Health and Medical Tourism

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Health and Medical Tourism

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Medical Tourism

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Medical Tourism

John Connell University of Sydney Australia

Disclaimer The views expressed in this book are not the views of the author or publisher but are the views of the sources quoted.

CABI is a trading name of CAB International CABI Head Office Nosworthy Way Wallingford Oxfordshire OX10 8DE UK

CABI North American Office 875 Massachusetts Avenue 7th Floor Cambridge, MA 02139 USA

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© CAB International 2011. All rights reserved. No part of this publication may be reproduced in any form or by any means, electronically, mechanically, by photocopying, recording or otherwise, without the prior permission of the copyright owners. A catalogue record for this book is available from the British Library, London, UK. Library of Congress Cataloging-in-Publication Data Connell, John, 1946Medical tourism / John Connell. p. cm. Includes bibliographical references and index. ISBN 978-1-84593-660-0 (alk. paper) 1. Medical tourism. I. Title. RA793.5.C66 2010 362.1–dc22 2010030663 ISBN-13: 978 1 84593 660 0 Commissioning editor: Sarah Hulbert Production editor: Shankari Wilford Typeset by AMA DataSet Ltd, Preston, UK. Printed and bound in the UK by MPG Books Group.

Contents

List of Figures and Tables List of Abbreviations

vi viii

Preface

x

1

Introduction: Patients without Borders

1

2

The Antiquity of Health Tourism

12

3

Mind and Matter: Health Tourism or Cosmetic Surgery?

23

4

The Rise of Medical Tourism

42

5

Medical Tourism and the New Asia

61

6

Marketing Medical Tourism

79

7

The Economics of Medical Tourism

112

8

Extremes, Ethics and Inequality

137

9

But is it Tourism?

159

10

Global Health

172

Appendix I Destinations and Delivery

185

References

188

Index

203

v

List of Figures and Tables

Figures Fig. A. Fig. 1.1. Fig. 2.1. Fig. 3.1. Fig. 3.2. Fig. 4.1. Fig. 4.2. Fig. 4.3. Fig. 4.4. Fig. 5.1. Fig. 5.2. Fig. 5.3. Fig. 5.4. Fig. 5.5. Fig. 6.1. Fig. 6.2. Fig. 6.3. Fig. 7.1. Fig. 7.2. Fig. 9.1. Fig. 9.2. Fig. 9.3.

vi

Medical tourism? Thai billboard, Bangkok 2010. Buxton Spa advertisement from the 1920s. Bali Sacred Journey, 2008. Banjaran Hotsprings Retreat, Malaysia 2009. Technology in medical tourism? Pratunam Polyclinic advertisement. Advertisement for drop-in clinic, Bangkok. A geography of medical tourism. Cosmetic surgery in Thailand? Translation centre, Bumrungrad International Hospital (BIH). Bumrungrad International Hospital (BIH), Bangkok. Bumrungrad patients by region. The map records both official BIH data on the regional origin of patients and the location of BIH offices overseas. Malaysia Healthcare advertisement, 2009. Dental tourism advertisement (a) and Sukhumvit street sign, Bangkok (b). Monterrey, Mexico. Gorgeous Getaways flier, 2010. Bumrungrad International Hospital brochure (Source: Bumrungrad International Hospital, Bangkok). Bangkok streetscape, Little Arabia, March 2010. Bumrungrad International Hospital (BIH), first floor. Hospital room in Bangkok Hospital, Phuket. Malev Airlines dental packages, 2010.

xii 8 15 31 34 46 47 52 57 63 65 66 67 74 80 94 100 116 135 166 167 170

List of Figures and Tables

vii

Tables Table 7.1. Table 7.2. Table 7.3.

Comparative prices (US$) of procedures, March 2010. Comparative prices (US$) of procedures, May 2010. Comparative prices (US$) of procedures, April 2010.

122 123 123

List of Abbreviations

ABC AIDS BIH BMG CABG CEO COPCAB CV DHCC EU GATS GDP GFC GG HIV IMTA ISAPS ISO IT IVF JCI KL MICE MTA MTC NCDs NGO NHC NHS NRI PHC SARS viii

Australian Broadcasting Commission acquired immunodeficiency syndrome Bumrungrad International Hospital Bavaria Medical Group coronary artery bypass surgery chief executive officer conscious off-pump coronary artery bypass curriculum vitae Dubai Healthcare City European Union General Agreement on Trade in Services gross domestic product global financial crisis Gorgeous Getaways human immunodeficiency virus International Medical Travel Association International Society of Aesthetic Plastic Surgery International Standards Organization information technology in vitro fertilization Joint Commission International Kuala Lumpur Meetings, Incentives, Conferences and Exhibitions Medical Tourism Association medical tourism company non-communicable diseases non-governmental organization National Heart Centre Singapore National Health Service non-resident Indian primary health care severe acute respiratory syndrome

List of Abbreviations

UAE UK USA VFR WHO

United Arab Emirates United Kingdom United States of America visiting friends and relatives World Health Organization

ix

Preface

Medical tourism, where patients travel overseas for operations and various invasive therapies, has grown rapidly since the late 1990s, especially for cosmetic surgery. The main sources of such tourists are developed countries and the main destinations are in Asia. Conventional tourism has been a by-product of this growth, despite its tourist packaging, but the overall benefits to the tourism industry have been considerable. The rise of medical tourism emphasizes a number of contemporary themes including the privatization of health care in postindustrial economies, the growing dependence on technology, uneven access to health resources, the accelerated globalization of health care and tourism, rampant consumerism and cherishing the body beautiful. One of the more intriguing changes of the past two decades has been a remarkable focus, even obsession, with bodily appearance. Both health and its visible signs have become more and more important. Day after day as I open my e-mails, I am told that I need to take pills, exercise or modify my appearance – usually one particular part of my anatomy. I am encouraged to have a hair transplant, take viagra, ordered to ‘lose weight fast without exercising’ and generally made to feel inadequate. As I was writing this Preface two new e-mails appeared on my computer screen entitled ‘Your manly strength and stamina will be restored again’ and ‘look great and speed up your metabolism with Acai berry’. They keep coming because people keep responding, as so many want to ‘look great’. Businesses have sprung up around inadequacy. Yet, fortuitously, my own lone foray into medical tourism was an hour of dental treatment in Bangkok that cost barely one-fifth of the equivalent in Sydney. No longer is plastic surgery to be frowned upon or merely for the elite, while looking good has become an obsession. Indeed cosmetic surgery is firmly engrained in popular culture; Stieg Larsson’s feminist heroine of The Girl Who Played With Fire (2009) engaged in breast enhancement, while Robin Cook’s series of medical thrillers turned to medical tourism a year earlier with his Foreign Body (2008), centred around an American’s hip replacement in India. Frequent television programmes effectively preach the virtues of diets and exercise (and even whole channels are devoted to lifestyles). No Sunday newspaper – at least in most Western countries and in many others – is complete without sections on nutrition, health, exercise, skin care and, of course, fashion. Positive thinking and self-improvement are said to offer new potential for personal satisfaction. So it is no surprise that alongside advertisements for pills and potions, are adverts for spas, tourism resorts where we can rejuvenate ourselves and, from time to time, indications from before and after pictures that more dramatic change is possible. x

Preface

xi

Yet while the growth of health tourism – or, more trendily, wellness tourism – has resulted in a boom in spas and various forms of rejuvenation, medical tourism is rather more than this. It is about international movements in search of cures and the resolution of more serious medical conditions, often by surgery, for various reasons and in diverse circumstances. There is both new demand and new supply for particular kinds of medical care and intense global competition to provide them. Affluence has enabled this, so too have disappointments with the performance of public medicine. New mobility, and its active marketing by governments and hospitals, has resulted in the rise of a new niche tourism industry. The travels of celebrities, such as Diego Maradona’s trip to Cuba for detoxification in 2000, Naomi Campbell’s trip to Brazil for laparoscopic surgery in 2008 (and even the trip of Blanche from the British soap opera Coronation Street to Poland for a hip replacement in 2005), have drawn attention to new possibilities, and to the linkages between cosmetic surgery and celebrity culture. It is an industry that in some part has eluded detailed analysis since so much of it is both competitive and clandestine, and some part of what follows must be qualified because of uncertainty about data, including even the most basic information on the numbers of tourists and their motivations. Piecing together numerical data would have challenged decipherers of the Dead Sea scrolls. Somewhat unusually therefore data on medical tourism are only addressed in later chapters. So much of the information on medical tourism comes from optimistic press releases, and their repetition as wisdom, and sometimes impressionistic and sensationalized journalism, with catchy titles such as ‘Boobs and balls: medical tourism companies cashing in on the World Cup’ (West Cape News, 15 March 2010; Slamdien, 2010) or ‘Basking on the beach, or maybe on the operating table’ (New York Times, 15 October 2006), rather than careful analysis of particular circumstances. Much of the literature is promotional rather than analytical, and numbers and growth rates are invariably inflated. Where confidentiality reigns for all kinds of reasons, and multiple e-mails went unanswered, too much dependence has had to be made on websites. This book none the less seeks to resolve some of these problems and enable a more adequate overview of an emerging component of the tourist industry and a distinct and controversial element of health provision. I would like to thank Sarah Hulbert of CABI for her enormous patience and support, Jenny Wang and Thantida Wongprasong for keeping me posted on Singapore and Thailand respectively, Nathan Wales for producing the maps, Olivia Dun for organizing the illustrations and, above all, Kirstie Petrou for her invaluable assistance in discovering bizarre sources and obscure blogs, navigating a wealth of websites, editing the imperfections in the manuscript and discovering how one medical tourism company actually worked. Tenkyu tumas. John Connell School of Geosciences, University of Sydney June 2010

xii

Preface

Fig. A. Medical tourism? 2009 ©Jack Hsu. Reprinted with permission.

1 Introduction: Patients without Borders

Improving ourselves physically is something that we all aim for. We want smoother and clearer skin, we want a curvier figure, we want lustrous straight hair, or we want pearly white teeth. All these wants related to how we look and how others see us are all very normal. We have always found our appearance directly related to how we feel about ourselves and how we perform. In many cases, we want to get all those improvements instantly. And we can do so, thanks to medical science. (Dr Sunil Dental Clinic (2010a) Bangkok, Thailand)

Medical tourism is a recent example of niche tourism, with the rapid rise of international travel in search of cosmetic surgery and solutions to various medical conditions, benefiting health-care providers, local economies and the tourism industry. While medical tourism may be a new niche in the industry, tourism has always been associated with improved health and well-being, perhaps more usually perceived as occurring through entertainment, rest and relaxation rather than by substantial bodily changes. Indeed travelling for improved health is the most durable niche in the history of tourism. A long history of spa tourism dates back to antiquity, and in more recent centuries variants of a more general health tourism have included phenomena ranging from naturism and

hiking/bushwalking to meditation and detoxification. In some respects medical tourism has evolved from all of these and taken on its own diversity, prompting Bookman and Bookman (2007: 42) to come up with such subcategories as pregnancy tourism, toothache tourism and detox tourism. There are many others. When and where the term ‘medical tourism’ itself originated is unknown. It has become important for many reasons: (i) disappointments with medical treatments at home; (ii) lack of access to health care at reasonable cost, in reasonable time or in a sympathetic context; (iii) inadequate insurance and income to pay for local health care; (iv) the rise of high quality medical care in ‘developing’ countries; (v) uneven legal and ethical responses to complex health issues; (vi) greater mobility; and (vii) perhaps, above all, a growing demand for cosmetic surgery that ties many other factors together. Sometimes, rather less positively, it has grown because of the impossibility of undertaking various procedures at home, and their availability overseas, which in the case of abortion, some forms of organ transplantation (‘transplant tourism’) and stem cell therapy, even contraception and ultimately ‘death tourism’, have raised ethical issues. Diasporic medical tourism has taken patients back to their homelands, while ‘transnational retirement’ migration, as global populations age,

© CAB International 2011. Medical Tourism (J. Connell)

1

2

Chapter 1

has provided yet one more component of medical tourism. In countries such as Malaysia, Mexico, Spain and the Philippines retirement provides a potential basis for a more comprehensive medical tourism. In other words medical tourism has grown as the outcome of changes in the institutional context of medical care, a more global economics of access to health (with ‘developing’ countries undercutting the price structures of rich-world countries) and new attitudes to personal identity and medical care, enabled by developments in international communication, transport and tourism. Medical tourism is thus underpinned by diverse political, economic, social and cultural influences. Medical tourism has also emerged from a greater willingness to accept alternative practices and procedures, and experience different cultures and places, even though most medical tourism is centred on ‘formal’ biomedical procedures. It has, however, followed various social and economic changes encouraging a more holistic approach to health care where health-seeking behaviour has become more likely to reflect the views of patients in terms of their own values, beliefs and philosophical orientations towards health and life, rather than those of the ‘medical establishment’. For some this has meant being more involved in such social determinants of health as community, belonging and hope; for others it has meant greater individualism. Ironically therefore greater support for complementary and alternative medicine has grown alongside the rise of cosmetic surgery, a function of an ‘obsession with self that is reaching an all-time high thanks to new media, technology and consumer orientated services’ (Smith and Puczko, 2009: 71). Yet one of the critical issues in the development of medical tourism is the regulation of standards. Not all health problems are amenable to international treatment, including most diseases, and patients must be well enough to travel. Cosmetic surgery tends to dominate most of the literature but there is much more to medical tourism. In many developed countries, notably the USA, health care has become increasingly expensive, often beyond the reach of some, and for complex procedures

beyond the ‘economic reach’ of many. Even straightforward procedures that are not technically challenging, such as dentistry and orthodontics, have become extremely expensive. As people live longer the demand for health care increases, and greater pressure is placed on fewer health workers (Connell, 2010), so that both costs and delays in care increase, creating interest in alternative sources of treatment. The structure of health insurance has made some distant sources increasingly feasible, while continued deregulation of the aviation industry and reduced airfares have enabled more ready access to overseas providers. Favourable currency exchange rates in some countries have further reduced the costs of overseas treatment. Technological change and the return migration of skilled health workers have raised the standard of medical care in many middle-income countries, and respected international accreditation has reduced concerns over such standards. Yet, at the same time, for all its economic lure, even the idea of seeking medical treatment in distant places in challenging circumstances, perhaps away from family and friends and local culturally familiar care, seems the very antithesis of societal norms. Such norms and values, inertia and uncertainty, and loyalty to national systems, have slowed the growth of medical tourism. None the less 21st century growth has been exceptional. Medical tourism was almost unheard of at the end of the 20th century, and ignored by the media. The number of news items in the global English language media rose from zero in 1990 to around 40 a year at the end of the century to over 2000 in 2007 (Eades, 2010). Spectacular growth in global media coverage was matched by the emergence of new destinations, expansion in established destinations, the emergence of medical tourism companies, the arrival of guidebooks, dedicated industry journals, medical tourism conventions, and belated academic interest. Medical tourism is primarily a 21st century phenomenon. While medical tourism is generally perceived as the movement of patients from relatively wealthy developed countries to developing countries such as Thailand and India, within Europe significant differences

Introduction: Patients without Borders

in the costs of treatment between countries, and the consolidation and expansion of the European Union (EU) has produced greater mobility of patients (and also health workers) within the EU region (Guerrieri, 1985; Smith, 2006; Glinos et al., 2010; Lunt and Carrera, 2010). Choice of provider and thus destination is partly influenced by short distances, favouring travel comfort and probable ease of communication, though Portugal has sent waiting-list patients as far as Cuba for eye surgery (Glinos et al., 2010). As in Europe crossborder movements occur between Canada and the USA, and in Asia, Africa and the Middle East much medical tourism consists of regional movements rather than travel from distant developed countries (Chapter 5). Almost everywhere, as complexities ensue, mobility has become bidirectional. At the same time as pressures on health services in developed countries have increased so standards of health care in ‘developing’ countries have also increased. While such improved standards have not been universal, and nor have they extended far into rural and regional areas of countries such as India, in the larger cities the ‘best’ hospitals and their skilled health workers are comparable, and are accredited as such, with the best global standards. Marketing medical tourism has been in large part about ensuring that this is as widely appreciated as possible. Accreditation, however, takes time and is another, perhaps necessary, constraint to growth. Limited transportation and tourism infrastructure have also slowed growth. In the least developed countries, and those where inadequate emphasis has been attached to health care, standards are poor. The perceptions of the growing middle class (and others) are that they are so inadequate that going overseas for ‘proper’ health care is essential, and is itself a mark of status. Nearly as many international medical tourists are from developing countries with weak healthcare systems as they are from rich countries with generally adequate systems. In the poorest countries mobility is not bidirectional. A somewhat elite medical tourism has been in existence for a very long time, with global nodes such as Harley Street in London and several European capitals like Berlin

3

having been famous destinations for over a century. In an article in the Wall Street Journal in 1985, entitled ‘I’d like Caviar, Duck a l’Orange and the Surgery’, London was accused of drawing wealthy Americans there (Berliner and Regan, 1987). Though these cities remain important, in the last two decades the direction of medical tourism has shifted from being towards the West to away from it. That has given rise to new structures of mobility. As the Senegalese Ambassador to Malaysia has observed, in a context where at the start of the century few Africans would have been visible in Kuala Lumpur or even have heard of it, Africans are arriving not just as business people and students, but increasingly for surgery: ‘Africans have been coming to Malaysia because it is cheaper to do so in this country rather than Europe where they used to go previously. One could get more mileage out of one’s money’ (quoted in Easen, 2009: 80). Medical tourism has substantially reversed an earlier pattern of wealthy patients from around the world travelling to richworld centres, such as Harley Street, and resulted in patients travelling to Thailand, Costa Rica and elsewhere. Within little more than a decade, around 20 countries, most effectively in Asia, have developed medical tourism, with several other countries anxiously and enthusiastically poised to enter the market.

What’s in a Name? Is ‘medical tourism’ the best term? Tourism suggests pleasure and relaxation – not necessarily characteristics associated with medicine. Given the diversity of movements that have been attached to the general heading of medical tourism, it is something of an umbrella term, whether for ‘medical’ procedures or ‘tourism’. Outside that umbrella, tattooing, rarely regarded as a medical procedure, is certainly more painful and invasive than many forms of treatment usually subsumed under medical tourism. It may also be the procedure undertaken on holiday that comes closest to being ‘authentic’ in taking on permanent local characteristics, rather than either the more passive experiences of

4

Chapter 1

yoga or operations where the outcome should not be ‘authentic’. Although tattooing is a cosmetic procedure, it is not discussed here. Similarly what has been called ‘pharmaceutical tourism’, where, for example, Americans travel to Canada and Mexico for medicines that are substantially cheaper than in the USA (Sutherland, 2005), is also excluded. Defining ‘medical treatment’ is difficult. While some ‘medical tourists’ may travel alone, some even in anonymity, most travel with friends and relatives, and it is they who are most likely to engage in ‘standard’ tourist activities, probably staying in hotels while patients stay in hospitals. Consequently, though queries can be raised over whether patients can be designated as tourists, their companions can usually be seen as such. Medical tourism has affinities with the similarly growing Meetings, Incentives, Conferences and Exhibitions (MICE) tourism in the focus on one particular activity that itself has minimal relationships with recreation and relaxation. More importantly it is also a significant part of a new form of ‘diaspora tourism’ where patients return to their home countries, kin and extended families to experience health care in a more-or-less familiar cultural context (Chapter 9). In such ways, and through expenditure in local tourism infrastructures (hotels, transport and restaurants), medical tourism is a valuable niche in the international tourist industry. Who are medical tourists? Cohen has suggested a fourfold classification: (i) ‘medicated tourist’ (who receives treatment for accidents or health problems that occur during an overseas holiday); (ii) ‘medical tourist proper’ (who visits a country for medical treatment – unrelated to the trip – and who may also decide on a procedure once in a country); (iii) ‘vacationing patient’ (who visits mainly for medical treatment, but makes incidental use of holiday opportunities, usually during the convalescence period); and (iv) ‘mere patient’ (who visits solely for medical treatment, and makes no use of holiday opportunities). Beyond this there are of course many tourists (‘mere tourists’) who have no medical treatment of any kind while overseas (E. Cohen, 2008: 227). Cohen argues that most of the literature covers ‘vacationing

patients’ and ‘mere patients’, where the medical component dominates, and prefers the term ‘medical travel’ since the recreational component is slight (E. Cohen, 2008: 227). However, even ‘mere patients’ bring income into the destination country and contribute to local employment generation within and beyond the health-care system. The role of intent is significant for some. Lunt and Carrera restrict the definition of medical tourist to ‘patients who are mobile through their own volition’ (2010: 27), as opposed to those who are effectively sent abroad by health agencies as an outcome of long waiting lists and a lack of available specialists. Many small countries routinely refer certain patients with particularly difficult health problems to superior services overseas. Medical evacuations on flights from small Pacific island states to New Zealand and Australia, often funded from aid budgets, are a constant reminder of global inequalities in health-care provision. While these are not conventionally seen as medical tourists, and are often funded institutionally, they engage in similar trips and experiences to other medical tourists. This book takes the perspective that such varied subcategories are not always easily distinguishable and that there is a continuum, where each category has at least partial involvement with tourism, hence ‘medical tourism’ remains a useful but imprecise term for all but ‘mere tourists’ and ‘medicated tourists’. This also includes those who make ‘on-site’ decisions, a significant part of dental tourism, despite most such procedures being trivial. Such a definition accords with definitions such as that of Pollard (2010a) who defines a medical tourist as ‘someone whose specific reason for travelling to another country is medical treatment’ so excluding those who fall ill on holiday or are resident expatriates there. This also parallels the criteria used in the influential McKinsey report (Ehrbeck et al., 2008) though this is quite different from more optimistic and inclusive industry usage (Chapter 7). Value judgements are implicit here. Milstein and Smith (2006), describing the plight of ‘seriously ill Americans’ who receive treatment at overseas hospitals because they cannot afford domestic care, deride ‘medical tourists’ as those who seek ‘low-cost aesthetic

Introduction: Patients without Borders

advancement’. Kangas (2007) rejects outright any designation of tourism for impoverished Yemeni travellers similarly desperately seeking care, as they do themselves, while longstaying ‘reproductive tourists’ may see their absence as more akin to exile (Matorras, 2005; Inhorn and Patrizio, 2009). Conversely, large parts of the industry use ‘tourism’ to promote something that might be quite unpleasant. While much medical tourism literature focuses overwhelmingly on cosmetic surgery, it is extremely difficult to differentiate medical tourism according to the procedures involved, their morality and worthiness and the behavioural characteristics associated with them in different contexts. Some cross-border movements, such as clandestine travel for health care, are particularly problematic. In recent years several hundred people a year have moved from Papua New Guinea a few kilometres across the international border with Australia in the Torres Strait, posing as local people with whom they share cultural characteristics, and receiving a superior health care from that possible in Papua New Guinea. Their treatment costs Australia around A$6 million a year, regarded by the President of the Queensland branch of the Australia Medical Association as ‘humanitarian aid to an impoverished Australian neighbour’ (Papua New Guinea Post Courier, 22 February 2010; see Chapter 8). In Thailand medical treatment for stateless people who have moved into Thailand, mainly from Myanmar (Burma), has been so substantial that it cost the health-care system 468 million baht (US$15 million) in 2009 (Bangkok Post, 2 February 2010). In a very different context the non-governmental organization (NGO) Women on Waves has sought to moor its ship outside the territorial waters of countries where access to abortion was extremely difficult, to enable women to cross the political border and gain access to reproductive health services off-shore; opposition was strong but advice, tests and limited services were provided outside countries like Ireland and Portugal (Gomperts, 2002). Such movements exemplify how many people engage in transnational cross-border mobility for medical treatment, effectively outsourcing themselves, and with no obvious resemblance to tourism.

