can speak freely, arguing that her story about Trump is “core political speech entitled to the highest protection under the law.”

The lawsuit also alleges that AMI and Davidson coordinated with Cohen as they negotiated the contract to kill the story. It cited as evidence a Feb. 18 New York Times article detailing a phone call in which Davidson told Cohen that the deal was done.

That phone call took place on Aug. 5, 2016, according to the Times. McDougal signed the contract the following day, according to a copy of the contract appended to her lawsuit.

AMI has asked the court to dismiss McDougal’s complaint, arguing that the deal is protected under the First Amendment.

Emma Brown, Robert Costa and Ashley Parker contributed to this report.

The Brazilian villagers turning plastic pollution into profit

After plastic waste contributed to deadly floods in Recife, one neighbourhood took action. Now people can earn a living by cleaning up the river in a scheme being imitated around the world

River Tejipio and plastic pollution in Recife, Brazil Photograph: Moisés Lopes/Tearfund

Sandra Laville in Recife, Brazil-Thu 12 Apr 2018 06.00 BST

Maria das Gracas started collecting her plastic bottles after she saw the body of her neighbour floating past her house, carried along with the pollution that helped cause the deadly floods.

She stores them by the front door of her one-story home, which sits on the litter-strewn banks of the Tejipió river in north-east Brazil.

When she has enough she will take them to the local storage skip, where a litter collector will pay her two reals for 50 plastic bottles – about 40 pence. She’s not just doing it for the money. She’s doing it to stop the tide of plastic drowning this community.

Every day Maria and other residents of Coqueiral, a poor neighbourhood in the city of Recife, feel the impact of the world’s plastic binge. It is visible in the waters of the river that once flowed freely through the area.

Rildo Wandray beside the river where he learned to swim. Photograph: Moisés Lopes/Tearfund
Fifty years ago when Rildo Wandray was a boy, he would jump into the Tejipió and swim, while his friends fished beside him.

Today the river is stagnant, obstructed at every tributary by a tide of plastic waste; Coca-Cola and Fanta bottles, water containers, crisp packets and wrappers.

Globally, some 2 billion people live in communities with no rubbish collections. While international attention has focused recently on the marine plastic litter crisis, the devastating impact of plastic waste on the world’s poorest is no less destructive, causing flooding, disease, and hundreds of thousands of premature deaths from toxic fumes caused by the burning of waste.

In Recife the plastic waste is exacerbating already devastating flooding from rising sea levels caused by climate change. And those living around the Tejipió have grown tired of waiting for the government to act.

For das Gracas, the tipping point came when flooding took the life of one of her neighbours. “I was trapped inside my home with my son,” she said.

“There was nothing we could do, the water came up and we could not get out. I looked out and saw a body float past. She was face down, I could see the hair. That night the flood nearly took me too. Ever since then I have collected my bottles, I wanted to try and do something to reduce the waste going into the river.”

Organised and supported by the local baptist church through its project Instituto Solidare, local communities are mobilising: street protests, public meetings, awareness campaigns. They are also trying to build a network of entrepreneurs who can make a living out of collecting the waste, and turning it into products they can sell.

The Recife campaign is supported by Tearfund, the international NGO which is lobbying for global development funding for waste projects to be increased from 0.3% to 3%; a move which would push waste higher up the international agenda, reduce global plastic littering, help cut marine litter and improve the environment and the lives of the world’s poorest and most vulnerable.

On Thursday – in advance of the Commonwealth Summit in London next week – international development secretary Penny Mordaunt is expected to address the need to increase UK funding globally to tackle plastic pollution, after lobbying from Tearfund and other bodies.

In Recife, Evandro Alves, who leads Instituto Solidare, says the world’s poorest are suffering the most from the plastic waste crisis.

“The situation here in this community, where life is already incredibly hard, has been getting worse,” he said. “We are are seeing more and more plastic being used and thrown away, and it stops here in their community. So we decided to mobilise.”


A street flooded with water from the Tejipió. The floods are caused in part by the huge amount of plastic pollution in the river. Photograph: Tearfund

The movement in Coqueiral, Alves believes, could be replicated across the developing world; taking the idea of a circular economy and localising it to empower the people to press for government action, but also to take advantage of the opportunities waste creates.

“The waste is a problem but it is also an opportunity for people to earn a living, to create a circular economy for themselves,” he said. “This could be transformative and improve the quality of life for people in the poorest areas of the biggest cities. This is a battle for everyone and everyone needs to be part of it. We understand this is not a short fix, this is a long fight.”

