Incorporating mammography into an overseas referral metric: Tongan doctors’ assessments of patient eligibility for medical travel

Tonga's largest public hospital received its second—although its first fully functioning—mammogram machine in 2016. If diagnosed with breast cancer, Tongan women must travel to New Zealand or Australia to access biomedical treatment (e.g. chemotherapy), but many can only do so with financial support from the Tongan government. Given limited funding, strict referral guidelines require doctors to quantify patients into calculations of risk. According to these guidelines, which I argue serve as an overseas referral metric, only “low-risk” patients—as determined by prognosis and treatment cost—are supposed to be funded. At present, doctors can sometimes draw on qualitative knowledge, such as long-term clinical experience, to circumvent referral guidelines. However, as mammography touts new epidemiological capabilities, it also has the potential to reinforce emphases on quantifiable evaluations of referral eligibility, which are often preferred by program funders. This could potentially exclude some women from treatment, as already-limited funding is increasingly reserved for those deemed “low-risk” according to numerical assessments. Based on recent ethnographic fieldwork (2016-2017) in Nuku‘alofa, Tonga, I draw on in-depth interviews and conversations with local doctors to elucidate the interplay between mammography access and practitioners’ processes of cancer diagnosis, patient risk assessment, and overseas referral. In following doctors' efforts to maximize accountability and risk management in referrals, I show how broader emphases on quantification and efficiency in global-health practice can generate intense moral dilemmas for those who must grapple with their implementation in the day-to-day. Significantly, these experiences demonstrate how numerical trends in global health not only permeate local health-care practices but also impact transnational health-care seeking, shaping a political economy of medical travel that structures opportunities for some women (and not others) to access biomedical treatment abroad.