5

Nor need medical tourism necessarily have positive or pleasurable outcomes. Some diseases and conditions are incurable but that has not prevented quacks and charlatans suggesting remedies and claiming cures, often based on the use of local medicines and techniques. Some acquired fame and notoriety and stimulated a flow of overseas patients to destinations with limited regulation. In the late 1970s Milan Brych, a Czech refugee doctor who had been removed from the New Zealand register of doctors, set up a controversial cancer clinic in the Cook Islands, which received a steady flow of patients from Australia lured by promises of ‘miracle cures’ with questionable medical validity. Experimental techniques, such as some forms of stem cell therapy, attract desperate contemporary travellers, and suggest analogies to pilgrimage. Tourism formally implies a stay of more than 24 hours in a destination, otherwise it is merely ‘visiting’, but quite complex procedures can be undertaken in a single day (and in an instantaneous jet and electronic age 1 day is a long time). Munich Airport hosts a clinic where complex procedures can be undertaken without even leaving the airport. More generally in Europe, ease of air transport has meant that ‘dental tourists’ particularly have been able to engage in ‘fly-in fly-out’ procedures in a single day, making minimal contribution to the national economy beyond the dental sector. Yet however slight their wider impact, they too can be seen as medical tourists, at one end of a temporal continuum. A variety of other approaches to medical tourism abound, with the most basic division being between health tourism (and a more recent variant, wellness tourism, that perhaps offers a more holistic and inclusive perspective, covering mind, body and spirit) and medical tourism. One definition of health tourism is: the sum of all the relationships and phenomena resulting from a change in location and residence by people in order to promote, stabilize and, as appropriate, restore physical, mental and social wellbeing while using health services and for whom the place where they are staying is neither their principal nor permanent place of residence or work. (Mueller and Kaufmann, 2001: 5)

6

Chapter 1

Such a formalistic definition covers a multitude of possibilities. A range of other definitions exist from the minimalist ‘any kind of travel to make yourself or a member of your family healthier’ (Erfurt-Cooper and Cooper, 2009: 6), which is much the same as one definition of medical tourism ‘travel with the aim of improving one’s health’ (Bookman and Bookman, 2007: 1), to the more detailed: An attempt on the part of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerland) to attract tourists by deliberately promoting its health-care services and facilities, in addition to its regular amenities. These health care services may include medical examinations by qualified doctors and nurses at the resort or hotel, special diets, acupuncture, transvital injections, vitamincomplex intakes, special medical treatments for various diseases such as arthritis, and herbal remedies. (Goodrich and Goodrich, 1987: 217)

However, surgery is excluded here. Some definitions have sought to distinguish ‘health tourism’ from ‘wellness tourism’, the latter being a subset of the former, with health tourism involving a ‘cure’ and wellness involving no specific problem but simply increased well-being. However, such concepts vary considerably in different cultural contexts where they are not necessarily easily or ever distinguished, and where their attainment takes on a range of forms (Smith and Puczko, 2009: 5–6). Goodrich and Goodrich (1987) were writing before the real onset of medical tourism, otherwise they might well have included it as a subset of health tourism, where invasive procedures were involved. Economists use the phrase ‘cross-border trade in health services’ but this dry phrase lacks popular resonance (Turner, 2007b) and includes much more than what is usually considered medical tourism. It can more easily be termed ‘transnational medical care’ (Sobo, 2009). While some writers have continued to use both ‘health tourism’ and ‘medical tourism’ to cover all forms of health-related travel behaviour (e.g. Garcia-Altes, 2005; Reddy et al., 2010) medical tourism alone has become such a large and diverse arena that some distinction between passive experiences and more

active intervention seems essential. Medical tourism may conceivably even be distinguished as ‘illness tourism’ (Reisman, 2010: 93–94) though that excludes most cosmetic procedures (without subtle interpretations of psychological illness). Almost all discussions of medical tourism reflect international movements, as this book does, but medical tourism also involves national movements. That is reflected in Jagyasi’s definition of medical tourism as ‘the set of activities in which a person travels often long distance or across a border, to avail medical services with direct or indirect engagement in leisure, business or other purposes’ (2008: 10). There are parallels between patients moving into capital cities for superior treatment or to take advantage of particular specialisms, but unlike the medical tourism that is discussed here, the economic dimensions are more muted. Medical tourism none the less covers a massive range of possibilities. One medical tourism guidebook, Patients Beyond Borders (Woodman, 2008), first published in 2007, refers to ‘medical travel’ rather than ‘medical tourism’ suggesting perhaps the gravity of health care, yet four other guidebooks use ‘tourism’ (Chapter 6). Companies involved in medical tourism choose various words. The owner of Dental Express, an Australian company that arranged dental treatment for foreigners in Manila, has stated: Dental tourism isn’t my favourite term… The biggest problem is people booking things at this beach or that beach, but not knowing anything about the dentist they’ve chosen. People think it’s a holiday but what part of eight days in a dentist’s chair sounds like fun? (quoted in Shanahan, 2009: 22)

Similarly the President of the International Society of Aesthetic Plastic Surgery (ISAPS), Foad Nahai, has argued that plastic surgery is too serious to be labelled as tourism: While we appreciate the involvement of the travel and hotel industries we must never lose sight of the fact that travelling abroad for a medical procedure is not a vacation, it is surgery. In the months ahead ISAPS will be actively promoting a new paradigm in the

Introduction: Patients without Borders

profession – not Medical Tourism, but rather a more serious approach: Medical Procedures Abroad. (Nahai, 2009: 106)

Some recuperation is, however, usually possible, and a journey with a serious purpose can have a frivolous and celebratory ending. This book uses ‘medical tourism’ largely as an umbrella term for circumstances where improved health is a key element within a holiday or travel overseas, and where this involves some invasive procedures (but also medical tests and check-ups), rather than the more passive involvement of health and wellness tourism, or even such healthy activities as hiking and bushwalking. Previously medical tourism was defined as tourism that was ‘deliberately linked to direct medical intervention, and [where] outcomes are expected to be substantial and long-term’ (Connell, 2006a: 1094) but that was limiting in excluding travel where medical intervention was not the primary purpose, but ‘low-level’ drop-in procedures (including dentistry) were involved, and perhaps in including travel where patients were so incapacitated afterwards that no semblance of tourism was possible and would even have been regarded as demeaning. Ultimately not even a loose umbrella term is therefore satisfactory: Thai massage may be scarcely less painful or invasive than teeth whitening, while ‘transplant tourism’ is far removed from what may immediately be pleasurable. Certainly there is a loose continuum from health tourism (or wellness) that includes relaxation techniques such as yoga and massage, cosmetic surgery (ranging from dentistry to substantial interventions), operations (such as hip replacements and transplants), reproductive procedures and even ‘death tourism’. Patients in each of these categories remain overseas for very different durations. What exactly should be classified as medical tourism is therefore never clear, and statistics are complicated by indecision and exaggeration. While this book focuses on the growing core of this relatively new niche, it places medical tourism within a wider and all-embracing health tourism, from which medical tourism has partly emerged and with

7

which it remains loosely linked. In the end however, and most disconcertingly, whatever the definition or category, data are elusive.

Image, Identity … and Insurance In many respects medical tourism was discovered and boosted by the media, notably in the USA. Without extensive media coverage not only would medical facilities in developing countries have largely remained invisible and unknown to potential clients in developed countries, but the assumption that they were of inferior quality would have persisted. From the end of the 20th century Western media began to emphasize the cost savings from high quality medical care overseas. After the American television programme 60 Minutes featured a short story on Bumrungrad International Hospital (BIH; Bangkok) in 2005 the hospital was bombarded with over 3000 e-mails from Americans interested in receiving treatment there (Turner, 2007a: 116). While some media reports clearly pointed to negative consequences, they indicated that problems were usually exceptional, resulting in what amounted to a ‘media imprimatur’ (Schult, 2006: 71) especially for Asia. With medical tourism companies becoming established and medical tourism making its debut in Wikipedia in 2004, the mid-2000s represented a breakthrough period for the industry. Medical tourism covers a diversity of procedures from costly operations that may have long waiting times, such as hip surgery, to a range of cosmetic procedures, such as teeth whitening or breast enhancement, that have little to do with medical needs but much to do with social status and even the acquisition of social or symbolic capital. Not only has demand for such cosmetic procedures increased substantially in recent years but they are usually given limited or no priority in some Western countries. Many cosmetic procedures, such as hair straightening and removal, skin lightening (and even simply lipstick application) and dieting, have been known and widely practised for centuries. More people have recently engaged in such

8

Chapter 1

basic cosmetic procedures, because they are encouraged to do so and because they can afford to pay. Aesthetics may have social and economic outcomes. Skin colour is not only a means of economic advancement, with lighter skinned Latinos in the USA earning significantly more than their darker counterparts (a controversial context that some social commentators claimed boosted Barack Obama’s ascent to the American presidency), and darker skin being seen in many parts of the world, significantly in Asia, as a function of agricultural and thus low class status. Demand for cosmetic surgery and skin lightening is thus likely to grow. In China cosmetic surgery is booming as Chinese seek bigger eyes and noses, especially among the young who perceive this as both aesthetic and invaluable in the search for jobs (Elliott, 2008; Waldmeir, 2009). Chinese hospitals may even undertake leg-lengthening for patients who, almost literally, ‘wish to get a foot in the door of employment prospects’

Fig. 1.1. Thai billboard, Bangkok 2010.

(Cabrera, 2009b: 63). In Thailand health and beauty are inseparable: Skytrain station billboards advertising the latest lines of developed whitening creams and on the facades of the many hospitals and clinics advertising laser teeth whitening, facelifts, cosmetic surgeries and rejuvenation therapies… one might assume that the dominant conception of beauty within Thai culture signifies skin bleaching, double fold eyelid surgery and nose surgery, teeth whitening and so on ... that associates beauty, success, modernity and progress with whiteness. (Aizura, 2009: 303; Fig. 1.1)

Popular Thai models and film stars are often of mixed Thai and European ethnicity, and women from north-east Thailand are widely judged inferior because of their darker skin. A Thai television advert has even offered a product for armpit whitening (Biggs, 2010). In India a best-selling brand of women’s cosmetics called ‘Fair and Lovely’ has recently

Introduction: Patients without Borders

been supplemented by a new product for men called ‘Fair and Handsome’ (Vedantam, 2010), and sales of skin-whitening products increased by 17% between 2008 and 2009 to 20 billion Rs (US$432 million) in the first 9 months of 2009. Such products are used in the diaspora as much as at a home. While this perpetuates cultural myths about the aesthetic and social superiority of whiteness it also recognizes real feelings of inferiority and discrimination, and is paralleled in east Asia, especially Korea, Taiwan and Japan, where dark and light skins are similarly polarized on the social scale (Medland, 2010). Paradoxically it also parallels the rise of solar beds and spray tans in the West. Demand for cosmetic change has intensified, accelerated by stories and photographs in a growing host of fashion magazines, television programmes and newspapers, themselves diffusing more rapidly than ever before. More than at any time in the past, people, and not even just young or principally young people, are urged to be healthy, fit and fashionable. The quest for fitness has boosted new ‘exercise industries’ – gyms and aerobics classes, personal trainers, lap pools and ‘boot camps’ – even raising questions over the use of public space. Fun runs have attracted larger and larger numbers. Makeover programmes, such as The Biggest Loser, are common and popular on many television channels. Even more directly Ten Years Younger in Ten Days was one of several ‘makeover’ programmes that almost demanded change. In every episode, as its web page observed, a married couple were: given the chance to reclaim the years that got away; boosting self esteem, restoring confidence and changing lives along the way … From fitness to fashion, dental and diet, to cosmetic procedures and treatments, every step will be taken to help wind back the hands of time. (www.au.tv.yahoo.com/10-years-younger-in-tendays/features/article)

It went on to note that ‘today’s hectic pace is taking its toll ... Longer working hours, stress, financial worries, poor diet, sun damage, excessive lifestyles and a lack of exercise are prematurely robbing [couples] of their youth’ (Dr Sunil Dental Clinic, 2010b). Somewhat

9

similar to that in the UK was The Spa of Embarrassing Illnesses, a television series subtitled ‘an inspirational series which offers hope where traditional medicine fails’, presented by a nutritionist that revolved around a group of people trying to conquer their ‘embarrassing and intimate health conditions’, which included more obvious medical conditions such as constipation and irritable bowel syndrome. Cosmetic dentistry boomed following its emergence in California in the late 1940s, with television shows such as Extreme Makeover pushing cosmetic dentistry ideals on the public and making ‘porcelain veneers’ a household phrase. The expansion of cosmetic dentistry was much influenced by consumerism and commodification, and a shift within the industry towards direct-to-consumer marketing, and the economic ‘need’ to market cosmetic procedures in an era where, in developed countries, dental problems (and many painful procedures) had been much reduced. Expansion of clinics overseas, less fear over procedures, demand for cosmetic improvements and the high cost of treatment in developed countries eventually created massive growth in dental tourism. By 2006 a quarter of the population of the UK stated that they had had cosmetic dentistry procedures (Ballou, 2009). Some 40% of Americans seeking health care overseas did so for dental procedures (Apton and Apton, 2010), a similar proportion to that in Europe. Despite such preoccupations with wellbeing and attractiveness, growing numbers of people are much less healthy. In many countries there has been a steady growth of non-communicable diseases (NCDs), occasionally to epidemic proportions. What are sometimes called the diseases of affluence, but perhaps better seen as lifestyle diseases – diabetes, obesity, cancer, heart attacks, etc. – have resulted from new patterns of life such as greater fast-food intakes and high levels of car ownership stemming from general affluence in an age of consumption. We inhabit a paradoxical world – often consuming too much but fearful of the consequences and still anxious to be healthy, fit and attractive. Accompanying the rise of both cosmetic surgery and NCDs, holistic approaches to

10

Chapter 1

health have simultaneously gone from fads to fashion. Herbal remedies, new diets, organic produce and farmers markets are everywhere. Even the World Health Organization (WHO) has recently begun documenting medicinal plants and remedies in a variety of countries. For some a greater interest in health has been combined with more-or-less spiritual practices, especially those that emanate from Asia, notably acupuncture, yoga and meditation, alongside massage and reiki (Smith and Puczko, 2009). Astrology has long been absorbed into the West from Asian and Middle-Eastern cultures and one of the fastest growing belief systems in this century has been feng shui, drawn into modern Western business design and healing practices (Emmons, 1992). Numerous ‘airport books’ boost self-help techniques and therapies, from business to anti-ageing and the attainment of the elixir of youth that draw on loosely ‘oriental’ beliefs and practices. In a number of ways health care has taken on new dimensions, many drawn from Asia, and both health and medical tourism have significantly involved Asia. Yet there is a more prosaic and less glamorous explanation for the growth of medical tourism including: (i) the rising cost of health care; (ii) the weakened status of the public health sector; (iii) long waiting lists for some procedures; and (iv) the inability of many, notably in the USA, to pay for necessary medical treatment. Lack of insurance coverage has effectively forced many residents of the USA, for example, to seek overseas care – as perhaps reluctant medical tourists – and especially those who are most likely to be under- or non-insured. These include first- or second-generation migrants, many of whom return to their home countries for treatment, so emphasizing the key role of the diaspora in medical tourism. Within Europe new institutional agreements finalized in 2008 have enabled significant cross-border movements for health care, as insurance policies have become internationally transferable within the EU region. This followed a ruling from the European Court of Justice, after a British citizen had gone to France for a hip transplant, that a year’s wait constituted an ‘undue delay’

hence reimbursement could be claimed from the British National Health Service (NHS). Some 4% of EU citizens have received treatment in other EU states, with proportions ranging from 3% in the UK to 20% in Luxembourg, because of the short waiting times for such procedures as hip and knee replacements and cataract surgery in countries such as France, Germany and Belgium (Charter, 2008; Lunt and Carrera, 2010). Even prior to that in 2001 Norway had set up a medical treatment abroad project – The Patient Bridge – to channel waiting-list patients to contracted hospitals in Sweden, Denmark and Germany, resulting in perhaps 10,000 treatments over 3 years, with general patient acceptance but physician reluctance (Botten et al., 2004). Several Dutch health insurers have made similar arrangements in Belgium, resulting in perhaps 13,000 treatments there in 2008 (Glinos et al., 2010). Distance, conservatism and language differences, but possibly also the continued efficiency and reliability of the NHS, reduced response rates in Britain. New obsessions with personal wellbeing, instant gratification and the body beautiful, the decline of the public sector, and inadequate insurance coverage have come at a time when there are no grand narratives of political and moral change. The only grand narrative is seemingly one of environmental catastrophe – a world running out of the natural resources required to sustain extravagant lifestyles and still growing populations – which have disabled rather than enabled the achievement of political change, so evident in the Copenhagen climate talks at the end of 2009. The absence of national and international visions has encouraged a retreat into personal ‘politics’ and private stories of transformation – cosmetic surgery, makeovers of home and person – because there is no viable collective agenda for transformation. Increasing obsession with wealth, fame, physical appearance and material possessions is linked to the decline of care and concern for others in the world and environmental neglect (Carlisle et al., 2009). Whatever the reason, there is no doubt that in the last decade many have changed the way that they think about bodies – and part of that thinking

Introduction: Patients without Borders

has resulted in the explosive growth of medical and health tourism.

Towards Medical Tourism Medical tourism is simply where and when patients travel overseas often over considerable distances, to take advantage of medical treatments which are not available or easily accessible (in terms of costs and waiting time) at home. Domestic medical tourism also exists, where patients travel nationally, for specialized, cheaper or superior care, and a motto in central Australia is ‘When in pain, get on a plane’, but this is not discussed here. Medical tourism is different from simply going to spas or taking walking holidays – to regain well-being and fitness – in involving some invasive medical procedures. Since such procedures may be no more ‘invasive’ than routine testing and teeth whitening, the distinctions between medical tourism and health tourism, where spa tourism may increasingly involve direct intervention (Chapter 3), may only be slight. However, medical tourism is much more than merely the desire for some movement towards the body beautiful – it is also about escaping the constraints of inadequate health-care systems in home countries and finding cheaper, quicker and even superior alternatives. It takes multiple forms, it is personal and it is political and it has shifted the way that many people think about health care – and about tourism. Medical tourism has distinct social consequences. It is quite different from the way in which patients perceive themselves as having personal relationships with family doctors perhaps extending over generations. The nature of trust has changed, increasingly based on impersonal formal accreditation and the experiences of others rather than on local relationships, a shift towards an anonymity that is one part of globalization, even where personal relationships emerge in new contexts. Likewise it marks the rise of private care in the face of concerns over public quality

11

and the waning role of the state in health provision. Medical tourism has taken its place as one more component of the tourism industry, through its linkages with hotels, airlines and the whole infrastructure of tourism, and in the leisure activities of the tourists. As it has expanded, it has also become rather more institutionalized through, for example, the establishment in the USA of the Medical Tourism Association (MTA), to coordinate hospitals, insurance companies and the new ‘travel agencies’: medical tourism companies. In a post-industrial world it has been actively promoted by many governments as part of the tourist industry. Several Asian governments such as Thailand and Malaysia have developed 5-year plans for medical tourism and tourism boards, such as that of Singapore, include specific medical tourism divisions. The Thai Prime Minister wrote at the end of 2009: Thailand’s service sector is key to the country’s continued economic growth and development. The government’s current focus on laying down foundations for the Thai economy in the post-crisis world includes a number of projects to strengthen our services sector, especially tourism. Health travel is rapidly gaining ground and becoming more popular with visitors to Thailand. This is because Thailand has international standard medical, health and wellness facilities offering high-quality services at affordable rates. (Vejjajiva, 2009)

Here as elsewhere medical tourism is seen as an area of future growth that will boost national development in the wake of the global financial crisis, and which, as the Prime Minister went on to say, in very conventional phrases, would draw on the ‘natural beauty’ of Thailand and the ‘hospitable’ characteristics of the Thai people. Situating and branding medical tourism within images of the tourism sector makes social and economic sense. While medical tourism is constantly evolving, in some part it has emerged from long-established health tourism, discussed in the following two chapters.