At public meetings, and marches through the streets residents hold placards aloft, demanding “Clean River, Healthy City,” and “Salve Orio Tejipió e suas communidades.” (Save the River Tejipió and our communities)

Young people in Recife are at the forefront of the campaign, eliciting support and mobilising on social media. In one direct action, pupils whose school is on the riverside, removed some of the waste from the Tejipió; a sofa, plastic bottles, a TV, tables, plastic chairs and built a house on the banks which they called Casa Lixo – House of Trash. Another post saw children holding a fashion show from clothes created out of plastic bags and cups.

Some women are involved in an enterprise making handbags, jewellery and toys out of the plastic and other waste collected from their communities. It provides them with employment and a small income – and in a small way builds the kind of circular economy which a 2010 Brazilian law promised but failed to create.

Olga Gomes, one of the women who works in the group Seleta, said: “We are putting a lot of work into researching the market and looking at trends and trying to make sure we can make a business out of what we are doing. For me it is empowering – it has given me work and given me a social life.”

Her optimism is shared by all the women, some of whom have been helped to flee violent relationships through the work provided and the social support of the Seleta project.

For Gomes, the task for the future is clear. “I want to see my grandchildren swim in the river like I did and I want this work to take me across the ocean.”

The movement is being adopted by some of the poorest communities across the world. In Jos in Nigeria and Maputo in Mozambique, other groups have formed. They are driven, as in Recife, by young people, who use their knowledge of digital media to spread the fight against waste across the globe.

Naomi Foxwood, senior campaigner for Tearfund, said: “This crisis is growing as disposable items – plastic bottles, disposable nappies, single-use polystyrene containers – are increasingly being used in quickly urbanising low- and middle-income countries.

“Young people, in particular, are at the forefront of this. They have energy, organising power, and a great sense of justice. For them it is a justice issue because often municipal waste is just dumped in the poorest communities, whereas it is collected from the more wealthy areas.”

 Plastic pollution in the Tejipió, Recife, Brazil. Photograph: Moisés Lopes/Tearfund

For those in Recife, there have been small victories. Last year the state government responded to the pressure and dug out the river upstream of Coqueiral to improve the river flow. The result is fewer floods so far this year. But the residents know the battle will be a long one.

Carol Santos who lives on the banks of the river with her three children understands the need to take personal responsibility for the waste she creates. But she also believes her community has been abandoned by the state and that large multinationals like Coca-Cola – whose plastic bottles are clearly visible in the mass of waste blocking the Tejipió, could do more to clear up the pollution their products create.

“The company could help to collect the waste and support the community to recycle it, but it doesn’t. We don’t see them,” she said.

Her home is flooded several times a year. “When the rains come the flood destroys everything. It is a desperate situation – at least nine times a year I lose everything, my children get sick from diarrhoea when it floods, its awful for them. We live here because we have nowhere else to go.”

Rohingya refugees present Burma with repatriation demands

By Max Walden | 12th April 2018 | @maxwalden_

A Rohingya refugee camp in Cox's Bazar, Bangladesh, September 19, 2017. Source: Reuters/Cathal McNaughton

REFUGEES in Kutupalong camp in Cox’s Bazar, Bangladesh have issued a visiting senior politician from Burma (Myanmar) with a list of demands regarding the planned return of Rohingya Muslims to Rakhine State.

Social Welfare Minister Win Myat Aye visited the camp on Wednesday as part of a three-day trip to Bangladesh, where he met with dozens of refugees. They provided 13 demands regarding their repatriation, calling upon Naypyidaw to guarantee a dignified and safe return to their homes.

The UN has said more than 671,000 Rohingya refugees have fled Rakhine State into Cox’s Bazar in neighbouring Bangladesh since Aug 25 in response to so-called “clearing operations” by Burma’s Tatmadaw army.

SEE ALSO: Burma: ICC seeks power to investigate, prosecute crimes against humanity

The military and Buddhist vigilantes stand accused of mass killings, rape and arson in Muslim villages – violence that rights groups have characterised as ethnic cleansing, crimes against humanity and even genocide.

Burma’s social welfare, relief and resettlement minister Win Myat Aye speaks with Rohingya refugees as he visits Kutupalong camps in Cox’s Bazar, Bangladesh, April 11, 2018. Quality from source. Source: Reuters

“The Rohingya people are peaceful and hard working,” said a statement handed to Win Myat Aye. “We have been given many different labels of Kala, Bengali, Illegal Immigrants and even terrorists. We are none of these, we are Rohingya Muslims and nationals of Myanmar.”

The refugees demanded that the Burmese government guarantee freedom of movement in Rakhine and the “right of Rohingya to return to our original land”, close camps for internally displaced persons (IDPs) and establish no more, and involve the UN refugee agency in their repatriation process.

Source: Shafiur Rahman/ Twitter

In addition, they called upon the government to permit international media, humanitarian organisations and human rights observers access to Rakhine State.

According to New York-based Human Rights Watch, Burma has bulldozed at least 55 villages that were vacated during the violence. The government has established several reception centres to house returnees.

SEEA ALSO: Rohingya villages erased, replaced by army bases in Rakhine State

“Rohingya people have been forced out of Myanmar four times now,” continued the refugees’ letter. “In 1979, 1990, 2016, and 2017. We want to return when it is safe and sustainable.”

The UN’s Assistant Secretary-General for Humanitarian Affairs this month said that Burma was not ready for the return of Rohingya Muslims. Naypyidaw and Dhaka in January agreed that all refugees would be returned to Burma within two years, a deal that has to date stalled with none yet repatriated.

“They (Rohingyas) will be taken back by giving citizenship with proper dignity and respect,” said Win Myat Aye as quoted by Bangladesh newspaper The Daily Star. He said the government was working to help Rohingya return to Burma.

“I have come to Bangladesh to witness their conditions,” he added.

Protests banned outside UK abortion clinic: SO WHAT?

By Martha Holeyman-12 Apr 2018

A council in London has created a safe-zone around an abortion clinic, to stop anti-abortion campaigners from protesting outside. We help you answer the key questions: So what has been decided? So what’s controversial about it? So what do other countries do to deal with abortion? So what’s happening in the rest of the UK?

A council in London has created a ‘safe-zone’ around an abortion clinic, to stop anti-abortion campaigners from protesting outside. We help you answer the key questions: 

So what has been decided? 

So what’s controversial about it? 

So what do other countries do to deal with abortion?

So what’s happening in the rest of the UK?

Global Medical Tourism

The success of hospitals in Southeast Asia inspired other countries towards medical tourism. Regional hubs emerged due to advantages of geographical proximity and specialization.

by Nittaya Wongtada- Apr 11, 2018
by Michael Czinkota

( April 11, 2018, Wahington DC, Sri Lanka Guardian) Medical tourism can be traced to 4000 B.C. – when Greek pilgrims would sail abroad to seek the healing power of hot springs and baths. Over the past two decades, the industry encountered dramatic shifts.

Once wealthy patients from emerging economies sought treatments not available in their home countries. Since the new millennium, however, the flow of patients goes in the other direction. Rising health care costs prompt travelers from advanced economies to seek international destinations offering lower-cost or timelier alternatives to domestic care.

For instance, a spinal fusion in the United States costs an average of $110,000 in 2016. The same procedure was $6,150 in Vietnam. Heart bypass surgery, which costs $123,000 in the U.S. in 2016, is $12,100 in Malaysia. For many patients from high-priced countries, the solution is clear – it pays to seek medical care abroad!

The size of such tourism has ballooned since the late 1990s. Its value ranges between US $45.5 billion and $72 billion in 2017, with approximately 14 to 16 million patients seeking medical care beyond their countries’ borders.

Modern medical tourism is a global phenomenon. Traditional models emphasized internationalization as an incremental procedure. But the industry surged after the Asian financial crisis of 1997, which drove hospitals in Malaysia, Singapore, and Thailand to seek patients from abroad. They had already undergone substantial modernization, catering to a domestic middle class that demanded medical services commensurate with their newly acquired wealth. With the economic downturn, however, a shrinking middle class could no longer afford these superior facilities. International clients, provided a ready solution to an excess supply of private medical facilities.

The success of hospitals in Southeast Asia inspired other countries towards medical tourism. Regional hubs emerged due to advantages of geographical proximity and specialization. Malaysia and Singapore, for instance, received an influx of patients from Indonesia, while many patients in India came from Africa and the Middle East. Brazil, Costa Rica, and Mexico all benefitted from their proximity to the United States.

A clear pattern has emerged in the lifecycle of medical industries. First, countries in the developing world begin to offer services similar to those found in advanced economies. As new segments of international healthcare populations emerge, just like sun flowers, new medical tourism destinations grow towards the new opportunity. Close proximity to wealthy consumers constitute a competitive edge. To retain their market share, leading destinations formulate new strategies and options.

In order to survive growing competition, hospitals in emerging nations tend to implement two strategies. Since technologies stem from post-industrialized countries, most can only imitate. Their novelty comes from specialization in specific medical procedures. Doing few tasks very often improves capability, capacity, and efficiency, and thus improves reputational success.