2 The Antiquity of Health Tourism

Medical tourism has had a long gestation period. The very earliest forms of tourism were directly aimed at increased health and well-being. The first recorded instance of medical tourism dates back more than 2000 years when visitors, perhaps the first pilgrims, travelled from around the Mediterranean to Epidaurus in the Peloponnese, said to be the birthplace and sanctuary of the god of healing, Asklepios, the son of Apollo. In Roman times taking the waters was popular and spas date back more than 2000 years, and health cures linked to water were common to many regions. The numerous spas and sacred sites that remain in many parts of Europe and elsewhere, in some places represented the effective start of local tourism, as people travelled to gain physical benefits. From then onwards particular therapeutic places and landscapes, from springs and mountains to temples and cathedrals, have played significant roles in most cultures and regions. Health tourism, in a relatively gentle form, has a long and unbroken history. What exactly constitutes health tourism varies. Golf, tennis (and other sports) might be pleasant and healthy exercise and sources of well-being for some, but dull or sources of tension and pain for others. Festivals, leisure centres and cruises can stimulate health tourism, and occupational psychology workshops can be a form of wellness (Smith and Puczko, 12

2009: 7). However, such leisure activities, no doubt healthy relaxation for many, extend the notion of health tourism beyond forms of tourism that are specifically or primarily about health. A vast range of practices, examined in this and the following chapter, bring together tourism and health, and a number of particular places, from sites of indigenous importance (such as Uluru (Ayers Rock) in central Australia), spa towns and coastal resorts to pilgrimage sites (such as Lourdes in France and Fatima in Portugal) and hill stations, have gained and retained particular prominence as places with curative properties.

The Rise and Fall and Rise of Spas Around 1700 bc water had become recognized as having healing powers and Hippocrates, the philosopher and ‘father of medicine’, had claimed that, for healing, ‘water is still, after all, the best’ (quoted in Smith and Puczko, 2009: 22). Cultures of bathing evolved in the Indus valley and in the Greek and Roman empires with piped water, bath rooms and river pools. Persians used steam and mud baths and the Dead Sea, where Cleopatra was said to have bathed, was a source of immersion therapy by 200 bc.

© CAB International 2011. Medical Tourism (J. Connell)

The Antiquity of Health Tourism

Massage was practised in what is now Thailand as far back as 100 bc. The Romans exported the virtues of bathing to the empire, with Bath having Roman facilities by ad 76, and other places similarly benefiting not long afterwards. Wherever hot springs existed they were seen as having particular properties that encouraged their use in bathing, alongside ritual activities, so stimulating local mobility to take advantage of them. By the 4th century bc the temple at Epidaurus in Greece was the most celebrated healing centre of the classical world where patients travelled long distances to seek medical and mystical cures. To find the right cure for their ailments, they were said to spend a night in a sleeping hall, with room for more than 160 people and, in their dreams, receive advice on how to regain their health. Health care might also have had a more practical basis, since Hippocrates was said to have begun his career there, and nearby mineral springs were probably used for healing. Not only did spas, bathing and some concepts of healing play a role in tourism within the Roman Empire but, in Augustan society between 44 bc and ad 69, tourism had taken on typically modern characteristics. In this first flowering, it incorporated ‘museums, guide-books, seaside resorts with drunk and noisy holiday-makers at night, candle-lit dinner parties in fashionable restaurants, promiscuous hotels, unavoidable sightseeing places, spas, souvenir shops, postcards, overtalkative and boring guides, concert halls and much more besides’ (Lomine, 2005: 69). Health tourism was a key part of this, and the journey itself, with a change of air, was important. Roman tourists sailed from Italy to Alexandria in search of cures or, if they could not afford this, visited one of the mineral springs or the volcanic islands of Lipari, north of Sicily. Such travel was linked to superstition, the role of oracles and ritual, the significance of certain sites and economics. Much later many cities and resorts, from Baden-Baden in Germany, to the appropriately named Bath in England and Hot Springs in Arkansas (USA), and across numerous countries from Turkey to New Zealand, grew up around thermal springs and their therapeutic

13

properties. The Romans developed baths from Aix and Vichy in France to Buxton and Bath in Britain. The eponymous Spa in Belgium was established before ad 100 and Baden-Baden little more than a century later, although neither became popular until the next millennium. Around Hot Springs, Arkansas, native Americans had gathered in the valley for many years before European contact to enjoy the healing properties of the thermal springs. Like other indigenous peoples they probably used the springs as sources of healing long before Roman times. After the decline and fall of the Roman Empire the use of spas dwindled, partly because of fear over diseases being transmitted through public communal bathing, and only revived hundreds of years later. A few select springs and wells, believed to be holy wells, remained in use. However, the Ottoman Empire constructed Turkish baths in the 9th century, and spas were developed in central Europe at places like Buda (Hungary) and Karlovy Var (Czech Republic), but not greatly used until the Renaissance when water therapies, bathing and also drinking and douching, again became more common (Smith and Puczko, 2009: 23). Japan similarly had spas based on natural hot springs (onsen), the first of which opened at least as early as the 8th century. Like Roman baths they were used to heal battle injuries. Many other Asian and European countries, including Japan and Taiwan, have a centuries-long history of spas and hot springs, which flourished from the end of the 19th century, but wherever springs occurred they were accredited some restorative or ritual significance. Where thermal waters were particularly distinctive, as in Iceland, where hot springs emerged from a barren and often bitterly cold landscape, or at Rotorua (New Zealand), nicknamed ‘Sulphur City’, they became the basis of tourism industries. ‘Taking the waters’ had again become common by the 18th century in many European countries, and spa treatment was regarded as beneficial for diseases such as gout, liver disorders and bronchitis, though the elite social role of spas was as important as any medicinal qualities. Spas were said to

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Chapter 2

possess distinct healing properties rather than merely relaxing and restorative virtues. The first modern hydrotherapy spa was developed in Germany in the early 19th century ‘offering health packages of treatments, such as fresh air, cold water and diet’ (Smith and Puczko, 2009: 23). By the 19th century spas were evident even in such remote colonies as the French Pacific territory of New Caledonia, while the parallel emergence of ‘hill stations’ throughout much of the colonial tropics, but famously in India and Vietnam (see below), further emphasized the apparent curative properties of tourism and recreation in appropriate, often distant, therapeutic places. The ‘golden age’ for spas throughout most of Europe was the 18th and 19th centuries when it was fashionable for ‘high society’. The wealthy flocked to spas such as Bath and Karlovy Var (Karlsbad) to drink, bathe, see and be seen. In several spas doctors organized diets and treatment regimes, and other diversions ranged from gambling to horse riding. In the USA, at places like Saratoga Springs in New York and White Sulphur Springs in Virginia, similar trends occurred but without the more hierarchical class structures of Europe. In the UK Harrogate was the north of England’s leading spa town between 1880 and World War I, the first resort in England for drinking medicinal waters, and with nearly 90 medicinal springs, ideal for aristocrats who, after tiring of the London season, were able to stop for a health cure before journeying on to grouse shooting in Scotland. Drinking the iron-rich waters was regarded as a valuable part of the cure. But the aristocrats eventually moved on, Harrogate declined and only a Turkish bath is now possible. Buxton also declined but was still actively seeking visitors in the 1920s (Fig. 2.1). After the Industrial Revolution spas fell away, partly replaced by more active sea bathing, also assumed to provide health benefits through contact with water. At the Yorkshire coastal town of Scarborough (England) spa waters brought in visitors from the early 17th century and sea bathing was later added as a cure so that it became Britain’s first seaside resort. Science and medical knowledge, and especially modern medical practitioners, challenged beliefs in the efficacy of healing

waters, or at least their primacy, though spa owners tended to counter this by developing better hydrotherapy practices and urging complementarity. As religion flourished from the 16th to the 20th centuries, churches became more significant centres for social activities than spas (Smith and Puczko, 2009: 25) and with the advent of sewerage and piped water supplies there was less need to flee the towns for physical and mental restoration. Spa towns in Britain and the USA experienced a long-term decline, unlike in central Europe where there was state investment (Bacon, 1997), though in France too, Gréoux-les-Bains and a host of other spas, mainly in the limestone regions, have similarly slipped into obsolescence, even if some facilities remain open, as much as tourism curiosities rather than components of health tourism. Recently, with the opening of Thermae Bath Spa in 2006, Bath has sought revival and attempted to recapture its historical position as the only town in the UK offering visitors the opportunity to bathe in naturally heated spring water. Moree, Medlow Bath and Daylesford in Australia all experienced similar decline and sought revival in various guises. At Daylesford, for example, it took the form of an alternative lifestyle centre, with accompanying activities including massages, reiki, shiatsu, acupuncture, aromatherapy, reflexology, spiritual healing and tarot reading, in a selfproclaimed ‘spa country’. In various circumstances, especially in central Europe, spas have taken on more evident medicinal functions, with travel packages combining medical check-ups with recreation and relaxation. Such tours have become popular in Japan; a package at one resort in Okayama, a town with several hot springs, offered a general medical check-up and any optional tests, such as abdominal ultrasounds or respiratory tests (ErfurtCooper and Cooper, 2009: 167, 190). American, and other, spas may offer Botox injections and laser hair removal, though both are simple procedures (see Chapter 3). In Central and Eastern Europe alone, spas were recognized to have a medicinal role to the extent that socialist national governments, and trade unions, funded health trips to baths or spas in different parts of the country, according to

The Antiquity of Health Tourism

15

Fig. 2.1. Buxton Spa advertisement from the1920s (source: Ward Lock, c.1923).

what kind of healing properties the waters had, producing a distinctive democratization of spa use. In Finland wounded war veterans were given access to spas as one form of compensation and an opportunity for physical rehabilitation (Smith and Puczko, 2009: 8, 26–27). But these were rare examples of a direct state involvement in spas, or more generally in health tourism, that went beyond promotion and limited investment. Outside Central and Eastern Europe spas have otherwise tended to be reduced to a more simple restorative role, experiencing competition from the rise of seaside resorts rather than complementarity with them, and, as at

Daylesford, embracing more holistic directions to survive. Spas have remained of undiminished and now expanding tourism significance in much of Europe, from the Czech Republic eastwards to Kyrgyzstan (Goodrich and Goodrich, 1987; Schofield, 2004; ErfurtCooper and Cooper, 2009), and in parts of Asia, such as Japan, where they never lost favour with local people. Poland, for example, has more than 40 spas offering a range of treatments from mud baths to inhalations and drinking the water, most supposedly with distinct curative properties for ailments such as rheumatism and respiratory illnesses.

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Chapter 2

In France Vichy has grown after World War II to provide treatments for people with rheumatologic, gastroenterological and dermatological problems (Smith and Puczko, 2009: 26). The Blue Lagoon, south of Reykjavik, in Iceland, has treatment clinics that focus on psoriasis and other skin diseases Some specific springs and spas thus retained medical properties, and others acquired them. More frequently spas and hot springs have taken on tourist functions that highlight leisure, relaxation and general recuperation, in association with activities such as dining and sightseeing, rather than any specific medical benefit. Globally, hundreds of natural hot springs draw millions of annual visitors. Some are no more than swimming pools, while experiencing Japanese hot springs has been likened to a religious experience akin to pilgrimage (Knight, 1996). In parts of northern Europe, where springs are absent, saunas emphasize the role of water, but in constructed contexts rather than natural landscapes. Most contemporary spas differ from earlier times, in having no medical staff (traditional or modern) to provide advice and direction, and being primarily a form of recreation with healthy consequences (see Chapter 3). Many are to be viewed as much as experienced. Their legacy is the even-moredetached bottled spring water that has become a major global industry centred on a continued belief in the pure and healthy qualities of mineral water, and a considerable degree of elitism, particularly in association with such waters as Perrier and Evian, where this is combined with isolation from industrialization and notions of purity and authenticity (Connell, 2006b; Wilk, 2006). Even so for 2000 years spas have provided something of a prototype for medical tourism, where improved health is seen as taking the waters, internally or externally, in natural environments, in some cases with the additional benefits of advice and direction.

Pilgrimage Taking the waters in ancient Roman times, and more especially travel to Epidaurus in

Greece, were the earliest forms of tourism and, in both of them, there was a dominant element of pilgrimage. Consulting oracles, engaging in appropriate rituals and going to places of spiritual importance were essential. Some adherents would have perceived it as something quite different: duty or a desperate search for indulgence or a cure, but a cure that was spiritual as much as physical. Over time pilgrimage became more voluntary, undertaken to reflect upon and deepen religious faith, or to earn religious merit, but inspired by religious devotion. The motives for pilgrimage varied from penance for sin and concern for the afterlife to the desire for benefits in the present life, such as fertility, healing or simply good luck. Pilgrimage often involved ascetic practices (restrictions on diet or sexuality) but also sightseeing. Many pilgrimage sites are linked to water in some way. Springs and water have always been beneficent, especially in traditional agricultural societies. Many pilgrimage sites have links with water and purification, none more so than at Varanasi on the Ganges, and in various places ‘holy water’ emerges from the ground. Water has acquired almost universal symbolism as a means of renewal and a form of purification of body and mind. Multiple links exist between springs, spas and holy places. The legacy of the spiritual significance of water lives on in many places, sometimes simply as a tourism phenomenon, as now so many are pilgrimage sites. In the Peak District of Derbyshire, a limestone area in northern England, the ancient tradition of decorating wells, whose origins are said to lie in supplication to pagan gods for the annual provision of spring water where surface water was absent, has continued in the contemporary tourist spectacle of well dressing (Bird, 1983). Therapeutic places commonly integrate water and spiritual well-being. Most religions, including Christianity, teach that God sometimes sent illness and suffering as punishment, but that repentance and penitence could lead to a recovery. Claims that prayer and divine intervention could cure illness, and that cures might be secured through visiting a religious shrine, have been popular throughout history. Most religions, large and small, are associated with some

The Antiquity of Health Tourism

places of special significance – such as the Vatican City, the Wailing Wall in Jerusalem and Mecca – and almost all have certain shrines, churches, mosques, synagogues, etc. of particular significance. Sometimes these are places where special events were said to have occurred – apparitions of the Virgin Mary at Lourdes, Fatima, Knock or Medjogurje, where the Buddha taught or rested (including his birthplace at Lumbini in Nepal, and Sarnath, near Varanasi, where he preached his first sermon), and Mecca, the birthplace of the prophet Mohammed. Some regions, like the Holy Land, have a proliferation of sites, while some religions, notably Catholicism, have a proliferation of holy places, some like Walsingham shared with other religions (Mahoney, 2003), many unknown to other than a few devotees, sometimes ephemeral and often contested. Pilgrimage constitutes something of a rite of passage, a journey of moral significance from the profane to the sacred, undertaken to ‘propitiate and exorcize those supernatural forces which create illness, death and misfortune’ and restore order in life (Gesler, 1996: 96). Many pilgrimage sites are in peripheral or isolated areas, such as Mount Kailash in Tibet and the Amarnath Holy Cave (Kashmir), necessitating long journeys and real separation from the everyday. Getting to, often walking to, such places was and is physically demanding and often costly. Pilgrimage sites are often places of last resort for cures to what have been incurable conditions, and a reaction to mass technology and scientific culture, that both rejects some forms of modernity (Turner and Turner, 1982) and prefers a ‘popular return to mystery at a time when the elite culture has turned to rational thought’ (Gesler, 1996: 99). Although ‘miracle cures’ at pilgrimage sites might be few, and biomedical benefits have usually been slight (Joyeux and Laurentin, 1986), the experience of visiting such sites involves a significant emotional experience, with positive psychological outcomes. Thousands of people have claimed to be cured at Lourdes, and in similar therapeutic places, and a combination of spring water and baths, exercise, ritual prayer, community, hope and the placebo effect are likely to have had beneficial influences on

17

the spiritual and physical well-being of many. Walking, even processing, to sites, sometimes over many days, as at Santiago de Compostela, created a mobile community. Even away from such sites a wide range of studies have demonstrated positive relationships between spirituality and mental and physical health, perhaps linked to community, social support and improved coping (e.g. Devereux and Carnegie, 2006; Sternberg, 2009; Williams, 2010), and such social determinants of health are intensified through pilgrimages to places of particular significance. Pilgrimage retains its vitality for many. Buddhist shrines like that at Hangzhou (China) are ‘spaces of healing’ where sick people travel in search of good health either through prayer and supplication or through actual medical treatment, in ‘a transformative space, a space of becoming healthy and whole’ (Walsh, 2007: 478). Contemporary transport services, and greater affluence in developing countries, have boosted the possibility of long-distance tourism, accounting for the greater popularity of the hajj pilgrimage to Mecca (Saudi Arabia), and enabling more to fulfil the last precept of the Five Pillars of Islam, that all Muslims must try to make the pilgrimage at least once in their lives (Timothy and Iverson, 2006). Culture and duty are here combined. Elsewhere few anticipate biomedical cures. For contemporary visitors to Lourdes the primary goal is spiritual renewal, but healing occurs in a place of meaning (Gesler, 1996). Especially in the developed world, the loss of faith in miracle cures has meant that pilgrimages have become a means of asserting spirituality, gaining spiritual sustenance and revitalizing religious faith, or they have even become more of a tourist activity, simply to see interesting places such as the Holy Land. It may have been as recently as the 20th century that travelling to pilgrimage sites began to be seen as pleasurable. While certain sites, notably the tomb of St James at Santiago de Compostela (Spain), became places where a particular form of tourism – combining physical and spiritual dimensions – largely took over from purely spiritual dimensions, some such as Mecca have remained primarily spiritual, open only

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Chapter 2

to Muslims, despite inevitably acquiring commercial overtones. Pilgrimages often evolved into holidays, as on the road to Santiago de Compostela, walked by devout pilgrims and atheists alike, so that differentiating between pilgrims and tourists is impossible (Gatrell and CollinsKreiner, 2006; Andriotis, 2009; Olsen, 2010). Travel companies have emerged that focus on spirituality, as in the case of the Indian company, Spiritual Journeys, whose home page observes: Spirituality plays an increasingly important role in the way we make sense of ourselves and our world. India has been the home of spirituality for over 4,000 years. Sages, philosophers and founders of religions have found sanctuary and enlightenment in the soil and spirit of the country. Spiritual Journeys seeks to nurture the spirituality within you by delving into the rich spiritual history of India. Your journeys will take you to some very special places and expose you to a cornucopia of ethnic cuisines, music, rituals, culture and beliefs. (Spiritual Journeys, 2010)

Ancient religious traditions are thus opened up and offered to others from quite different traditions as sources of well-being and spiritual health (see below). It is not particularly surprising that many health practitioners now argue that spirituality is at the core of good health or wellness (e.g. Steiner and Reisinger, 2006). Spirituality may, however, be a much more personal phenomenon rather than either being linked to organized religion, as most pilgrimages are, or to a particular place.

Hill Stations Place has often been linked to physical wellbeing, without any real spiritual or ritual significance. Wherever feasible when Europeans established tropical colonies they also established hill stations, temperate townships that provided a respite from the mosquitoes, heat, humidity and pollution of lowland towns. The health benefits from mountain retreats, like spas and coastal retreats, were constantly touted as beneficial to the colonial

administrators and subsequently to the wider populations of towns that grew through the Industrial Revolution, yet only elites could take advantage of them (Kevan, 1993; Gesler, 2003). Throughout the British and French empires hill stations (and also water cures) were believed to have therapeutic properties, and play ameliorating roles against diseases such as malaria and yellow fever. Countries without hill stations were hardship postings (Kennedy, 1996; Jennings, 2007). In more temperate climates mountains were popular summer destinations for ‘cooling off’ and enjoying the scenery, so that the Alps, especially such holiday towns as Lucerne and Interlaken, took on a year-round significance, as eventually the Rockies performed a similar role in North America. In India several destinations became famous as havens for rest and recuperation, such as the hill stations at Darjeeling and the lakes of Kashmir, Shimla (Simla) and Ooty, most developed in the mid-19th century. In Darjeeling the British established a sanatorium, mainly for lung diseases, and a military depot and tea plantations, and it became the informal summer capital of the Bengal Presidency in 1840. Two decades later, Shimla was declared the summer capital of the British Raj in India, and British soldiers, merchants and civil servants moved each year to escape the summer heat of the plains. In southern India Oootacamund (Ooty) similarly served as the summer capital of the Madras Presidency, with winding hill roads and a railway financed by influential British citizens. It was a popular summer and weekend resort for the British during the colonial days, and soldiers were sent there to recuperate. The end of the colonial empire brought the decline of many such places, brilliantly and evocatively described, notionally for Kalimpong, by Kiran Desai in her book The Inheritance of Loss (2006), and subsequent efforts to revitalize them as tourist destinations. While colonial hill stations were located in tropical contexts, uplands were seen everywhere as places to escape to and revive that in some respects contrasted with the coast. Sanitoria were constructed in countries like Switzerland, as people with tuberculosis were encouraged to go to mountain areas,

The Antiquity of Health Tourism

while those with bronchitis or rheumatism went to the seaside. Various places were believed to have distinctive curative properties, and mobility and subsequently tourism responded to that.