However, this tactic may be ineffective as other hospitals develop similar capabilities. Consumer preferences will hinge on how closely services comply with their own cultural preferences and norms. Hospitals attract patients based on familiarity with local approaches and usages. Such an approach gives room for the increasingly recognized component of holistic healing.

It is important to understand how the lifecycle of hospitals continues to evolve. Different stakeholders – from governments to accreditation services to healthcare providers to patients themselves – will be affected by the expansion of the industry. For example, to date, there is still much unfounded reluctance to accept health care services offered by international sources. Once the industry manages to break out of restrictive domestic silos, a fundamental reconfiguration of service and cost will be the consequence. Let’s look forward to that!

Nittaya Wongtada is a Professor at the NIDA Business School of the National Institute of Development Administration, in Bangkok, Thailand.

Michael Czinkota teaches international business and trade at Georgetown University’s McDonough School of Business and the University of Kent. His key book (with Ilkka Ronkainen) is “International Marketing” (10th ed., CENGAGE).

This comment is based on the article “Transformation in the Global Medical Tourism Industry”, Transylvania Review, Vol. 25, 2017.

Countering heat stroke

  

Despite the recent showers that were observed in several parts of the country, especially in the evening hours, one cannot deny the intolerable heat experienced occasionally, during the other times of the day. Hence, the risk of getting dehydrated is nevertheless high due to the prevailing hot weather during the day.

2018-04-12

As such, the need to take necessary measures to avoid suffering a heat stroke is vital under this circumstance. Speaking to , Consultant Physician at the Colombo South Teaching Hospital and the President of the Sri Lanka Geriatric Association Dr. Dilhar Samaraweera shared his insights on how a heat stroke could affect an individual and how to prevent the risk of suffering a heat stroke during hot weather conditions. 

According to the doctor, people have been reported to the hospital after suffering conditions of heat stroke during recent times and especially during this part of the year. Those who have reported to hospitals during recent times as a result of heat stroke are mainly marathon runners (who have collapsed after strenuous activities), elderly patients (who experienced exhaustion due the heat) and people exposed to the sun for prolonged periods, resulting in dehydration. (Those in the latter group include people representing the forces). 

Process of avoiding damage 
Explaining what a heat stoke is, Dr. Samaraweera said that the condition can simply be defined as a situation where the body temperature could rise above 1040F / 400C or higher, which may result in either the loss of consciousness or loss of function. Due to severe dehydration the patient would fail to maintain the normal body temperature since he or she has already sweated and no longer has the ability to sweat further. According to Dr. Samaraweera, when a person perspires, the evaporation of sweat would help bring the body temperature down to the degree at which the normal body temperature is maintained. Moreover, when the environmental temperature increases, the body will try to perspire and reduce the temperature, thereby working towards maintaining the normal body temperature. Otherwise, when the external temperature increases, the body temperature will also increase. Therefore to avoid such damage, the human body has a mechanism of producing lot of sweat and evaporating it to maintain a normal body temperature. 

When inquired about what happens when a person gets dehydrated, he said that in such an instance, the sweating will entirely stop at which point the body temperature will rise rapidly. “The body will try to maintain the temperature by diverting the blood to the skin; a condition known as ‘Cutaneous Vasodilation’, which is the mechanism to reduce the body heat. The blood vessels will dilate in the skin, resulting in sweat and the reduction of body temperature, thereby trying to maintain the normal body temperature. Through this process, the body will try to maintain a constant blood supply to the skin. However, under such circumstances there will be a compromise on the blood supply to the brain. As a result, one may have an alteration in the level of consciousness. Also, one may experience total loss of consciousness and even death. This is what happens during a heat stroke” Dr. Samaraweera explained.

Vulnerable groups 
There are two ways an individual could develop a heat stroke. The first method is when an individual is exposed to a hot environment. Even if the person is not engaged in exercise, if he or she is exposed to a very hot and humid temperature the chances of developing a heat stroke is high. This particularly affects infants and elderly people above 65 years of age. “They are very likely to develop a heat stroke due to their impaired thermoregulatory mechanism, which is not well developed when an individual is very young. In the case of an elderly person, the thermoregulatory systems does not function well owing to the ageing process. 

The other category vulnerable to developing a heat stroke are people engaged in vigorous physical activities, which may result in increasing their core body temperature. People who prolong standing under the hot sun for long durations such as in the army or sportsman engaged in vigorous activity are vulnerable to get dehydrated. This condition might eventually result in a heat stroke,” he added. 
Additionally, people with heart disease and chronic kidney disease are often under medications to control their health conditions and the chances of them losing much sodium and water are high. When such people are exposed to hot weather they will be prone to lose more salt and water due to the increasing temperature. Such people need to consult their doctors in the event they feel dehydrated in addition to staying away from the heat, the doctor said. 