Coastal Resorts To a greater extent than hill stations, more accessible coasts were invariably seen as stimulating and bracing places with sea air being regarded as beneficial, especially where cool breezes contrasted with oppressive urban-heat islands. Even by Roman times, it was possible to claim that ‘the shoreline from Rome to Naples was comparable to the contemporary French Riviera’ (Lomine, 2005: 78), with resorts, villas, yachting and bathing in hot coastal springs. Climate and urban crowding ‘drove both the masses and the upper crust in seasonal migrations from sultry and vapor-ridden Rome’ (Lencek and Bosker, 1998: 34), but as the Roman Empire fell, so beach culture also collapsed. It was not until the 18th century that seaside resorts revived, and in a different region. In Britain sea bathing for pleasure then gradually began, with Scarborough, already a spa town, leading the way. Several coastal towns flourished after they had been chosen by court doctors as places where royal invalids might regain their health (Gilbert, 1954: 15). Somewhat later, recreation and tourism shifted seawards in developed countries and, with railways, extended from elites towards the working classes, and sea bathing became – surprisingly recently – a healthy form of recreation. In some respects ‘sea-bathing as a form of therapy and penance was invented by the British, the same nation that gave the world, nearly simultaneously, the cold bath, the steam engine and the Industrial Revolution’ (Lencek and Bosker, 1998: 71). Only in the mid-19th century did the preeminent British coastal resort, Brighton, pass the spa of Bath in popularity (Gilbert, 1939). The health benefits from coastal or mountain retreats were constantly touted as beneficial factors in all forms of tourism, not least to the populations of the towns that grew during

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the grim years of the Industrial Revolution, whether in Europe, North America or much later in Asia. In Britain seaside resorts emerged as an adjunct to the spa season, but by the late 18th century they had taken on a life of their own, and had become fashionable in their own right. In Europe fishing villages gave way to tourism, as they were to do almost two centuries later in Asia. As late as the 18th century the fashion for sea bathing spread from England to the continent, and even later from the cold waters of Britain to the warm seas of the Mediterranean, by which time fashion rather than health dictated coastal holidays. In many developed countries coastal towns grew rapidly in the 19th century, with such places as Atlantic City, Boulogne and the Isle of Man experiencing unparalleled numbers of visitors seeking sea air and sea bathing. As affluence increased and transport infrastructure developed, again especially railways, the centres of gravity of coastal tourism shifted towards the tropics. By the early 19th century tourists were beginning to stimulate coastal growth in the French Riviera and Florida. California, the many shores of the Mediterranean and Queensland all later boomed. Visits to the coast were long recommended for their curative powers, both through escaping urban miasma and benefiting from sea air and salt water. Taking the air at the coast was at least as important as sea bathing, and guidebooks published by doctors affirmed the benefits of sea bathing and air quality, with the combination of ‘ozone’, ‘bracing’ and ‘tonic’ being central publicity themes, though the focus shifted between bracing in Britain, refreshing in Spain and a relief from urban humidity in the USA (Beckerson and Walton, 2005). Islands, such as the Isle of Man, the Isle of Wight (and even Long Island), that might combine a voyage, separation and surrounding waters and clean air, were particularly popular. Brighton was given its start as a seaside resort by doctors in the early 19th century, and later, doctors prescribed both bathing in and drinking sea water as a cure for ‘struma, consumption, renal calculus and scirrhus’ while the dry air (because of the absence of

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rivers) was seen as unusually refreshing so that ‘neither dropsical, nor chloritic complaints, pleurisies, nor quincies, nor any other inflammatory ones prevail’ (quoted in Gilbert, 1954: 57, 63). Beliefs and responses changed but Brighton continued to be recommended as a healthy resort, and doctors themselves moved there. More generally sea bathing ‘was constructed as a therapeutic response to a set of medical conditions that ranged from vague psychological ailments to grave physical maladies’ (Lencek and Bosker, 1998: 74), while cold sea water enhanced moral character as much as it remedied physical conditions. Promenades as both nouns and verbs became common. For many decades coastal resorts and businesses promoted their health-giving characteristics. ‘If melancholy and spleen were the disorders that drew patients to the beach in the eighteenth century, in the nineteenth century tuberculosis was the maladie du jour for the Romantic generation’ (Lencek and Bosker, 1998: 109). Consumptives even migrated from the UK to New Zealand in search of relief (Bryder, 1996). Though in the second half of the 19th century other strategies for treating tuberculosis were found to have better results, ‘the enduring presence of pulmonary disease until the 1930s was convenient and, although no resort was keen to attract the sick, most were delighted to welcome non-infectious and profitable convalescents’ (Beckerson and Walton, 2005: 65). Yet the specifically therapeutic functions of beaches faded in the 20th century, only reviving when sunbathing, rather than the air or water, became fashionable. Recuperation even took on elements of spirituality; the beach – the interface between land and sea – became ‘a sacred place’ with symbolism attached to sunrise and sunset, and a place for ‘spiritual solace and support’ (PrestonWhyte, 2004: 353). Swimming was invested with spiritual qualities by some, though it was not until late in the 19th century that it became even mildly popular, and surfing belatedly followed as recreation became more active. In the 19th century bathers ventured into the sea near dawn and dusk, since medical science held that the sun dried up the body’s

necessary fluids leaving it softened and prone to physical ailments and moral corruption. People rarely lingered on the beach but exercised, conversed, took to the water and moved on (Corbin, 1994: 78). Even so ‘class prejudice was an even more potent sunblock’ (Lencek and Bosker, 1998: 200) as it remains in many parts of east and South-east Asia. By the 1920s that ‘wisdom’ had been swept away and, instead of guarding against the sun’s rays, people were encouraged to bask in the sun and ‘bake themselves back to health and vitality’ so that sunbathing became ‘not only therapeutic but a rite of purification and spiritual healing’ (Lencek and Bosker, 1998: 201). Beach wear became briefer and briefer, culminating in the bikini, a state of mind as much as two pieces of cloth, and new arguments over morality. Medical journals prescribed a combination of sunshine and fresh air, without evidence of long-term problems and, where sunbathing was impossible, solariums became substitutes. Cheap transport and the greater certainty of sunshine boosted the Mediterranean and Caribbean, at the expense of northern climes, and changed the wider geography of tourism and health. However, when melanomas and skin cancer became linked to excessive exposure to sun, beaches became ‘ambiguous landscapes’ (Collins and Kearns, 2007) with risk now being attached to body exposure in hitherto pleasurable and therapeutic environments. Seaside resorts thus went through a series of diverse therapeutic purposes, from places to take the air and the waters to places to exercise, and avoid the sun, each of which became reconciled in their continued manifestation as places of retirement. Sports, such as surfing, golf, cycling, walking (or tramping) and mountaineering, similarly became part of the tourist experience – mainly in the mid-20th century – and were supposedly pleasurable ways of combining tourism and well-being (despite golf being described by Mark Twain as ‘a good walk ruined’). Access to the open air and exercise was both healthy and an element of personal freedom, in an interwar world that was often conservative and constrained. The countryside was seen as endowed with educational and humanizing forces; the activist

The Antiquity of Health Tourism

of rambling and countryside preservationist, Cyril Joad (1934: 150), observed: Whence can we derive … an education alike of body, of mind and of spirit, so happily as from Nature? The feeling of the air upon the skin, of the sun upon the face: the tautening of the muscles as we climb; rough weather to give us strength, blue skies and golden sunny hours to humanise us – these things have their influence on every side of our being.

By the end of the 19th century golf links, with their refreshing sea breezes, adorned large parts of the British coast, and beaches, moors and mountains were places of physical activity. In most perceptions ‘getting back to nature’ was seen as an invaluable part of wellness. In some respects this was taken to its extreme in naturism, which had several philosophical sources, many emerging from early 20th century German ideas of health and fitness. Concepts of returning to nature and creating equality were also inspirations. German doctors were using heliotherapy, treating diseases such as tuberculosis and rheumatism with exposure to sunlight. From Germany the idea spread to the UK, Canada, the USA and beyond. Naturism gained prominence in Germany in the 1920s, in the midst of ‘a growing fetish of the countryside’ (Bell and Holliday, 2000: 130), but was suppressed after Hitler came to power. Proponents of naturism argued that it was valuable for health (evident in the title of the long-standing British magazine Health and Efficiency), and a more egalitarian and relaxed social life by removing all markers of social status and offering a sense of liberation. At Wreck Beach (Vancouver) people: once naked, no matter what their class gender or ethnic origins, are bona fide members of the community. In their nudity they share a bond, a trans-personal sense of belonging. In their ritualized participation in the timeless space of sun-worship, they mutually step outside the tyranny of the clock and the tyranny of ‘normal’ surveillance. They are, in a sense, united in a timeless space of ludic pleasure and sensual recuperation: they belong to a place out of time and out of normalcy. … As such it became a place of pilgrimage for those who reject the

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remnants of restrictive morality and the aesthetics of modern consumption. (Evans, 2000: 19, 6)

Such notions of egalitarianism, alongside both natural bodies and nature, whether at beaches or in country settings, offered hints of the wilderness philosophies of writers like Thoreau and, in America, drew on native American mythologies and rituals (Bell and Holliday, 2000: 135). Here too, in somewhat extreme form, particular isolated places offered distinct forms of relaxation and recuperation in what might pass for pristine social and ecological contexts. Inactivity, rather than exercise, however, was a large part of coastal tourism. As Smith and Puczko noted rhetorically, but with some truth, ‘If wellness tourism was merely about relaxation, then one might argue that the traditional beach holiday with its emphasis on sunbathing is the ultimate form of relaxation!’ (2009: 9). Indeed lying in the sun, eating and drinking, and becoming less fit, may reduce stress significantly and benefit psychological well-being. Cruise-ship tourism, where movement is minimized further, may be even more relaxing. Not only is passive gazing at both human and physical landscapes beneficial to well-being, but many exotic and expensive forms of wellness tourism offer no more than an elite form of meditation and gazing. None the less beaches and coasts have long been places of good health and well-being, in a variety of forms and in every part of the world.

The Role of Therapeutic Places Physical and psychological well-being have long been enhanced by displacement from daily life to therapeutic places with particular perceived spiritual or physical properties. In some places such ‘physical and built environments, social conditions and human perceptions combine to produce an atmosphere which is conducive to healing’ (Gesler, 1996: 96). Pilgrimage destinations especially were sometimes so remote that just getting there was a form of purification, a means of participating in community and sometimes healthy

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exercise. Most were linked to water in some way, frozen into a lingam at Amarnath, bubbling from the ground in multiple sites or cascading through waterfalls, or alternatively were higher places closer to the spirit world. While most tourism – to beaches or even hill stations – was over quite short distances, pilgrimages often took people further and across national boundaries. In its link to spirituality and through its supposed healing qualities in many ways it was the precursor of new forms of tourism, and even of medical tourism itself. Throughout the world a number of particular sites – mainly spas – early on became associated with effective curing properties and, while many small spas fell out of use, those that survived were revived as the basis of a thriving tourist industry in the 20th century. Spa tourism boomed at the end of the century, re-igniting linkages with revived modes of thought concerning spiritual well-being and a new concern for ecology and the environment that sometimes spilled

over into broader issues of authenticity, examined in the following chapter, and a more holistic perspective on bodily links to the environment. Even in the very earliest years, on the Roman coastline, tourism was as much about recreation as about self-realization, or relaxation, recuperation and restoration. Two millennia later, the spiritual dimensions that had often been a part of tourism were less obviously part of 20th century coastal tourism, and of the mass tourism that had become dominant. Physical activity and hedonism replaced contemplation. Yet just as tourism was taking on purely recreational forms, spirituality became reinvented by some in ways that offered new links between health and therapeutic places, though these were increasingly constructed rather than directly involving elements of the natural landscape. At the same time modern biomedicine (i.e. sciencebased medicine) achieved an almost universal dominance, offering an unprecedented range of alternatives for health care.

3 Mind and Matter: Health Tourism or Cosmetic Surgery?

While health was generally perceived as a physical phenomenon, the mind and spirit were rarely excluded. Ill health was often attributed to spiritual and cultural causes, even as biomedicine accompanied scientific development and a movement away from localized cultural beliefs about health. However, in recent years there has again been a shift of belief systems away from an exclusive regard for biomedicine, and from the primacy of science (evident also in the revival of creationism, and opposition to evolution in some Western societies). While older forms of tourism, with their links to oracles, pilgrimage and particularly venerable sites, might have been seen to emphasize ritual and religion, a sense of spirituality and the particular roles of both mobility and therapeutic places were never completely displaced by ‘new’ forms of knowledge and practices, and in the 20th century were often revived in various contemporary forms. Bodies, minds and belief systems were rarely disconnected. This often took a form where more spiritual and less strenuous activities, such as yoga and massage, once primarily the province of some Asian countries, became absorbed into Western practices with health and well-being becoming more holistic phenomena. Nurturing the mind and the spirit in various ways, for long an important part of tourism, resurfaced in new forms. This chapter primarily

examines more obviously all-embracing practices, where travellers sought some form of enlightenment, and where various ideologies were combined to promote particular kinds of healthy bodies and minds, while recognizing that biomedicine never lost its dominance, and cosmetic surgery stimulated a vibrant new strand.

Secular Pilgrimage Although religious beliefs dominated notions of spiritual well-being, more secular philosophies eventually played a greater part in travels for health and wellness (Chapter 2) while romanticizing and cherishing particular locations. Travelling itself became invested with quasi-spiritual dimensions especially where it took Western peoples away from familiar material landscapes to distant, perhaps countercultural nirvanas where alternative cultures were said to provide enlightenment, peace and spiritual harmony. From at least the 18th century onwards European explorers sought lands and cultures whose lives might add new dimensions to those of the West. Such voyages, in search of ‘lost worlds’ took Europeans through MiddleEastern and African deserts, Amazonian jungles and Himalayan mountains in the quest

© CAB International 2011. Medical Tourism (J. Connell)

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for knowledge, bringing back stories of exotic lost cities and intriguing cultures, that sometimes captivated European imaginations. What often seemed to be ‘Boy’s Own’ adventures, as much as serious engagements with different cultures and lands, continued until well into the 20th century with authors such as Bruce Chatwin writing of Patagonia and the songlines of Aboriginal Australia, and lauding archaic knowledge. The 20th century also brought the rapid rise of both travel guidebooks, which evolved from formalistic discussions of architecture and mountain ranges, to more vivid depictions of local cultures and idiosyncrasies, and travel stories that brought such places alive. Michel Peissel’s Mustang (1964), Thor Heyerdahl’s account of the voyages of the Kon-Tiki, and other similar books, captivated readers with their depictions of seemingly idyllic societies, and hinted at the possibilities of a hesitant global tourism. Even anthropological accounts, for example of Pacific islands, rhapsodized over cultures that seemingly lived in harmony with their environments, and where the indigenous population were healthier than those of the West, resulting in books with titles such as Where the Poor are Happy, The Happy Island and Love in the South Seas (Connell, 2003). Notions that pristine cultures with superior cultures and ways of life existed in distant places lingered on and revived through the counterculture. While few had the resources to replicate such elite travels, by the mid-20th century a form of escape became possible with greater affluence and a thirst for adventure, stimulated in the wake of the bleakness of post-war regimentation and perceptions of drab and soulless lives. Writers such as Jack Kerouac, the progenitor of the ‘beat generation’, whose semi-autobiographical book, On the Road (1957), documented his road-trip adventures across the USA and Mexico in the late 1940s, and dealt with Buddhism, drugs and sex, set the scene for others to travel and explore different cultures and themselves. Films such as Easy Rider offered invocations to ‘head out on the highway’. The ‘beat generation’ made mobility a philosophical adventure, a search for self and salvation, and Route 66 became a means of escape and liberation (Gibson and

Connell, 2005: 178–182). Although the search for a new spirituality was the antithesis of the materialism that attended the 1960s in the West, for many travel itself was merely fun, enervating and an escape, however brief, from the stultification of suburban angst, into more natural places. The ‘counterculture’ of the 1960s brought ‘flower power’, the hippie era, Timothy Leary’s invocation to ‘Turn on, tune in, drop out’ (that urged people to embrace cultural changes through using psychedelic drugs) and early hints of ‘green philosophies’ that first emerged from Rachel Carson’s Silent Spring (1962), and eventually took a more radical ecological form. The counterculture emerged in west coast USA and spread to other Western nations, with small inroads across the Iron Curtain. At the end of the decade Joni Mitchell wrote the bestselling ‘Woodstock’, a song that cherished the famous open air concert and whose lyrics seemed to epitomize the era: ‘We are stardust/We are golden/And we’ve got to get ourselves/Back to the garden’: the certainty that life should be simpler and that other wisdom was possible. There were hints of elitism in this that sometimes brought criticism of a ‘modernist gospel of “less is more” applied to everything from money and energy-inefficient technology to clothing and self-restraint’ (Lencek and Bosker, 1998: 248). Elements of a back-to-nature movement waxed and later waned in the 1970s, in part as economic growth slowed. Inherent in counterculture were ideas that other cultures held valuable knowledge of the environment, religion, spirituality, medicine and well-being. The counterculture rejected established institutions, including medical institutions, and sought inspiration and well-being in distant places. Alternative cultures, cosmologies and philosophies – loosely ‘ancient wisdom’ – were said to provide enlightenment and peace, and therefore a better base for good health. Some of its adherents, whom Lencek and Bosker later called ‘the narcissists of the “Me Generation”’ (1998: 251) gravitated to communes, usually in idyllic locations, and also to ‘primitive’ coastal resorts from Goa to Kuta, and Asian cities from Kabul to Kathmandu. Hippie trails

Mind and Matter

were carved out from Turkey to the mystical and supposedly licentious Asia. The Beatles communed with the Maharishi and Orange People brought their liberating yet disturbing philosophies to the West. Celestine prophecies followed. Drug use was given validity and anthropological weight, as a means of self-discovery, spiritual fulfilment and enlightenment, by Carlos Castaneda, whose books, The Teachings of Don Juan: a Yaqui Way of Knowledge, A Separate Reality and Journey to Ixtlan, all of which emerged between 1968 and 1972, described his ‘apprenticeship’ to a traditional Yaqui Indian shaman from northern Mexico, which gave him knowledge of psychotropic plants and their ability to induce altered states of awareness. By the time that his books were denounced as fiction they had influenced many to consider other realities, states of consciousness and alternative means towards well-being. Countercultures encapsulated what came to be called the New Age movement, a concept impossible to define, since it combines variable elements of Eastern religions such as Hinduism and Buddhism, fragments of loosely political perspectives on sustainability and collectivism, and indigenous perspectives on land, rurality and spirituality. Central to New Age philosophies were beliefs in the need for sustainability, abhorrence for processed food and a strong belief in holistic health, where good health had a very strong spiritual component and alternative ‘natural’ medicines were used in addition to, or in the place of, conventional medicine. Broadly, holistic health sought to integrate all aspects of people’s needs, whether psychological, physical and social. This embraced ‘alternative’ practices such as therapeutic touch, homeopathy and naturopathy, with hypotheses (where they existed) and practices not accepted by science-based medicine (biomedicine), which offered at least a strong placebo effect. Ayurveda, meditation, yoga, acupuncture and other techniques were all variously part of the New Age movement and of a wider context of alternative medicine. In some cases New Age practitioners came together in particular communities such as Findhorn (Scotland) with both an ecological and spiritual focus (Smith and Puczko, 2009: 51–52).

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Sustainable values at the Findhorn Ecovillage are expressed in the built environment with ‘ecological’ houses, using local stone and straw bales, as tangible demonstrations of the links between the spiritual, social, ecological and economic aspects of well-being. Alternative health practices were filtered through various activities. New Age ambient music, for example, stressed the healing powers of certain natural landscapes and New Age philosophies, and renewed interest in traditional cultures, herbal remedies, crystals and a range of unorthodox spiritual beliefs, some associated with particular places of mystical significance, such as Sedona, Uluru and the environs of Byron Bay in Australia, and sometimes linked to traditional beliefs about earthly origins and ancestral practices. Listening to ambient music alone was said to bring relaxation and spiritual healing, since it was centred on background sounds that had the explicit purpose of aiding meditation and relaxation, or enabling practices such as alternative healing, yoga and ‘chakra auditing’ (Connell and Gibson, 2009). Thus at Byron Bay one local performer who mixed Aboriginal references with tribal and mystical symbols stressed that his music was invaluable for ‘reawakening and realigning to the sounds of mother earth’ and ‘permeating, vibrating and opening various chakras’ (quoted in Gibson and Connell, 2003: 181). Diverse mystical beliefs have been used as sources of wellbeing. Chakras, according to traditional Indian medicine, are believed to be ‘force centres’ of energy permeating from within the body. Knowledge of the chakras is central to many different therapies and disciplines, including Ayurveda (see below), aromatherapy, reiki and crystal/gem therapy. Reiki practitioners use their hands and crystal practitioners place crystals on different parts of the body, often corresponding to the chakras. Acupuncture similarly focuses on balancing energies within the chakra system, but with a physiological basis. In every era individuals have sought other forms of knowledge and enlightenment, and claimed to have found them in distant places and other cultures, displaced from everyday work and domestic experiences. The conservation practices and technical

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knowledge of environmental issues by indigenous peoples with limited contact with ‘modern’ society stimulated a Western concern with ‘learning from the past’, embodied in distant cultures, and evident in the rise of permaculture, some notions of deep ecology and the emergence of books such as Wisdom of the Elders (Knudtson and Suzuki, 1992) where small-scale, indigenous societies with close connections to nature had invaluable knowledge. Such assumptions have never disappeared. Other subsequent forms of travel combined more specific notions of pilgrimage and healing. African Americans travelling to West Africa were not simply visiting the ancestral lands that other diasporic homecoming tourism involved, but were visiting the sites of enslavement of their ancestors: ‘places that resemble shrines and are attributed a strong potential for cathartic healing’ (Schramm, 2004: 138). In a quite different context some Vietnam veterans, making an annual journey across America, the Run for the Wall in Washington, found it a psychological necessity that strengthened community and contributed to the ‘personal healing of veterans who are still suffering from the psychological emotional and spiritual effects of their Vietnam War experience’ on the ‘open road’ where ‘the wide open spaces and the beauty of the landscape characterize the American heartland’ (Dubisch, 2004: 109, 106). Respect for nature, other cultures and forms of healing took quite different forms, but often involved some detachment from home. However nonsensical and exploitative some of the outcomes of such quests may have been they left a legacy in health food, festivals (such as the Burning Man festival in the Nevada desert), a handful of communes (such as Christiania, Copenhagen), mysticism, drugs and greater respect for other cultures and traditions. Openness to alternative approaches to life spilled over into an appreciation for complementary and alternative medical practices such as meditation, homeopathy and acupuncture. Some New Age health (and other) perspectives filtered out to a wider world that also slowly embraced more holistic perceptions of health and

well-being, and eschewed the certainties and dogmas of conventional religion and medical practice. Larger numbers of people came to use mainstream medicine for diagnosis and basic information, while turning to alternatives for what they believed to be healthenhancing measures. In 1997 some 14% of Americans had sought the services and advice of both a medical doctor and an alternative medicine practitioner (Eisenberg et al., 1998). A year later in England 10% of adults had used alternative therapies (defined as acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, osteopathy, reflexology and aromatherapy); more of these were women rather than men and younger people were more likely to try alternative therapies (Thomas et al., 2001). Some were practised by those for whom biomedicine had been unsuccessful, such as cancer and acquired immunodeficiency syndrome (AIDS) patients, to relieve pain as much as offer cures. In some part they calibrated a broader acceptance of holistic health care and a willingness to accept a range of health therapies and practices.

‘New’ Pilgrimage As alternative belief systems were absorbed into Western cultures so their adherents sometimes moved to places where their practice might be particularly effective and authentic. Western tourists travelled in search of yoga, meditation, homeopathy and a range of other approaches as the search for cures took on more spiritual and holistic perspectives. Adherents of these alternative practices and beliefs sought not just personal awareness and healing, but at least a temporary escape from ‘Western societies [that] created a form of materialism that does not always nurture the soul adequately’ (Smith and Kelly, 2006: 16; see also Williams, 1998), and a movement away from its physical and philosophical confines and constraints. The legacy of these journeys has been the expanded presence of health tourism (one basis for medical tourism) in cultural contexts quite different from those of traditional

Mind and Matter

tourists. In India ashrams and gurus attracted followers. One of the more famous ashrams, Osho in Pune (India), attracted followers from more than 100 countries (though a large proportion are from India) and from a diversity of religious backgrounds, to engage in meditation and various approaches to healing (Smith and Puczko, 2009: 73–74). Its website described it as: This lush contemporary 28-acre campus is a tropical oasis where nature and the 21st Century blend seamlessly, both within and without. With its white marble pathways, elegant black buildings, abundant foliage and Olympic-sized swimming pool, it is the perfect setting to take time out for yourself. This is a place where you can simply relax and where you can also enjoy the company of visitors of all ages from over 100 countries. You can choose if you want to do something, or if you just want to rest, swim, meditate – or just to be. You may like to nourish your body-mind-soul with a stunning selection of individual sessions, like bodywork and massage, and longer workshops and courses – all designed to help you become more aware of yourself. (Osho, 2010)

Other ashrams had less luxurious, more spiritual elements, but all enjoined notions of eastern spirituality and healing. Ayurveda tourism became a related element of the ‘new’ Asian (more specifically south Asian) tourism. Ayurveda (the ‘science of life’) is a system of traditional medicine indigenous to south Asia and continuously practised there. Ayurvedic practitioners have identified medicinal preparations and surgical procedures for curing various problems, and several components, such as the use of herbs, massage, and yoga as exercise or alternative therapy, have been more widely adopted in other approaches to health care. Contemporary Ayurveda largely involves massage, claimed to be particularly suitable for such chronic ailments as arthritis and rheumatism, but more austere treatments include internal herbal applications. Though the Indian state of Kerala has actively promoted Ayurveda tourism, for most tourists in Kerala Ayurveda was a secondary concern involving occasional massages, rather than the central preoccupation

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(Chitramani and George, 2009; Hannam, 2009). Such tourists were viewed dismissively by local physicians. Like ashrams many Ayurvedic retreats have taken on more luxurious elements where spiritual practices and even exercise have been marginalized, and core practices excluded where they are inconvenient to foreigners (Spitzer, 2009). The Australian company, Ayurveda Elements, offers holidays to Ayurveda resorts in India claiming for one of these, the Beach and Lake Resort (Kerala), that: Beach and Lake have qualified and experienced Ayurvedic doctors all with a Bachelor of Ayurvedic Medicine and Surgery degree. The potent Ayurvedic medicines employed are from the reputable Vaidyaratnam Aushudashala and the esteemed Kottakkal Arya Vaidyashala. The supervising physician is Dr V. Franklin, one of the best known Ayurvedic doctors in Kerala and a specialist in Panchakarma treatment. Dr Franklin hails from a traditional Ayurvedic background and a family that can trace their tradition back 400 years. Formerly the District Medical Officer for the Kerala Government, Dr V. Franklin has travelled the world giving seminars and consultations. In 1999 he was named: ‘Tourism Man of the Year ’ for so successfully combining tourism with Ayurveda. (Ayurveda Elements, 2010)

The resort’s owner suggested ‘When we love ourselves we allocate time for rest and rejuvenation. An annual retreat is the best health insurance’ (quoted in Chapman, 2008: 36). Many such resorts and retreats offered distinctive, sometimes minimalist, nutritional programmes. Detox retreats offered diets and nutritional plans, minor therapies (such as nasal reflex therapy) and massages, along with exercise. Yoga, as both exercise and philosophy, is said to unite the mind and body by removing the tensions of everyday life, and has become part of a further strand of health tourism with south Asian dimensions. While British yoga tourists may go to places as diverse as Morocco and Ireland, India appealed to many yoga tourists ‘for its mystery and spirituality’ (Ali-Knight, 2009: 92) and for being the home of yoga. Yoga has become a part of holidays, where it is more obviously an exercise, as

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yoga has also ‘come out of the ashram’ towards celebrity status (Rosin, 2006). In some meditation retreats, many advertised in magazines like the British Yoga and Health, its spirituality remains central. Vipassana (silent) meditation is practised at many retreat centres, in virtually identical forms, just as silence and silent meditation are also present in parallel Christian practices (Conradson, 2007). In Australia and New Zealand the Vipassana meditation website suggests: Vipassana means to see things as they really are. Ten-day courses in this ancient meditation practice are offered in every state of Australia and in New Zealand. The technique is a pure science of mind and matter. It is also an art of living, an antidote to all the stresses and strains of life. It provides a deep pool of peace and harmony within, and ultimately leads to the end of suffering. (Dhamma, 2010)

Most yoga tourists at retreats are educated, older women in professional employment, with some spiritual (if not religious) orientation who are also interested in vegetarianism and organic food, and in seeking to reduce stress and experience more ‘balance’ (Lehto et al., 2006; Ali-Knight, 2009; Gerritsma, 2009) in a more holistic health experience. Experiencing local practices has taken multiple forms. The Australian company, Inner Journeys, explained the benefits of its ‘ecotourism and adventure’ tours in the 2000s that offered ‘partnership with indigenous people’, and included a ‘North Thailand Traditional Healers eco-tour’ (Inner Journeys, 2010):

self-growth. Pursue your own truths for self awareness and spiritual development through a workshop, spiritual retreat or eco-tour adventure that blends personal growth with relaxation, meditation, learning traditional knowledge of healing and a sharing of visions. Inner Journeys offers the opportunity for holistic vacations in beautiful peaceful locations that encourage fellowship and personal growth. Our eco-tourism programs combine adventure travel with cultural interactivity and a focus on spiritual healers and traditional healing. These programs stimulate the mind and enhance your self awareness, spirituality and the world. They truly are food for the soul, body and mind. (Inner Journeys, 2010)

Fliers for homestays in a Lisu hilltribe village (northern Thailand), who were said to ‘retain their original culture in day to day life’ offered the possibility of ‘internal cleansing and detoxification, spiritual awakening, vipassana meditation, Swedish massage, acupressure, Hawaiian massage and reeducation’ (Lisu Hill Tribe, 2010). On a much grander scale the American company, Journeys of the Spirit, offers travel to Bhutan, Oaxaca (Mexico), Kenya, Sedona and elsewhere, and special women’s journeys to Bimini (Bahamas) to swim with dolphins, and to Glastonbury (UK). As they suggest on their website:

and also a ‘Shaman of Borneo eco-tour’ and ‘Sedona Encounters’.

The magic of these experiences involves the opportunity to enter a dream of peace and unconditional love so you can see for yourself what is possible in your life. Having the ability to see reality from another point of view, from another level of consciousness, will help you gain clarity, open your heart, stimulate your creativity, and encourage you to make healthier life choices. Imagine yourself connecting deeply with earth’s sacred sites and nature, making heart-felt connections with new friends, and exploring the mystery of the most beautiful sacred sites and power places on earth. You’ll come home rested with a new perspective and with gratitude for life! (Journeys of the Spirit, 2010)

Unique ecotourism adventure travel learning of traditional medicines and spiritual paths from indigenous people. Personal selfempowerment, Reiki and spiritual retreats exploring your own spirituality for

A second American company, BodyMindSpiritJourneys, offers a very similar range with the same perspectives. In recent decades in numerous ways there has been a massive

Visit the traditional hilltribe healers of North Thailand and learn of their herbal, spiritual and energy healing methods. During the journey we visit hilltribe villages, Buddhist Wats (temples) and Home Clinics of Lanna Thai Healers. We meet our hosts on personto-person levels and share knowledge and experiences.

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proliferation of holistic retreats, centres and travels of various kinds, where the spiritual and physical are in some way combined, sometimes alongside renewed attempts to experience and benefit from the wisdom of supposedly traditional peoples. Most such healing and travel experiences emphasize being close to nature, and thus emphasize remoteness and involvement with ‘natural’ peoples, where nature is still part of everyday life, as opposed to the chaos of urban life (Hoyez, 2007), while constructed places are often designed to enable and support particular healing practices. Natural landscapes are seen to be associated with peace and tranquillity, providing places for restoration and reflection (Milligan, 2007). Retreats from the everyday intentionally rupture familiar conjunctions of bodies and places and enable new forms of physical and mental experiences (Lea, 2008). Links between nature, spirituality and well-being are thus recurrent themes in such forms of ‘new’ pilgrimage. Since the late 1990s, for example, the extraordinary spread of feng shui outside (and inside) Asia has accentuated consciousness that living with the environment is more beneficial than challenging it, and that well-being is affected by the physical and emotional environment, so that particular physical environments and locations are more propitious for health and wealth. Feng shui is used by some for healing purposes, separate from Western medical practice, to create a harmonious atmosphere (Emmons, 1992). Once again esoteric beliefs have been increasingly absorbed into health-care practices. The ‘journeys’ based on such premises may also involve personal mental transformations that take on fragments of eastern philosophies and practices without necessarily requiring mobility. Highly personalized transformational journeys may link body and mind in an amalgam of old and new ideas about being, nature, spirituality and health. Thus Deepak Chopra, one of the leaders of such philosophizing, offers an ‘exclusive oneday journey of transformation’: We all want to grow younger and live longer. Scientific research demonstrates that we can literally turn back the markers of getting old, including blood pressure, muscle strength,

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cholesterol levels and many others. Deepak Chopra, acknowledged as one of the world’s greatest leaders in the field of mind body medicine has revolutionized our understanding of the meaning of physical, mental, emotional and spiritual well-being. … he will show you, first hand, how to improve your life, stay healthy, stop disease and find greater spiritual fulfillment. Learn how to maintain a youthful mind, cultivate flexibility, strengthen your immune system, nourish your body and achieve a long life filled with joy and vitality. ‘You can’t change the body without changing the self, and you can’t change the self without bringing in the soul.’ Using ten steps to wholeness Deepak reveals how you can change the distorted energy patterns that are the root cause of ageing, infirmity and disease. As the day progresses you will be guided through the keys that will unlock a new you. In essence Deepak’s message is that your highest vision of yourself can be turned into an actual physical reality if you commit yourself to a deeper awareness, focus on your relationships, embrace every day as a new world and transcend the obstacles that afflict body and mind. (Deepak Chopra, 2010)

Chopra achieved massive personal success through arguing that good health, and the absence of disease, was the outcome of personal choice and the exclusion of negative emotions. Much alternative medicine, such as this ‘mind body medicine’, is tied up with a sometimes eclectic mysticism and spurious science (such as Chopra’s theories about the relationship between quantum mechanics and healing) that excludes scientific rigour, perhaps as a legacy of residual ancient belief systems (including astrology) and a willingness to suspend intellectual disbelief in a quest for cures where biomedicine has thus far failed. The scientific evidence for the benefits of alternative medicine is mixed; where exercise is involved it is beneficial, herbal medicines have value and many practices are harmless, with a possible beneficial placebo effect, yet other alternative procedures may merely ‘prey on the desperate and vulnerable in society, raiding their wallets, offering false hope and endangering their health’ (Singh and Ernst, 2008: 348; see also Baer, 2003; Ehrenreich, 2009). Ethics are involved in every kind of health and medical procedure.

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However valid alternative therapies may or may not be they continue to exude a fascination, where biomedicine can never succeed and where psychology plays a part, and have contributed to new forms of health populism. People have repeatedly travelled in search of new ideas, practices and better ways of living, evident, for example, in the book Eat, Pray, Love (2006), Elizabeth Gilbert’s account of her search for the meaning of life in Italy, India and Bali, a journey that involved meditation and yoga in ashrams, kundalini shakti, herbal cures and gastronomy. Despite its massive popular success it was criticized for being ‘narcissistic New Age reading’ and ‘the worst in Western fetishization of Eastern thought and culture’ (Callahan, 2007). Gilbert subsequently appeared regularly on The Oprah Winfrey Show. While Gilbert’s book may be perceived in many ways, it attests to the eternal quest for knowledge, wisdom and healing in different geographical and cultural contexts, the willingness to travel for cures that are both spiritual and physical and, in a rather different way, to emphasize that selfhelp has been a crucial element of the new wellness movement. That Italy played a part indicated that beneficial places and cultures need not necessarily be Eastern, and vast numbers of similar books and films have eulogized Provence, Tuscany and a host of loosely ‘therapeutic’ places where lives can be rejuvenated in new relationships with nature, local people with simple (sometimes confusing) ways, cottages and food. Gilbert’s website provided directions to the shop of the Balinese Wayan Nuriasih, who she befriended, and a steady flow of visitors have followed in search of Wayan’s various services from massage to Balinese dance lessons and a ‘healthy vitamin lunch’. For some a holiday in Bali may combine a guided herb walk, yoga, massage (and shopping) with a visit to Wayan’s shop in the small town of Ubud: A steady stream of western women of a certain age and fashion sense (heavy on the scarves, beads and natural fibres) pass through Nuriasih’s during the three hours we are there, many pausing to declare her treatments miraculous (‘I didn’t even need stitches’, one woman says pointing to a cut

on her forehead Nuriasih had treated that morning). Nuriasih ‘reads’ our bodies. Just by looking at me, she diagnoses a lack of vitamin E, adequate calcium levels and a recent knee injury. The experience costs about US$10 and is interesting, but, despite the testimonials I decline the full treatment (about US$75). (Munro, 2008: 12)

The company Spirit Quest Tours launched an Eat, Pray and Love Bali tour that offered: Visit with Ketut Liyer, Elizabeth Gilbert’s Balian and teacher. Grab a vitamin lunch at Wayan’s tiny restaurant. Enjoy Balinese Hindu temples as the Balinese do – learn how the locals pray. Meditate or practice yoga each morning, or sleep in! Relax with a Balinese massage or reflexology. We will eat, we will pray, and we will love all that is Bali! (Spirit Quest Tours, 2010)

Numerous companies offered similar packages (Fig. 3.1) combining spiritual practice with deluxe accommodation, often centred in Bali. Many such journeys and ‘new pilgrimages’ also exemplified a distinction between tourists and travellers, a distinction that was purest in the eyes of those who called themselves travellers and who perceived themselves as having become closer to the cultures of the ‘oriental’ people that they visited and from whom they might have gained valuable knowledge and experiences, however superficial and transitory. Travel was in some part as much the acquisition of social capital and status symbolism as of beneficial mental, spiritual and physical well-being. Yet, as global capital in the form of the leisure industry followed, the distinctiveness of other cultures faded, to be replaced by regulation, commercialization and social disruption.

Wellness and the ‘New’ Spas While minority Western beliefs were becoming more exotic, expanding to incorporate a range of Eastern philosophies and practices (almost exclusively from south Asia), and leading to travel to the seemingly authentic sources of well-being, a new wellness industry was being

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Fig. 3.1. Bali Sacred Journey, 2008.

created that incorporated in some limited form the exoticism of the East but was centred on fine hotels. Few standard resort hotels are without some form of spa, or more grandiosely titled ‘health centre’ (Smith and Jenner, 2000; Henderson, 2004), seemingly as central to the experience as the restaurant, while many hotels have designated themselves as spas or wellness centres. Contemporary spa tourism is closely linked to the emerging ‘wellness industry’. While numerous definitions of wellness exist ‘it is hardly possible to define wellness in a single sentence. Wellness describes physical activity combined with relaxation of the mind and intellectual stimulus, basically a kind of fitness of body, mind and spirit, including the holistic aspect’ (Schobersberger et al., 2004: 199–200). Wellness tourism has emerged from such vague metaphysical notions, and varied understandings of what holistic approaches

might include, becoming an expensive niche in the health-tourism industry, centred on spas, whether new or established. This has accompanied rising affluence, status symbolism and the search for new experiences, rather than a return to beliefs in the efficacy of water-based health treatments or spiritual values. Spa tourism has been defined as a: tourism which focuses on the relaxation or healing of the body using water-based treatments, such as pools, steam rooms and saunas. Emphasis tends to be focused on relaxation and health and beauty treatments rather than the spiritual aspects of certain exercises such as yoga. Surroundings are usually sumptuous with prices to match. (Smith and Kelly, 2006: 17)

Indeed spas, and the magazines that followed, have increasingly positioned themselves at

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the luxury end of the tourism market. Spa visitors, as in Australia, are mainly educated and affluent women (Voigt et al., 2010). Several factors have contributed to increased spa visiting and probably what is typical of Hong Kong is reasonably true elsewhere; here the rationale of spa-goers could be classified by four factors: (i) ‘relaxation and relief’; (ii) ‘escape’; (iii) ‘self-reward and indulgence’; and (iv) ‘health and beauty’ (Mak et al., 2009). Relaxation and relieving stress were general reasons for going to spas, and facials and massages the most sought after benefits (Erfurt-Cooper and Cooper, 2009: 168). Much of this has been very loosely linked to practices such as aromatherapy, treatments with ‘natural’ products of various kinds (from mud to seaweed and herbs) and peace, contemplation (even meditation) and sometimes ambient music, and thus with some limited convergence with ‘New Age’ philosophies, but spas are more about pampering than health care. Most spa resorts provided a combination of facilities to meet such goals, and combined therapies of different regional origins. The first modern spa resorts emerged in the USA in or near California from the late 1950s but their spread did not occur until the 1990s. By 1997 innovative US doctors began to introduce ‘medical spas’ that combined modern Western and alternative treatment in more luxurious settings (Smith and Puczko, 2009: 37). It has also been argued that ‘in the late 20th and early 21st centuries, as traditional religion once again declined, spas became one of the most desirable public spaces in which to congregate’ (Smith and Puczko, 2009: 25). However, there is little evidence of any contemporary decline in religion around the turn of the century, especially in North America, and most contemporary spas tend to offer private therapy. Central European countries particularly have supported the resurgence of spas and wellness tourism. Switzerland Tourism’s 50-page brochure Wellness Hotels (2009) begins: Switzerland is an island of well-being in the heart of Europe: unspoilt nature is on the doorstep, the spas are modern and varied, and the hotels world class …

Sensual spas, mystical bathing rituals, exotic hammams and special treatments using local herbs: Switzerland has never invested so strongly in wellness before. The result: places of well-being where every day stresses are shut out while you reconnect with your own inner energy. Perhaps you choose to float weightless, bewitched by the scent of jasmine, in a Japanese luxury bath, before being massaged until you feel as soft as butter. After that, wallow in a whirlpool bath, or perhaps rest a while as you gaze out on an alpine panorama … And wellness is a philosophy of life: as witnessed by the menus, full of light delicious, market-fresh dishes.