Red Flag Signs andFirst Aid
Explaining the symptoms related to a heat stroke, he said that a person would notice that he or she is experiencing a low rate of sweating in addition to indicating a very red and bright coloured skin tone. Cramping muscles, weakness in muscles, tiredness, exhaustion and feeling faint are the other symptoms of a heat stroke. “The patient would also experience an increased heart rate with rapid, shallow breathing in addition to feeling light headed. Symptoms of vertigo and headache are also common following which a person will experience alteration of consciousness or total loss of consciousness.

The best example to explain this is the heating of a vehicle. When we drive a vehicle and if there is a radiator leak, the engine will start heating up. When the engine starts heating up, there is an indicator light that lights up in the meter. Once you recognize that there is a warning light, the vehicle should be immediately stopped and allowed to cool down. It is also necessary in some instances to add water to the radiator tank and let the vehicle cool for sometime. If the driver ignores these warnings and continues driving, the engine would heat up and eventually stop functioning” he warned. 

Stating that the example is similar to what happens within the human body in the case of a heat stoke, he added that when warning signs surface, such as when someone feels tired, exhausted or is experiencing a headache or lightheadedness in addition to less sweating and dry skin, it is pivotal that one should immediately stop whatever work he or she was engaged in. The patient should take a rest and seek a place that offers shade. If the person is suffering from heat and exhaustion, it is important that he or she should immediately cool oneself. This cooling can be done using any method such as pouring water on the body. It is better if the person can get totally immersed in water or if possible sponge or cold compress the body using cold water. Also fanning can be used to cool oneself” he added. 

According to the doctor, the evaporation of water would help reduce the body temperature. Therefore, if the clothes the person was wearing is bulky or tight, it is better to either loosen or avoid wearing such clothes and opt for comfort clothing. If the person is able to drink, water should be provided. If available, Oral Rehydration Solution (ORS) would be the best to be administered on the patient since it also contains salt. Explicating that the body loses not only water but also other electrolytes and especially salt/sodium; which is why the patient experiences cramps, weakness of muscles and even confusion, Dr. Samaraweera advised that king coconut would be the ideal if available since it is the closest natural solution to saline. 

Prevention
In order to prevent the risk of heat stroke it is important to ensure that a person consumes plenty of fluids. During situations where an individual experiences much heat and evaporation, it is recommended to consume at least 2.5 to 3 litres of fluid (for an average person) each day. Water, king coconut and fruit juice are recommended in order to stay hydrated. 

“Avoid exposure to the sunlight between 11.00 a.m. and 3.00 p.m. since the heat would be extreme during these hours. Wearing sunscreen and light coloured clothing is recommended when exposed to hot weather. One should note that dark coloured clothing will absorb more heat, which would affect the increasing body heat as well. Wear loose and comfortable clothes instead of opting for bulky and tight clothes when exposed to the heat. Also, those who exercise should avoid engaging in very strenuous activities during times when the temperature is high because it can cause exhaustion. Also, it is encouraged to consume other fluids such as fruit juice in addition to the intake of water when exercising because it helps to keep the body hydrated. People living indoors are encouraged to keep doors and windows open to let the air flow in and facilitate proper ventilation. 

Also, it should be noted that the fan has a negative aspect despite being used to counter the heat because what circulates within the household is often hot air. This will in fact contribute to the increasing level of body temperature resulting in dehydration and exhaustion. Therefore, when the fan is used to counter the heat, it is recommended to keep a bowl of water inside the room since the water would help cool the circulating air. One should also be cautious about the alcohol intake because it is a substance, which causes diuresis; a condition which reduces the water content in the body by the actions of the kidneys. Therefore, alcohol should be avoided at all cost during high temperature because it will dehydrate a person further” he added. 

Moreover, Dr. Samaraweera strongly advised against leaving anyone alone inside a parked vehicle under hot weather conditions. The temperature in a parked vehicle under the hot sun will rise by 200F or more than 6.70C within ten minutes. He said that such a rise in the temperature could result in a heat stroke, in the event someone is inside the parked vehicle, which is left under hot sun or a warm environment. In a final note, Dr. Samaraweera added that if someone suffers a heat stroke or observes any symptoms in a person related to the condition, it is strongly advised to administer first aid and immediately rush the patient to the nearest hospital for further treatment.