Switzerland Tourism classifies its hotels as ‘first-class wellness hotels’ if they have a comprehensive and clearly defined wellness programme based on six elements: (i) movement and fitness; (ii) water; (iii) warmth; (iv) beauty; (v) nutrition; and (vi) relaxation (though their website adds a seventh: ‘mindness’). Broadly similar themes, and equally diverse therapies, preoccupied the expansion of wellness tourism in Germany, the Czech Republic and other parts of central Europe, and to a rather lesser extent in other developed world countries. Affluence and luxury were usually combined with a degree of difference and exoticism, especially as spas and wellness expanded to developing countries. At the intriguingly named Chi spa on the island of Yanuca in Fiji: They offer a dusk till dawn spa ritual, where you are guided gently, like a small child, to an ocean-front villa, bathed, scrubbed, polished, massaged, fed sushi and chocolates, put into a king-size bed with a TV remote control (or your partner, as the treatment is available for couples) and then woken at sunrise for breakfast and a facial … Where once hotels had state of the art gyms and heated swimming pools, now they need to build a whole village … complete with spa pools, fragrant steam rooms, ocean views, lush gardens, therapists trained in the latest Asian healing philosophies, relaxation pavilions, water features, temple-like ambience and products made from plants plucked from the highest reaches of the Himalayas. (Tulloch, 2008: 105)

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Although elitism may typify contemporary spas, and account for somewhat artificial invocations to benefit from alternative therapies, spas have continued to combine certain traditional techniques in a purpose-built context, linked into the putative ambience of relatively elite resorts. None the less for many such spas linkages to place and tradition are merely designed to imply some greater authenticity. Spas like the newly constructed resort on Koh Samed island in Thailand employ the concept of authenticity: Paradee Spa’s concept is centred on the age-old Thai therapeutic elements or thad. These are Earth, Water, Wind and Fire, and it is believed that all things possess one or a combination of these four elements. When the thad becomes unbalanced ailments occur. … To live well and be in harmony with one’s surroundings, all the elements should function in equilibrium. The spa has blended this four-elements concept and the modern science of wellness in all of its treatments, like the Swedish and oil massages, head shoulder and foot massages, traditional Thai massage, and its signature treatments, Sunrise and Sunset. … According to the spa manager, the Sunrise massage on the fine white sand of Ao Kiew Nok is designed to enhance blood circulation, improve the skin texture with a vitamin D rub to strengthen the bones … balance the mind and body and also comport the eyes … It took place on the fringe of a private cove, Ao Kiew Nai. The massage table stood on a wood platform strategically positioned between the rocks, with many small candles and torches lighting the setting … The sound of the gentle waves lapping against the beach accompanied the sky’s transformation from gold to violet and navy blue, painting a captivating landscape … The Sunset massage is designed to stimulate natural energy while you’re immersed in the island’s tranquillity. The soft, salty scent of the sea at sunset and the sound of the waves replace the floral or herb aromas and pre-recorded music commonly used in an enclosed facility. (Tan, 2010: R13)

Jirung Health Village in northern Thailand likewise: offers alternative health therapies which combine aspects of Western, traditional Thai and Chinese medicine combined with

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Buddhist philosophy to help heal maladies of the body and mind … As well as various detoxification and spiritual rejuvenation programmes … one can also go biking, learn how to make herbal toiletries and practise yoga or fon jeung (a melding of Lanna [northern Thai] dance and tai chi techniques). (Bangkok Post, 25 March 2010)

Similarly the resorts on Koh Samed and Yanuca, and the key hotels listed by Switzerland Tourism, all link distinctive natural landscape features with largely generic treatments (spa baths and massages) and other procedures drawn from a cornucopia of possible global practice. Spas have departed some way from a central role in healing and wellness towards luxury and holistic exoticism. And geography has been scrambled in global processes that stress authenticity and nature yet transport techniques across continental boundaries. Ayurvedic doctors practise at Balinese spas, Thai massage has reached Kerala, the Lisu have embraced Hawaiian massage and hammams are no longer exotic in Switzerland. Not surprisingly even the magazine Luxury Spafinder suggested of Bora Bora (French Polynesia) that there are limits: The island’s top spa resorts teach that authenticity is not always what it seems and sometimes not as important as we think. Some parts of the world induce an obsession with authenticity, with experiencing the ‘real’ version of the place. Whether the real Bali still exists has been a staple anxiety in travel writing for more than 50 years now. … Bora Bora causes an especially acute case of Authenticitis … One of the best spas I visit utterly lacks a sense of place. Expertise trumps authenticity. (Abel, 2008: 91)

Part of that ‘expertise’ resulted from a slow shift towards holistic perspectives that hinted at biomedicine. Chiva-Som (‘haven of life’), one of Thailand’s first health spas which opened at Hua Hin in 1995, has a ‘treatment philosophy aimed at lifestyle transformation … education, empowerment … and a follow-up procedure … designed to ensure that the benefits of a stay continue long after you have left’ including ‘cookery classes [which] teach the secrets of the resort’s healthy food and include a trip to the

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organic gardens’. An initial meeting at the spa ‘will be a private consultation to determine your current health and your wellness goals during your stay’ so that although the ‘experience packages may all be luxuriously pampering they also address real health problems such as weight management, stopping smoking, detoxing and destressing. Children are excluded and mobile phones and computers allowed only in bedrooms’ (Tavornwong, 2009: 17). At least in principle broad goals of relaxation therapy and exercise are linked to low level medical examinations and positive health and nutritional interventions. Spas like Chiva-Som, Banyan Tree (Phuket, Thailand) and Banjaran Hotsprings

Retreat, Malaysia (Fig. 3.2) have been described in similar terms, with their combinations of luxury accommodation and cuisine and modern and traditional approaches to health (that tend to relate to exercises and diet) where they ‘aim to cater to three elements of their customers’ health – mind, body and spirit – and offer an atmosphere where guests are treated like royalty (and charged accordingly)’ (Laing and Weiler, 2008: 385; cf. Burt and Price, 2003; Upjohn, 2009). As spas and resorts have become increasingly synonymous it has been argued, at least in the USA, that ‘the mantra is that a resort is “not a resort” unless it has a spa’ (Monteson and Singer, 2004: 282). And where the luxury Le Mas Candille on the French

Fig. 3.2. Banjaran Hotsprings Retreat, Malaysia 2009 (source: The Expat, December 2009).

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Riviera can advertise in the Financial Times (20 March 2010) both champagne and spas under the banner of ‘charm, gastronomy and wellness’ it is evident that ‘wellness’ has become both cliché and elitism. Contemporary spas are unashamedly oriented to the ‘luxury end of the market in its appeal to hedonistic sybarites’, and emphasize relief from stress, which tends to be a more middle-class phenomenon, and which in contexts where, as in the Caribbean, ‘the descendants of black slaves are administering luxury therapies to the heirs of the white plantocracy’ (Dann and Nordstrand, 2009: 127, 128), raises questions about ethics and inequality. Moreover the validity of the purportedly health-giving practices may hinge on the extent to which they involve diet, exercise and biomedicine. As the initial consultation at Chiva Som, and many similar spas, indicates, health care has tentatively moved towards a more medical context, and some spa resorts have deliberately included at least some forms of biomedicine. As proponents of this variant of medical tourism argue: Medical offerings can add credibility – and a whole new dimension – for the spa consumer. From the lifesaving and life-giving possibilities of stem cell banking, to relatively minor procedures like Lasik or dental work – the concept of incorporating medical diagnostics, procedures and even surgery may become increasingly appealing for those who travel to spas, rendering their time away from home even more productive. In addition, the medical cost savings possible when traveling to places where medicine is less expensive as well as the possibility that some medical procedures are covered by insurance can help offset the price of a spa vacation. (Ellis, 2010)

This remains largely futuristic and spa resorts are yet to significantly overlap with biomedical practice, though they increasingly offer more invasive, demanding (and costly) techniques. The Terme di Saturnia Spa and Golf Resort in Maremma, Italy, offers isophoresis, an alternative to liposuction that uses ultrasound to force vitamins and plant extracts below the skin to break down fat deposits. Other spas offer derma fillers that smooth problems around the eyes, nose and mouth

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by using a needle to add hyaluronic acid that lifts and flattens wrinkles and folds. Chiva Som itself uses infrared lasers and ‘radio-frequency treatments’ to tighten and smooth sagging skin. Other procedures use electric currents that squeeze muscles to release toxins and water (Butler, 2009b). Not only is there a considerable degree of convergence with procedures used in the cosmetic surgery that is part of medical tourism, but such ‘gentle new procedures’ are becoming part of mainstream cosmetic surgery. As the example of Koh Samed suggests, several parts of Asia, notably Thailand, Malaysia and Indonesia (Bali), have been well placed to benefit from the growth of spa tourism, for several reasons. The main market for spa tourism remains Western tourists, despite the growth of local interest (and retention of interest in Japan), who are drawn to nature and to ‘Eastern’ practices that are perceived to ‘offer an intact world with authentic, original, genuine and deep encounters’ (Fuchs, 2003: 382), and include meditation, yoga and Ayurvedic practices, associated with ancient, exotic and colourful religions. Asia provides a background and context where natural and cultural landscapes are also colourful and exotic. Spa tourism is also linked to the idea that natural treatments and therapies are ecologically sensitive, using local ingredients. More prosaically Asia has an advantage in the existence of a tourism infrastructure, and relatively cheap accommodation and airfares (Laing and Weiler, 2008). Such natural and created advantages have led to the active marketing of spa tourism in Asia, perhaps to a greater extent than anywhere outside the European heartland. Some of the same places, for the same reasons, have also become centres of medical tourism.

Cosmetic Surgery: New Norms, New Bodies While the expanding wellness industry was primarily oriented to a loose combination of spiritual and physical health, the demand for psychological well-being has spilled over into a booming cosmetic surgery industry, to

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remove perceived bodily imperfections and the effects of ageing. The ageing of the baby boomers, their greater expectations of life and of medical care, and with capital and ability to travel (at a time when international travel costs were relatively stable) account for the boom in spa tourism, the rise of alternative health care and the greater acceptability of cosmetic surgery. But cosmetic surgery had also been boosted by media focus on celebrity culture, enhanced materialism and the wideranging commodification of the body. It is a burgeoning industry, and increasingly a global one, that has shifted the direction of personal care from mere bodily well-being to changing body contours. However, most peoples have used, and continue to use, some forms of bodily decoration and cosmetic treatments, alongside cicatrization and tattooing, for thousands of years, so that body transformations are hardly new, while some cultural forms such as the elongation of necks by rings and the insertion of lipdiscs are neither simple or trivial transformations. Perfumes, hair oils and elaborate coiffeurs are universal, all adding to notions of well-being and aesthetic pleasure. Tattooing has never been more popular. What is conventionally understood as cosmetic surgery is, however, usually somewhat different, being intended not merely to decorate but to remove bodily flaws. Even that is scarcely new. Reconstructive surgical techniques were being carried out in India at least as early as 200 bc and a skeleton at a Stone Age burial site in France, dated between 5100 and 4900 bc, shows that cranial surgery was undertaken then, with two trepanations, or surgically created holes in the skull (Alt et al., 1997). Skull trepanation was also being undertaken in the New Guinea islands before European contact (Watters, 2007), as in some other pre-contact societies. Rhinoplasty was undertaken in India in the 18th century, and the first major surgery in the Western world borrowed from these techniques. However, surgery on the head and face was regarded as dangerous and it was not until the 19th century that it became more frequent, for patients with either severe physical deformities (such as cleft palates) or who had been injured or burned, rather than for ‘cosmetic’ reasons.

The first male-to-female sex-change operations were carried out in the 1950s, in response to psychological needs, and that decade also marked the emergence of aesthetic plastic surgery, focused on either maintaining or restoring ‘normal’ appearance (for example through removing evidence of ageing) or enhancing it towards some ideal proportions. Where that differs from the reconstruction of ‘deformities’ is indefinable. Breast reconstruction after cancer and Lasik eye surgery, conventional plastic surgery operations, may be aesthetic but they respond to real needs. It was estimated that in 2007 some 12 million cosmetic procedures were performed in the USA alone, and that this total had more than doubled from the start of the century, and crossed the main ethnic groups. However, in 2009 the extent of plastic surgery declined in the USA for the first time in the decade, mainly because of high costs in the wake of the global financial crisis (GFC; Saint-Louis, 2010). In Australia more than 50,000 cosmetic procedures were undertaken in 1998, a total that was twice that of 1995 (Keenan, 2004: 32). In the USA the five most common procedures were: (i) breast augmentation; (ii) liposuction; (iii) nasal surgery; (iv) eyelid surgery; and (v) abdominoplasty (tummy tucks). In Australia cosmetic surgery was dominated by: (i) liposuction; (ii) breast implants; (iii) facelifts; and (iv) eyelid surgery. Botox injections were the single most common cosmetic operation, with 4.8 million procedures in the USA alone in 2009, primarily to reduce wrinkles. Botox, not surprisingly, is the leading product in what has increasingly become known as ‘vanity medicine’. While Europe constitutes a second major market for cosmetic procedures, Latin America was an early starter and Asia is following fast. Cosmetic surgery provides a means of obtaining instant ‘perfection’ in a society that heralds achievements, celebrity, and their imitation. As society has become more selffocused and opportunistic, pressures to conform to unrealistic expectations to be ‘the best that one can be’ cannot easily be resisted even in an age of individualism. Women have been most affected by such pressures, with beauty so often a measure of women’s worth. Media

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pressures emphasizing that perfection brings happiness have primarily been directed at women. At least by the 1920s in Western societies, long before the advent of aesthetic plastic surgery, the use of cosmetics signified modernity, hedonism, love and democratic ideals of hard work being rewarded and, in the USA, the personification of the American dream of individual reinvention and personal fulfilment (Walker, 2007). Implicitly the converse implied that others were imperfect, and the availability of cosmetic surgery amplified this distinction. The cosmetic industry now flourishes across the globe, ordinary housing estates have acquired mansion qualities, cars have grown in opulence and cosmetic surgery, once the province of Hollywood stars and the wealthy, has become an option for all. European stereotypes of beauty retain primacy, in extreme form in the Shibuya girls of Tokyo, and even among Asian–American mothers who ‘take their sixteen year old daughters for double-lid surgery; they present it to them with love, kisses and their blessings as a high school graduation present’ (Blum, 2003: 10; Richie, 2003). More recently, as fashions subtly shift, Korean eyes have become a sought-after form for other Asian women. Cosmetic surgery has produced a cultural and physical convergence that challenges gender, racial and size boundaries. The media have played a key role in the growth of cosmetic surgery, with ‘reality’ television shows as the American Extreme Makeover and regional variants such as the Australian versions Ultimate Transformations and Body Work, entirely centred on bodily transformation, while popular programmes that run on day-time television, such as The Oprah Winfrey Show and Dr Phil, intermittently featured cosmetic surgery episodes. Even programmes aimed at teenagers, such as the Australian Girl TV, featured nonsurgical makeover themes, complete with before and after shots that were similar in style to cosmetic surgery programmes (Keenan, 2004). Those who watch such programmes are more likely to seek cosmetic surgery than those who do not (Markey and Markey, 2010) and girls as young as 12 express

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a wish for cosmetic surgery (Reist, 2009). An 18-year-old Australian came under criticism in 2010 for borrowing A$13,000 to go to Malaysia for ‘a tummy tuck, boob job and “designer” vagina’ in a bid ‘to feel young again’ (Channel Nine News, 2010). Magazines have taken up similar themes, routinely pointing out the flaws in the bodies of stars (who have therefore let themselves down) and congratulating those who have lost weight (and thus conformed), and by extension chastizing others, so playing on insecurities and possibilities. Home, garden and diet makeovers, in magazines and television programmes, are no less important, and pursue the same orientation to an expanding world of choice and personal consumption. Cosmetic procedures such as liposuction, the removal of ‘excessive’ fat, only invented in 1974, have been taken up by teenagers, while fashion magazines especially have been heavily criticized for constantly depicting body images that are unattainable for most people, but raise unrealistic expectations that merely produce ‘status anxiety’ and discourage personal development. Cosmetic surgery encourages women especially to achieve fulfilment by being younger, more beautiful, hairless (selectively) and Western, so promoting a certain ideal, a subjective interpretation of beauty and an unrealistic notion of perfection (Gilman, 1999; Williams, 2003). Modern society has thrived on this sense of judgement and the ability to transform, modernize and improve. In shows like Extreme Makeover ‘episodes are about the process of becoming – processes that begin during surgery and then through recovery, grooming and further “personal growth” in everyday life’ (Jones, 2008: 53). Cosmetic surgery normalizes certain notions of beauty and the need to attain them. Medical tourism companies that market, organize and broker medical tourism (Chapter 5) have expanded on such themes, and emphasized both the growing social acceptability of cosmetic surgery, and the declining relative costs. As one Australian company, Gorgeous Getaways, has pointed out: The sharp growth is a result of changing attitudes as cosmetic surgery becomes

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sociably acceptable. The numbers of people who approve of cosmetic surgery for themselves or others have increased by 50 percent over the past decade. The reasons for having cosmetic surgery is [sic] primarily for individual empowerment, not out of the need to be ‘perfect’, but many people express an inner desire to improve their esteem and confidence. Changing the external appearance will inevitably inspire self-confidence and belief to achieve dreams. Cosmetic surgery was once all but socially acceptable but now, through our quality services and procedures and cost effectiveness, it has become affordable and accessible to all. (Gorgeous Getaways, 2010)

Body shape and specifically obesity are associated with particular versions of morality which are historically contingent upon the value placed on bodily aesthetics (Colls, 2006). Commonly, fat in a Western context is considered to represent particular individual traits such as indulgence, laziness, greed, a lack of restraint, violation of order and space, and stupidity. There is a consequent tendency to infer qualities that relate to being a particular size, where big is not athletic, fit or healthy and obesity represents failure and inadequacy. Consequently in contemporary Western societies especially, women who are slim and firm are seen as the ideal and obese bodies need corrective procedures, whether through diet, exercise or surgery. Though exercise and diets are valuable, in the ‘now society’ surgery is instant and less mentally and physically demanding. Concepts of the body beautiful have become global, institutionally celebrated and involve younger and younger (and also older) people. Beauty pageants too are global. Banned in China until 2003 they subsequently became seen as a way for young Chinese women ‘to get ahead in a fiercely materialistic society’ and ‘with the growth in cosmetic sales and readily available cosmetic surgery, there are signs of a social revolution in a country in which such things were once an indicator of Western decadence’ (Spencer, 2003: 76). Yet despite so many conclusions about cosmetic surgery being linked to consumerism and social status, it spills over into medical procedures, based on real needs, which have become invaluable. One way or

another cosmetic surgery has boomed and, for many, become a ‘lifestyle choice’.

Harley Street In the midst of counterculture and alternative ideologies in developed countries the resort to standard ‘modern’ medical practice has remained at the core of most people’s medical practice. In most developing countries people have been particularly anxious to avail themselves of modern medical treatments such as penicillin and secure medical employment for their more educated local people. While ‘modern’ treatments have never entirely replaced local practices, so that often complex hierarchies of resort remain (e.g. Hamnett and Connell, 1981), in most countries preferences for modern medical care displaced the resort to local knowledge and local practitioners. In developed countries such beliefs scarcely wavered and certain places became the cores of high quality medical practice and of the early modern phase of medical tourism. No place was more famous than Harley Street in central London. Doctors began to move there in the mid-19th century though ‘there was no particular reason why Harley Street should have been chosen [other than] to live in a prestigious area among well-to-do people, some of whom might need their services’ although it was close to newer teaching hospitals (Adams, 2008: 32). By the end of the century its reputation had been established and Harley Street doctors were specialists rather than generalists. Patients included Charles Dickens and Sir Edwin Landseer. London, and Harley Street, was the centre of medical specialization in England, but its heyday lasted little more than half a century, from the 1890s until 1948, when it was killed off by the introduction of the NHS, and lost the glamour of elite medicine and surgery (Adams, 2008: 71). Yet part of that glamour lived on with patients visiting from the provinces and increasingly from overseas to secure what continued to be regarded as the best medical advice and treatment, although in a more democratic egalitarian age there was less basis for that supposition.

Mind and Matter

While nowhere rivalled Harley Street as an early global destination, other developed countries had similar concentrations of elite medical care and, like Harley Street, other Western cities retain a powerful attraction. German cities have proved attractive destinations and Berlin has some prominence. Meoclinic alone in Berlin received over 60,000 overseas patients in 2006 (10,000 more than 2 years earlier) including over 4000 from the Gulf, with other German hospitals also taking many, and companies such as German-Medicare organizing travel and hospital packages, for patients reputed to spend as much as 80,000 per visit (Albers, 2008). Five per cent of patients in one children’s hospital in Genoa, Italy, in 2007, came from North Africa, the Middle East, Latin America or Eastern Europe (Massimo et al., 2008). In the 1960s significant technical breakthroughs in the USA attracted affluent patients from around the globe, and by the 1980s renowned medical centres such as the Mayo Clinic, Johns Hopkins Hospital and the Cleveland Clinic had developed formal programmes to attract overseas patients; such programmes included services such as interpreters, assistance with visas and travel and luxury suites (Jenner, 2008). Some projections suggested that as many as an annual 400,000 international patients may have been arriving in the USA by 2008 (but this is improbable), with some prominent hospitals having up to 10% of their patients coming from overseas. Hospitals like the Shady Grove Fertility Centre developed in vitro fertilization (IVF) programmes and others included naturopathy (Vequist and Valdez, 2009). Most patients were ‘usually wealthy people travelling to the U.S. for high-tech care’ (Quesada, 2009: 69), from Latin America, the Caribbean, Europe and the Middle East. The Cleveland Clinic had a Global Patient Services department from 1975, which was initially national, but by 2009 claimed to be dealing with about 2600 international patients a year, working with 80 different countries and employing 13 different language interpreters (Lambier, 2009). Western cities have prolonged and sometimes enhanced an elite pre-eminence in an increasingly competitive market.

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Even while this book was being written President Mubarak of Egypt was being treated in Heidelberg, Germany for an inflammation of the gall bladder (and where he had previously been treated in 2004 for a slipped disc), the President of Nigeria was in Saudi Arabia for prolonged medical treatment and the King (or Sultan) of Trengganu (Malaysia) returned from medical treatment in Germany. The Vanuatu Prime Minister received treatment in Australia and advised other government ministers and senior officials to do the same (Vanuatu Daily Post, 15 March 2010). The Premier of the Canadian Province of Newfoundland and Labrador travelled to Miami for cardiac surgery, prompting extensive criticism in Canada while declaring: ‘This is my heart, it’s my health and it’s my choice’ (Telegraph Journal, 2010). Other leaders have undertaken similar journeys, but there is an irony here since Malaysia is a centre of medical tourism, Egypt aspires to be a medical tourism centre, Nigeria has touted its recent success in developing ‘world quality health care at home’ (Mordi, 2010), while on the west coast of Canada some in British Columbia were also contemplating the establishment of medical tourism. For wealthy elites from every country, but especially from developing countries, where even those charged with developing the health services are fearful of using them, travel to developed countries is a significant and long-established form of medical tourism. Many of the private practitioners in Harley Street have sought to gain international (and national) patients, partly trading on its historic importance by simply using street names. Some also have introduced hints of holistic therapies in the quest for patients. 76 Harley Street is a new concept in comprehensive medicine and dental care, with special focus on health risk reduction, minimally invasive aesthetics and optimising human performance, under one roof. (76 Harley Street, 2010) Our premises are located in an elegant Georgian building in the heart of London’s private medical community. The surgeons and nurses at 111 Harley Street are highly

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trained, skilled and experienced in the latest cosmetic surgery procedures and patient care. During the initial consultation, individual goals are identified and a realistic treatment plan is created. We are one of only a handful of clinics in the UK to offer a full range of the latest surgical and non-surgical procedures, enabling patients to find the most suitable treatments to address their concerns. At 111 Harley Street we treat the whole person, using latest generation technology and profession-leading protocols. We also take a long-term view of what procedures may be suitable for a patient at each particular stage in their lives. Our goal: to make our patients look, feel and live healthier. (111 Harley Street, 2010)

HCA International, the largest private hospital group in the UK, has one of its clinics in Harley Street, and representatives in Pakistan, Nigeria, Kuwait, the United Arab Emirates (UAE), Greece, Cyprus, Libya and Egypt (Reisman, 2010: 71). Several Harley Street businesses have moved even more obviously into medical tourism, developing external linkages and marketing to international clients, especially for cosmetic surgery (including dentistry) and fertility. The Harley Street Fertility Centre is one of the leading specialist centres for the diagnosis and treatment of infertility in the UK, with the latest in technological advances. It has clinics operating in London, Berkshire and Mauritius. Couples who can take 10 days off from work can have the same treatments including 10 days half board in a 5 star Resort hotel. For foreigners, a holiday experience of a life time with unmatched services, gourmet dining, watersports, health spa and golf to match the best in the world in this island paradise. (Harley Street Fertility Centre, 2010)

Expertise has therefore been taken offshore through diversification, with encouragement to British clients to combine treatment with a holiday (where time was available). Early in 2010 this was taken a stage further with the downsizing of the London clinic and expansion in Mauritius (Chapter 10). While Harley Street, like other metropolitan centres in the developed world, has retained a reputation for global excellence, with national and international elites seeking out their services at

considerable cost, increasingly clients have moved elsewhere to take advantage of cheaper services. At the historic core of global health-care systems medical tourism has made significant inroads.

Encountering Therapeutic Places For thousands of years tourists, visitors and travellers – in increasing numbers through the 20th century – sought distant places and distant peoples with culturally relevant knowledge and resources as sources of both physical and spiritual enlightenment. Travelling itself has long been a source of wellbeing, whether for cancer patients who expect no real recovery but enjoy the experience (Hunter-Jones, 2005) or for sick children taken by charitable foundations such as Make-AWish to the places of their dreams. Travelling promoted physical and mental well-being but arrival at therapeutic places offered even more. Even in the midst of rapid change early beliefs have played a role – unsurprising where good health and cures can never be assured – and health is placed in a more holistic context. Historic spas have been revived and spiritual places have diversified from places of European visions (such as Lourdes and Fatima) to places of more esoteric beliefs, usually in Asia: all parts of a new diversity of therapies, beliefs, practices and places. Yet throughout these changes biomedicine has grown too, and cosmetic surgery has grown particularly fast, with the great hospitals and specialist clinics of Western cities retaining their significance, further adding to a diversity of therapeutic possibilities. Globalization has contributed to the greater flow of knowledge and information, as much about alternative therapies as about alternative places for biomedicine, which offers both the ‘authenticity’ of Harley Street and a very different authenticity of massages in Thailand or Ayurveda in India. At the very least, alongside growing affluence, multiple options abound, but with some convergence of cosmetic surgery and wellness – different but related conceptions, internal and external, of the healthy body, good body and body beautiful.

Mind and Matter

Health and wellness tourism, and many alternative ideologies, attach particular significance to space and places. Although medical tourism exists in certain particular places, it lacks some of the direct therapeutic links to place (evident in the role of water in therapies) that its antecedents had and continue to have. Even so, in many such circumstances, places have been (re)invented as sites of tourism, with more limited spiritual and health orientations, but involving both some forms of escapism, from the self and the world, and some forms of confrontation of the self and a re-negotiation of place in the world and relationships to others (Smith and Puczko, 2009). Yet the popularity of modern spas, where health is tokenism, reiterates that inner well-being has given way to its external expression. Somewhat paradoxically, in many societies a more ‘cash-rich, time-poor’ life has stimulated ‘lifestyle purchases’, including spa holidays, and ‘therapy holidays complete with life-coaches, nutritionists, psychologists and fitness instructors’ (Smith and Puczko, 2009: 8), often building on current obsessions with body shape and image. Such obsessions mark a focus on materialism, self-improvement, positive thinking and self-help in a variety of forms (that parallel shifts in

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evangelical Christianity) and urge the triumph of attitude over circumstance, enhanced by television series, that simultaneously raise possibilities, present ‘successes’ and offer choices and options. Most contemporary health and wellness tourists, and those engaged in cosmetic surgery, are from developed countries, and engaged in expensive procedures beyond specific health requirements. While the last few decades have seen a constant search for, and resort to, alternative therapies, in different cultural contexts, and the practice of a wide range of therapies, some of doubtful validity, at the same time biomedicine has continued to triumph (and expand its reach), evident in the continued success of Harley Street (and the repeated mobility of the wealthy to such places) and in the growth of cosmetic surgery. While Harley Street in many respects is the precursor of contemporary medical tourism, and has remained an important destination, it has increasingly given way to substantial new geographical flows as modern medical tourism has flourished. Not only are medical therapies vastly more diverse and available to many, but the destinations where such therapies, new and old, are accessible has rapidly multiplied. That is the subject of the next chapter.

4 The Rise of Medical Tourism

Physical and mental well-being are crucial to good health and to health and medical tourism in their many manifestations. Much of health tourism involves various forms of relaxation: diet, exercise and new modes of thought. Although bodies (and minds) were sometimes transformed they were not transformed by surgery or other dramatic procedures. While spirituality may be at the core of health and well-being for some, medical tourism focuses on more physical matters, where the emphasis is very much on biophysical processes, though psychological issues are highly important and spiritual elements are not entirely absent. Some variants of medical tourism, such as cosmetic dentistry, however, may be seen as little to do with health, even for those involved, since they lack dramatic, invasive procedures, and have no ‘medical’ component, and they are given less attention in what follows. Medical tourism, where travel is intentionally linked to direct medical intervention, and outcomes are expected to be substantial and long term, is quite new – satisfying the needs of a growing number of people, who can be both tourists and patients, from a range of countries, benefiting themselves and a growing number of destinations, many in Asia. As recently as the late 1980s little evidence of medical tourism existed (Goodrich and Goodrich, 1987: 219–221). It emerged in 42

contemporary form in the 1990s from the congruence of: (i) the rising cost of health care and insurance in developed countries; (ii) longer waiting lists; (iii) declining costs of air transport; (iv) access to the Internet; (v) the demand for cosmetic surgery; (vi) the ageing of the often affluent post-war baby-boom generation (with their higher expectations of medical care and new needs); (vii) the ability to pay for treatment; and (viii) the free time to travel and combine medical care with a holiday. In destinations the development of medical technology and surgical skills, the emergence of a middle class with new needs, privatization and restructuring after economic problems encouraged supply. In many developing countries (from sub-Saharan Africa to Russia) a growing elite with capital and contempt for local medical care enhanced demand. Its genesis had few links to health tourism and was wholly pragmatic. In this and the following chapters, various numbers have been included primarily to give a crude sense of comparability between regions and countries. Though little credibility can be given to most numbers, some of which are inherently implausible and thus prefixed with phrases such as ‘said to be’, it seems not unreasonable to assume that they are inflated in similar ways in different countries and different hospitals (see Chapter 5). Many such numbers have first been stated in newspaper articles,

© CAB International 2011. Medical Tourism (J. Connell)

The Rise of Medical Tourism

boosting particular countries or hospitals by generous guesstimating, then uncritically accepted in the absence of formal studies or objections, and by dint of repetition have gained inappropriate credibility.

The Diversity and Rationale of Medical Tourism As medical tourism has expanded it has acquired additional diversity, from relatively straightforward cosmetic surgery (such as teeth whitening) to complex operations, involving transplants and stem cell therapy. Procedures, such as cosmetic dentistry and Lasik eye surgery, are advertised in in-flight magazines and other freely distributed tourist publications, in contrast to more elaborate operations that are the outcome of considerable thought, research and expenditure, rather than spur of the moment decisions. Hair transplants in Mauritius are advertised in Air Mauritius’s in-flight magazine and teeth whitening is advertised in tourism brochures in Budapest (Hungary), Chiang Mai (Thailand) and a multitude of other tourist destinations. For relatively simple procedures, little different from tattooing, it is important simply to be a popular tourism destination where advertising to tourists may work. By contrast complicated and expensive procedures are aimed at patients, who may become medical tourists, using the Web and specialized companies rather than tourism publications and outlets (Chapter 6). The bulk of medical tourism thus lies outside the conventional institutions of the tourist industry, but has gradually become part of it (Chapter 9). Economic issues and economic benefits are central to medical tourism because of significant differentials in the costs of procedures between countries (Chapter 7) but they are not the only factors. Where the private health sector dominates costs tend to be the key factor; where the public sector dominates waiting lists are more important and in many developing countries adequate access to superior health care is a critical influence. For procedures that are not recognized by

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governments as a priority, and may not therefore be covered by insurance, waiting times can be very long. Outside the USA this can be the most influential factor. Waiting lists for such non-essential surgery as knee reconstructions have been as long as 18 months in the UK, and over 2 years in Australia, Canada and elsewhere, but surgery is almost instantaneous in Thailand and India, and a fraction of the cost. In Ireland ‘undue delay’ occurs for most procedures; in the Netherlands waiting lists can be long, whereas Belgian waiting lists are negligible, and it has become a significant cause of cross-border migration (Hermans, 2008; Healy, 2009). While waiting lists account for a substantial part of medical mobility within Europe, other factors such as financial savings and even the medical benefits of warm climates for diseases such as rheumatoid arthritis (for Norwegian patients in Spain) have been important (Glinos et al., 2010). In India most procedures can be completed within a week of arrival and patients sent home after a further 10 days (unless they stay on as tourists). Some surgery, such as knee reconstructions, regarded as non-essential or low priority in the Western world, may be necessary for certain forms of employment, and hence worth travelling for. Other nonurgent procedures such as cataract surgery are similarly delayed. In British Columbia, Canada, for example, waiting times for hip and knee replacements were 22 and 28 weeks, respectively, in 2005, whereas they were performed ‘within a few days of referral in most medical tourism destinations’ (Horowitz and Rosensweig, 2008: 10). Canada has consequently sought to set waiting times of 26 and 16 weeks, respectively, for non-urgent procedures such as hip replacement and cataract surgery. As many as 87% of British people travelling abroad for medical treatment did so primarily because of the long domestic waiting lists (TRAM, 2006), and 15% of a sample of British citizens were willing to travel anywhere in Europe to avoid lengthy waiting lists (Beecham, 2002). Moreover where waiting times are lengthy and queues long, consultation times are likely to be short. In the USA particularly, patients complain that doctors spend only a few minutes with them, which raises concerns about the validity of diagnosis

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and minimizes development of personal relationships, loyalty and trust. Doctors in Mexico see fewer patients in a day and so spend more time with them – between 30 minutes to an hour – compared with only a few minutes in the USA, so stimulating medical tourism (Hyo-Mi et al., 2009). In some small and poor countries certain medical treatments are simply unavailable. Many small island states have inadequate facilities for complex surgery: Vanuatu, with a quarter of a million people, has just one surgeon. Impoverished countries such as Yemen, with a population of about 17 million, lack treatments for cancer, heart diseases and several complicated conditions. Limited expertise has resulted in conflicting diagnoses, overcrowding has resulted in diagnoses being made too hurriedly and travel overseas was minimally to receive an accurate diagnosis (Kangas, 2002, 2007). Consequently in many such countries, especially in subSaharan Africa, both overseas referrals and independent mobility are common. In some developed countries substantial numbers of people are wholly without health insurance, perhaps as many as 50 million in the USA (where almost half the population, over 120 million people, are without dental coverage), at least until mid-2010. Some are uninsured or under-insured for particular procedures such as dentistry. Uninsured patients who seek to undertake procedures in the USA can be asked to pay inflated ‘list’ prices that are higher than the prices paid by those who are insured (Herrick, 2007: 2). While many of the uninsured may also be unable to pay for overseas travel and treatment, this increases the probability of choosing lower-cost overseas medical care. Most of the larger medical tourism companies (MTCs), such as Planet Hospital, are based in the USA with a clientele that is predominantly made up of retired baby boomers who do not qualify for Medicare or who have inadequate health insurance (Butler, 2009a). Milstein and Smith (2006) describe such people simply as refugees: ‘middle-income Americans evading impoverishment by expensive medically necessary operations’. However, in California at least, the propensity to travel abroad for medical and dental treatment was correlated with

income, and ‘those living at the lowest level of poverty’ were the most likely to have been treated abroad (Laugesen and VargasBustamante, 2010). The highest concentration of uninsured Americans is close to the Mexican border (Brown, 2008), the main areas of Hispanic settlement, and Planet Hospital has a low-cost insurance plan, called Diaspora, marketed to Hispanics, which provides overseas care (Reisman, 2010: 34). However, lower prices of medical care in Mexico may even encourage people to forgo insurance altogether (Brown et al., 2009). The absence of insurance has stimulated diasporic medical tourism (see below). Insurance provisions may impose stringent and unwelcome restrictions on the choice of provider, surgeon, prosthetics and time, and on where and how procedures can be undertaken. Insurance never covers all possible procedures, including joint replacements which usually also have long waiting lists, and such elective procedures as cosmetic surgery, hence patients are more likely to travel for expensive elective procedures where cost differentials are considerable: a process termed ‘complementary exit’ (Laugesen and Vargas-Bustamante, 2010). Cosmetic procedures such as rhinoplasty, liposuction, breast enhancement or reduction, Lasik eye surgery and so on, or simply the removal of tattoos, have created new ‘non-medical’ demands that must be paid for privately, since governments, as in Australia and France, are uninterested, even for certain forms of reconstructive surgery. Various forms of dental surgery, especially cosmetic dental surgery, are also not covered by insurance in countries like the UK and Australia, hence dental tourism has become particularly common. Conversely some countries, mainly in the Gulf and Middle East, such as Egypt, Jordan, Libya, Yemen and the UAE, provide government support for treatment abroad, sometimes including living expenses and support for a companion. Many others, including most Pacific island states, fund referrals to countries such as Australia, the USA and New Zealand. Within the EU patients can move across national borders for medical care with the cost being paid by their own governments (Charter, 2008). Patients

The Rise of Medical Tourism

from the affluent British Atlantic territory of Bermuda are supported for health care in the USA. All are examples of what has been called ‘institutionalized exit’ (Laugesen and Vargas-Bustamante, 2010). Infrequently, but especially in the Gulf, employers may pay for overseas medical care. In Yemen the Aden Refinery spent US$500,000 a year in the late 1990s on overseas medical care for its employees, including providing living expenses and overseas apartments (Kangas, 2007). Several Mauritanian organizations have signed agreements with Tunisian clinics for their employees’ medical care (Lautier, 2008). Saudi Arabian, Mauritian and UAE employers have similarly extensive provision for care. Where free enterprise is dominant insurance may force mobility, while other structures of government may facilitate it. Partly because of insurance limitations many patients are from the migrant diaspora, but drawn as much by the desire for medical treatment in a familiar linguistic and cultural context (and unfamiliarity with local health care). In many respects these remain ‘hidden tourists’, largely undocumented and ignored in publicity, yet they have effectively pioneered medical tourism in some countries. Since many of those who are uninsured are relatively poor, they either choose not to have medical care or cross the nearest border, a situation that has boosted medical tourism to Mexico. Some 41% of Hispanic households in the border town of Laredo, Texas, used physician services in Mexico, and at least half of all Californians who used medical services in Mexico were Mexican immigrants (Wallace et al., 2009). Similarly most medical tourists in Colombia are Colombian-Americans (Schult, 2006: 120). Even in the mid-1990s it was estimated that some 250,000 people were crossing the Mexican border to avail themselves of cheaper medical services in Mexico, many of whom were MexicanAmericans, though another 50,000 were said to be travelling in the opposite direction for health care in San Diego, California (Bookman and Bookman, 2007: 49). Not only are medical services usually cheaper at home, but staying with extended families further reduces costs and may be inherently pleasurable and supportive.

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Technological change has been crucial to the rise of medical tourism. Since the 1990s economic growth has enabled expenditure on rapidly improving health systems in some developing countries, mainly in Asia, where new technologies have been adopted. The best hospitals in most countries now have access to technology that is the equal of any in developed countries, and superior to that in many regional and provincial hospitals in developed countries. Over the same time period health workers have acquired the skills to use such technology, make subtle diagnostic judgements and dispense a high level of medical care. Some technological developments have resulted in overseas possibilities existing that may not exist in home countries (perhaps because of economies of scale, or technological constraints). Thus, in India, the Wockhardt hospitals are the only ones in the world to perform conscious offpump coronary artery bypass (COPCAB) heart surgery, designed for people for whom surgery under anaesthesia is particularly risky (Dunn, 2007). In Mexico not only do major private hospitals along the border offer technology comparable to that in First World countries, but some employ medical technologies that are more advanced than in the USA since they have not been approved there (Hyo-Mi et al., 2009). Hip resurfacing, a less invasive alternative to hip replacement, was unavailable in the USA until 2006. Conversely, and unusually, some developing countries offer possibilities unavailable in the West. Some non-resident Indians, after working overseas, have returned to India for detoxification through Ayurvedic treatment (Spitzer, 2009). Certain procedures, where ethical issues arise, also have a restricted geography. In most developed countries patients have long become accustomed to being treated by doctors and nurses of overseas origin. In the USA, for example, a quarter of medical students are from overseas, and in Canada, the UK and Australia it would be almost impossible to receive more than the most superficial hospital care in most cities without being treated by overseas-born workers. Familiarity with such migrant health workers has meant that treatment in hospitals

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in their countries of origin is less likely to be seen as a radical step. One medical tourism guidebook has made the intriguing (if inaccurate) observation that: fully one third of the doctors in the USA were trained overseas … where medical schools are vastly inferior to those in the U.S. Conversely almost all the doctors at major medical tourism hospitals were trained in the U.S. This seeming contradiction points out a curious fact: when you have surgery at home you are receiving average medical care, but when you have surgery overseas you are getting the very best. (Gahlinger, 2008: 31)

There has at least been a convergence in standards of care at the best hospitals throughout the world. Growth of medical tourism has been facilitated by infrastructural changes. Transport costs have significantly declined relative to wage levels in most countries, because of deregulation, growing competition between airlines and especially no-frill competitors, that have made some parts of the world, notably

central and Eastern Europe and South-east Asia more economically accessible (Doganis, 2006) and thus also more familiar. Budget airlines such as Wizzair, Jet2 and SkyEurope reduced the cost of getting from London to Budapest to as little as £40 return in 2010 (which also enabled substantial procedures to be carried out on a day trip) (Treatment Abroad, 2010). Connectivity is also invaluable. When Ethiopia and Mongolia developed better flight connections to Bangkok they became ‘an ideal market for us and we start to see explosive growth’ (Anon., 2010c) in medical tourist numbers. The extension of the EU to Eastern Europe removed any need for visas and made travel more straightforward, and similar processes facilitated the politics of mobility elsewhere. Electronic communication has been as important, above all through the Internet, and the emergence of new MTCs, that are not health specialists, but brokers between international patients and hospital networks. The Internet provides instant access to knowledge – what is possible and where, advertisements

Fig. 4.1. Technology in medical tourism? (source: Straits Times, 29 October 2007).

The Rise of Medical Tourism

and access to crucial price information – and a means of interaction with the health-care providers. It also enables the instantaneous transfer of patient files between countries. Growth has followed the changing market context of health care and its deliberate marketing (in association with tourism) as medical care has gradually moved away from the public sector to the private sector, ensuring that a growing majority of people, especially in the richest countries, and above all in the USA, must pay – often considerably – for some forms of health care. Not surprisingly cheap alternatives are welcome. The growth of MTCs has been one of the more striking and distinctive features of medical tourism. Distance provides anonymity. Such procedures as sex changes (gender reassignment), are small but significant parts of medical tourism, especially in Thailand, where recuperation and the consolidation of a new identity may be better experienced at a distance from standard daily life. None the

Fig. 4.2. Pratunam Polyclinic advertisement (source: Bangkok Post, 16 August 2009).

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less sex changes, and also orchiectomy (better known as castration), are routinely and casually listed in Bangkok daily papers (albeit those oriented at expatriates) as part of a range of standard health procedures (Fig. 4.2). Many cosmetic surgery patients may prefer recuperation in a relatively alien environment where they are quite unknown. Drug rehabilitation and detoxification are also often clandestine or in isolated locations away from temptations (and media). What makes medical tourism, and especially cosmetic surgery, so appealing for some is that others need not know there was anything medical about the trip. Tourists are happy to return from overseas looking better than when they left – holidays can after all be very healthy experiences – and declare this the outcome of suntan, good food and exercise (Connell, 2008: 239). Even where privacy may not necessarily seem to be crucial to the operation, that it parallels exclusivity can be important. A Mauritius hair-grafting clinic,

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Challeng’eHair Paris, a name designed to suggest elite connections, argues: ‘Situated not far from most exclusive hotels, the clinic receives patients from around the world. Many stars and persons of international fame, who naturally require the utmost discretion, owe the restoration of their hair to this clinic’ (Islander, December 2004: 38). Changed status and the acquisition of social capital are rarely entirely in the background. Travelling beyond national boundaries usually offers alternative options. Irrespective of insurance certain operations may not be available in origin countries or have a low priority. In Australia, for example, breast reconstruction surgery has very low priority, even for survivors of breast cancer, hence overseas surgery is an attractive option. Abortions are banned in several countries or restricted to the earliest periods of pregnancy, hence in countries such as Ireland, they necessitate overseas trips. Insurance companies and national health systems may deny treatment to patients, for example for infertility, because of age. In some countries such as the UK waiting times for fertility treatments may be very long, and at an important period in couples’ lives, hence many ‘fertility tourists’ have gone overseas (Graham, 2006), just as have many families seeking adoptions. In Australia and New Zealand the Royal Australasian College of Physicians bans doctors from carrying out lap-band surgery on obese children under the age of 15 and limits it for older teenagers. In the UK health authorities are usually also unwilling to countenance stomach stapling for patients if they are aged less than 18; this is not the case in many medical tourism destinations where the ‘customer’ is much more likely to be right. At Bumrungrad International Hospital (BIH) in Thailand, for example, if patients sought hormone therapy and surgery to change sex, doctors neither introduced obstacles by making psychiatric examinations, nor offered or suggested counselling (Turner, 2007a: 16). Medical tourism offers unprecedented and largely unfettered freedom of choice. Choices have extended into some distinctive forms. Reproductive tourism is a relatively recent specialized form of mobility even within medical tourism, following developments in medical science. It involves

travelling overseas to undergo IVF, surrogate pregnancy and other forms of assisted reproductive technology, including freezing embryos for subsequent reproduction (Jones and Keith, 2006), which raise ethical issues (Chapter 8). Denmark has become the ‘sperm powerhouse’ of Europe, as one of the few countries in Europe where there is a substantial supply of sperm for infertile patients, especially for patients from the UK where sperm imports are banned. As one Danish doctor noted in 2006: ‘You can fly Ryanair [a low cost airline] from Stansted [near London], and we have deals with hotels: fertility tourists get a discount’ (quoted in Pavia, 2006: 4). Here as elsewhere medical travel is increasingly part of a tourist package (Chapter 9). Other relatively controversial forms of medical tourism include ‘transplant tourism’, ‘stem cell tourism’ and ‘death tourism’, each of which raise parallel controversial ethical issues. A final form of medical tourism may be ‘transnational retirement’: the establishment of overseas nursing homes, where patients effectively stay permanently, as in Kenya, where converted hotels (as the tourism market declined) were turned into homes for East African Asians, retiring and returning from the UK. International retirement has similarly taken Americans to Mexico, the British to the ‘costa geriatrica’ of Spain, and Japanese to Thailand, Malaysia and the Philippines, where the climate is advantageous and some marry local women as carers. While a vast range of medical procedures may be included under the umbrella of medical tourism some like ‘death tourism’ are relatively trivial in terms of numbers (and tangential to more obviously hedonistic forms of tourism). Most medical tourism involves no dramatic interventions and centres on such banal activities as screening and routine check-ups and low level procedures such as dentistry, rather than on cosmetic surgery – where failures have featured in press accounts – and such surgical procedures as hip replacements. Such routine procedures are more easily combined with standard tourism than substantial surgical interventions. In some regional contexts various factors have come together at a particular time as stimuli for medical tourism. In Asia this

The Rise of Medical Tourism

conjunction of trends was ‘the unlikely child of new global realities: the fallout of terrorism, the Asian economic downturn, Internet access to price information, and the globalization of health services’ (Levett, 2005: 27), that have given the region prominence in medical tourism (Chapter 5). Problems of visa rules, foreign exchange restrictions and limits on medical insurance coverage were temporary breaks on growth, but are now largely things of the past century. The migration of medical tourists is widely encouraged, actively marketed by hundreds of MTCs and supported by some insurance companies and other private companies to reduce costs. Since 2006 no fewer than five guidebooks on medical tourism, four from the USA, have appeared: testimony to growth, the significance of marketing and its new global reach.

From Early Days Outside the West, and its established primacy, one of the earliest places to develop medical tourism was Cuba, a country in search of much-needed hard currency, which attempted to divert residents of Latin America and the Caribbean from US hospitals (Goodrich, 1993). It had some successes in the 1990s and other Latin American countries also benefited mainly because of proximity to the USA – a vast source of sick people and costly hospitals and the world’s largest source of people seeking cosmetic surgery. Politics and the difficulty of getting to Cuba reduced its potential, and assisted other Latin American countries, perhaps not so ironic for the lone, formally socialist state engaged in an activity that exemplifies the dominance of the private sector. Cuba has received medical tourists from other Spanishspeaking parts of the Caribbean and Latin America, including Argentina, Ecuador, the Dominican Republic (Huff-Rousselle et al., 1995: 10) and Venezuela. It was estimated to have attracted about 20,000 medical tourists in 2006, for a range of activities from joint replacements to eye surgery and addiction rehabilitation. Michael Moore’s film Sicko (2007), in which he took a group of uninsured Americans for medical treatment in Cuba, significantly increased awareness of Cuban

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health-care facilities, and emphasized the role of the media in diffusing information on overseas medical care. Otherwise the presence of Venezuelans and the absence of US patients indicate that political factors have a role in medical tourism. In the Caribbean only Cuba has achieved any real success, despite the efforts of various countries to develop specialist procedures. Caribbean island states found it difficult to enter the medical tourism market, despite close proximity to the USA, the existence of a substantial tourist industry, low prices and language advantages, being unable to compete with Latin America (Huff-Rousselle et al., 1995; Paffhausen et al., 2010). However, the Caribbean has benefited from the return of diasporic patients, and several states have sought to be competitive through specialization. Cuba specializes in skin diseases, Antigua in dentistry, Barbados in IVF and the Dominican Republic is more focused on health tourism. Puerto Rico is oriented to its diaspora. Like other Caribbean island states Jamaica has contemplated medical tourism. In 2005 the Minister of Tourism argued that: There were opportunities to capitalise on the health tourism nexus and [he] suggested that perhaps this was a niche to which some of the hospitals could look to establish business opportunities and develop centres of excellence … there was a huge market for cosmetic surgery, fat farms and indigent services. (quoted in Chambers and McIntosh, 2008: 920)

Such considerations in countries with weak economies usually remained no more than contemplations, in the face of: (i) superior resources and intense competition from elsewhere; (ii) the inability of some countries to adequately service the national population; and (iii) concern for political discontent that might follow such an external orientation of health care. Plastic surgery, extremely popular in Latin America, early became the core of medical tourism in the continent. Brazil led the way as the first significant destination for cosmetic surgery outside the USA, and Lasik surgery was invented in Colombia, but neither country acquired substantial numbers

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of medical tourists. Argentina has followed Brazil in developing a growing reputation for plastic surgery. Other countries, such as Colombia, Guatemala and Uruguay, where a private initiative, Uruhealth, has been supported by the Ministry of Tourism, have sought to follow, none particularly successfully. It has, however, been claimed that Cali (Colombia), formerly the ‘sports and salsa capital’ of South America, has become a leading destination for medical tourism, with perhaps 15,000 overseas patients a year, mainly from the USA and Spain, particularly for plastic surgery (Pease-Watkin, 2010). Elsewhere in Latin America Chile has a strongly regional market for high-income patients from Bolivia, Ecuador and Peru, as people move across nearby national borders. Central American countries have, however, established reputations for some medical activities, benefiting from greater proximity to the USA and from US insurance company policies that favour treatment there rather than in the USA. Costa Rica has succeeded, and even been described as the ‘Beverly Hills’ of Central America, having grown rapidly with cosmetic surgery and subsequently dentistry. As many as 150,000 foreigners may have sought medical treatment there in 2006 (Herrick, 2007); with a national population no more than about four million this would constitute one of the highest international patient to population ratios in the world, with a considerable national economic impact, but such numbers are improbable. A more plausible figure is 22,000 Americans alongside others (Costa Rica Views, 2010). One of the leading providers, Clinica Biblica, affiliated to Tulane University in New Orleans, receives about 40 foreign patients a month, primarily from the USA, has one floor devoted to foreigners, and English-speaking staff. Nearby Panama has no globally accredited facilities but has bilingual doctors and the American dollar as its official currency, hence it has had minor medical success, and is currently being recommended (but by those with vested MTC interests) as a major destination for dentistry: Panama can be seen as the ‘go-to’ location for dental work. Comparable to Miami, Panama city is sophisticated, with tall buildings

balanced by picturesque historical sections and even an in-town rain forest … For the patient who wants to tour there is a diversity of nature unsurpassed in the hemisphere whether for island getaways or ecotourism in the jungle. The icing on the cake is that they accept the US dollar: travelers will have no bothersome conversions of money and credit card surcharges for the money they spend. (Apton and Apton, 2010: 42)

Mexico has been particularly successful in attracting medical tourists from the USA, again based on proximity and substantial price differentials in medical and dental care (and for purchasing pharmaceuticals), but the presence of a huge diaspora population there, has been even more influential. Mexican hospitals have long attracted Americans for plastic surgery and more recently hospitals in traditional tourist destinations such as Cancun have promoted reduced-price surgical procedures for retirees based in Florida and the Gulf Coast. Dentistry and cosmetic surgery are both aimed at visitors from the USA, especially adjoining California and Texas. In 2009 some 80–90% of patients in border-town dental clinics were Americans, though in hospitals the proportion was usually below 30%; many were both obese and elderly, with 60% of dental patients being older than 50 (Hyo-Mi et al., 2009). As in other Hispanic contexts, a large proportion of medical tourists are Mexican-Americans travelling ‘home’ for treatment (Blouin et al., 2006: 214–215). Mexican hospitals have developed facilities for bariatric surgery for weight loss, notably lap-band surgery, which is seen by many US employers as an elective procedure and not covered by insurance. Most such procedures cost no more than a third of US costs, and travel costs are low, provoking strong opposition in the USA with dentists offering disputed stories of infections, undetected oral cancer and shoddy work (see Chapter 6). As in many other parts of the world the Mexican government has sought to stimulate medical tourism, partly following a decline in numbers associated with the country’s dire reputation for drug-related gang violence. Very popular with Americans are low cost dental procedures in the border towns. Clinics estimate that 40 percent of their

The Rise of Medical Tourism

patients are foreigners during the tourist high season that spans the months from October to March. Figures would be higher if the epidemic of drug and gang related violence in some border towns could be eradicated. (International Medical Travel Journal, 11 March 2010)

In 2010 Mexico was seeking 650,000 visitors, primarily from nearby cross-border Hispanic communities who would hopefully spend US$50 million by 2020, with 40 hospitals already listed as ‘quality hospitals’ by national and international standards, eight of which were already certified by the Joint Commission International (JCI). Initiatives included training more bilingual SpanishEnglish nurses (International Medical Travel Journal, 2010), in order to reach a wider population. Outside the Americas medical tourism has developed in various countries not previously associated with significant levels of international tourism, such as Belarus, Latvia and Lithuania in Eastern Europe. Both Latvia and Lithuania have sought to develop medical tourism based on dentistry and cosmetic surgery, and both have many diasporic returnees. Latvia saw medical tourism as ‘a quick way of getting a new image for the city, which has suffered heavily from Latvia’s economic collapse … [with] the extra bonus of keeping doctors and nurses in the country, rather than seeing them follow those who have left to earn more’. Following economic ‘collapse’ in the 2000s, Latvian cosmetic surgeons were getting fewer local patients, so badly needed foreign ones. Though appropriate skills exist the economic downturn meant that technological progress had not kept pace with that in Western Europe (International Medical Travel Journal, 1 April 2010). Here as elsewhere medical tourism has been created from economic objectives, but in Latvia and Lithuania, this more exceptionally followed the existence of some spare capacity during economic recession. Movement for medical care within Western Europe had become quite common by the 1980s, mainly from south to north, and as early as the 1970s it was widely said in Sicily that ‘the best doctor is Alitalia’ (quoted in Guerrieri, 1985: 240). West European countries tended to have more comprehensive state

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health-care systems and insurance cover, and European development in areas like cosmetic surgery came belatedly but was boosted by cheaper transport and word of mouth. Costs of dentistry in Hungary are perhaps 30% of those in the UK, and in the eastern Baltic states are about a quarter of them. Dental tourists from nearby Germany and Austria preceded the British in central Europe too where, as in Latvia, national governments became instrumental in planning for health tourism. Hungary, for example, declared 2003 to be the Year of Health Tourism, and tourism brochures there and in other parts of central and Eastern Europe, Latin America and Asia (Fig. 4.3) are full of adverts for dentistry and other short-term ‘drop-in’ procedures that may turn out to be not very different from taking an hour or so off to go shopping. Indeed perhaps that is what much dental tourism is – a sophisticated form of shopping for new teeth, whiter smiles and better fitting dentures. As many as 25,000 people from the UK were estimated to be travelling to Budapest for dental work in 2007 (Haslam, 2007). Poland also offers lowcost dental work and Szczecin, less than 150 km from Berlin, is a popular destination for Germans, while the small town of Sopron, in Hungary, 70 km from Vienna in Austria, is said to have more than 200 dentists and 200 optometrists, about ten times as many as would be expected in a town with just 20,000 people (Herrick, 2007: 5). The Czech Republic and Slovakia have similarly developed dental tourism (and also spa tourism) with facilities like the Piestany Dental Clinic in Slovakia, becoming effectively a ‘British dental clinic abroad’ and claiming to have treated over 1000 patients from the UK in 5 years from 2005. Ukraine and Moldova have more recently entered the world of dental tourism especially and have sought to undercut Western and central European destinations. Indicative of the significance of medical tourism is the manner in which countries whose historic economies have collapsed have turned towards it, like Latvia and most recently Iceland, in the wake of the GFC. Iceland announced its entry into medical tourism in 2010 with a proposed new hospital at Keflavik, a location chosen mainly because of the area’s experience of tourism.

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Fig. 4.3. Advertisement for drop-in clinic, Bangkok (source: travel brochure).

The hospital will be run by Iceland Healthcare and specialise in medical treatment including cosmetic surgery, fat-removal and joint replacements … Initially patients are expected to number 2000 a year, and the first clients are likely to arrive in the second quarter of 2011. Initially the company will focus on marketing in Norway and Sweden, and soon afterwards in the United Kingdom. Future plans include service offering in the USA. The rise in health care and medical tourism will be a precious source of income for Iceland, having suffered crashing banks and a collapsing economy in 2008 and 2009 … 2010 sees travellers from the UK flocking to Iceland due to the favourable currency exchange rate. UK customers are seen as a key market for medical tourism. (International Medical Travel Journal, 18 March 2010)

A real estate company will own the hospital and lease it out to Iceland Healthcare. Here as elsewhere, with the sole exception of Cuba, medical tourism is emphatically led, and usually exclusively owned, by the private sector, and competition has intensified. On the fringe of Europe, Turkey has sought to benefit from its location by attracting medical tourists from Europe, the Middle East and Russia. Its main sources are, however, low-income countries in Europe such as Albania, and countries in the former Soviet bloc, notably Georgia, Azerbaijan, Turkmenistan, Uzbekistan and Kazakhstan (i-Newswire,

2010). Like parts of central Europe, medical tourism is linked as much to therapeutic spas as biomedical procedures. New investment and government support have raised the quality of national health services and increased the availability of contemporary technologies, primarily in the large urban centres of Istanbul, Izmir and Ankara. Turkey has more JCIaccredited hospitals (see Chapter 5) than any other country in the world. Medical tourism in Turkey was said to have grown by 40% between 2007 and 2008 and some projections even estimate that private and public Turkish medical establishments will make around US$8 billion in 2015 by serving one million foreign patients (Today’s Zaman, 2010). Malta and Cyprus vie for primacy in the Mediterranean. Both stress anglophone doctors (trained in the UK or the USA), accessibility, a mild climate and diverse surgical offerings; Malta has gained a mainly British clientele while Cyprus had drawn more from the Middle East. Indicative of growing competition and distinctive efforts to enter a congested market have been those of Georgia, hitherto with no international reputation for medical care, which has sought to follow the example of other post-transition Eastern European countries, in this case by filling a particular gap: Despite Georgia’s sketchy history of medical reforms and a dilapidated medical infrastructure, some Georgian doctors, such as Dr. Mariam Kukunashvili, the director of

The Rise of Medical Tourism

Healthcare Agency International (HIA) in Tbilisi, believe the country can compete for international patients … She said that while the country has its ‘drawbacks’, Georgia is an ‘attractive’ medical treatment destination in certain fields, in particular infertility treatments and surrogate mother selection. This is so in part because Georgia permits procedures that are banned in Europe and elsewhere: ‘We have our attraction – for example surrogacy egg donation – and this was the beginning’…. HIA is popular with patients because it offers a database of surrogate mothers with photographs – a practice that has largely been discontinued in other countries due to privacy issues. HIA also offers background information and details about the women. ‘Egg donors [for HIA] generally are very intelligent and very well educated,’ Kukunashvili said – traits that prospective parents value. Georgia is more affordable than other destinations. According to Kukunashvili, the agency charges [US]$20,000 for the entire surrogate package, including the fee for the mother, medicines and delivery – which is a fraction of the cost for the entire procedure in the United States. (Corso, 2010)

Georgia has also sought international patients for other procedures, including hair transplants and dentistry. While Georgia may be a viable destination for expensive fertility procedures, its location makes it less attractive for other procedures, since many prefer a direct flight to a ‘well-known destination’ such as Istanbul (Corso, 2010). A marginal geographical location, lack of effective marketing, the legacy of recent warfare and simply the absence of word-of-mouth recommendations hamper growth and emphasize the challenges to all potential new entrants. For a decade Asia lagged behind South America and even continental Europe, despite innovative surgical procedures in Thailand where sex-change surgery was pioneered, being held back by some degree of physical isolation from major markets, the perception that high quality medical care was absent, a lack of access to marketing mechanisms and the absence of significant diaspora populations. However, rather like South America, economic growth and the rise of the middle class, especially in such ‘Asian tigers’ as

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Singapore, Taiwan and South Korea, followed by Thailand and Malaysia, was responsible for the national development of superior, high quality hospitals that later played a key role in medical tourism. Aspirations and needs changed. Thonburi Hospital in Thailand explicitly ‘targets patients with middle class incomes and who prefer the services of a private hospital instead of a public hospital’ (Niyomyath, 2009: 32) and that market gradually became an international one. Similarly in Singapore, the Minister of Health pointed out that the national objective was to reach the ‘sleeping giants’: the growing middle class in India and China (quoted in the Straits Times, 15 December 2006). By contrast, in India, perhaps more than anywhere else, the rise of medical tourism was effectively led by Indians returning home with capital and the knowledge that new technologies and skills had been acquired (Chapter 5). Most Asian countries remain sources rather than destinations. China has pioneered stem cell research, but is not yet a significant destination. Hong Kong has a number of internationally accredited hospitals, and if these were able to link into the substantial Chinese diaspora population, and deploy some traditional Chinese medicinal practices, Chinese growth might begin from there. Only in China and India are traditional procedures, rather than modern biomedicine, an influence on medical tourism. Taiwan and Korea have sought to develop medical tourism, and are high-cost destinations, hence are focusing on diasporas and plastic surgery. The Philippines has recently declared its interest, based on global familiarity with English-speaking Filipino nurses and doctors but, as with both industrialization and tourism, it has lagged behind other Asian states. As a consultant noted: There used to be a time gap in terms of medical technology reaching the shores of Manila, but not anymore. Also with every third medical practitioner in the UK or the US known to be of Filipino descent, first-world patients attach a reasonable amount of confidence and comfort in being treated in the Philippines. (quoted in Kinavanod, 2005)

Whether this will be enough to stimulate growth, remains to be seen. The rise of Asia,

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and its significance, is discussed in the next chapter. The rest of the world followed more slowly if at all. South Africa has grown in prominence, especially for cosmetic surgery, with costs less than half those in the USA, from where most patients initially came. It benefited by being the most English speaking of the newer medical tourism destinations, and by being regarded (and marketed) as a leader in medicine since the first heart transplant was conducted there in 1967. Only Tunisia is otherwise significant in Africa. As the managing director of Treatment Abroad has noted: ‘most African countries are focused on solving domestic health care issues rather than seeking overseas patients’ (quoted in Easen, 2009: 81), though, even if they sought to do so, external perceptions of the quality of African medical care present a massive challenge. South Africa has acquired a growing African market. The Manager of Surgeon and Safari noted in 2009: Over the past ten years most of our patients have come from the first world, from English speaking countries like the US and the UK, but this is changing. We now see increasing numbers of patients from within Africa travelling to South Africa for treatment. (quoted in Easen, 2009: 81)

In 2010 Africare Health was drawing its patients from such places as Liberia, Nigeria and Kenya, but also Equatorial Guinea (Slamdien, 2010). Many were regional elites from other sub-Saharan Africa states with less adequate health-care systems (but also included expatriate communities in neighbouring countries, who formerly travelled to the USA). There as elsewhere ‘the growing middle classes are increasingly demanding quality medical services that are not available at home and are willing to pay for them elsewhere. The increasing availability of generic drugs and low cost insurance in Africa is also buoying demand’ (Easen, 2009: 81). Demand and supply, however, are converging rather less in Africa than in Asia. As in the Caribbean, Central America and sub-Saharan Africa, most regions have one or more countries that have sought to position themselves as, at the very least, regional medical tourism leaders. In North

Africa Tunisia claims dominance with as many as 250,000 foreigners said to have visited the country for medical treatment in 2009. If true that would represent a massive increase from 2003 when 42,000 foreigners, more than three-quarters from Libya, were said to have arrived for medical treatment (Lautier, 2008). In 2009 most came from neighbouring countries such as Libya (perhaps up to 70% of all medical tourists) and Algeria, and also from sub-Saharan Africa (about 12%, notably from the francophone states of Cote d’Ivoire, Senegal, Mali and Burundi). Some 18% of the medical tourists were said to be Westerners (from France, Germany, UK, Italy, Belgium, Switzerland, Portugal and Spain), drawn mainly by opportunities for plastic surgery (Tunisia Online News, 2 February 2010). In other words Tunisia draws patients from nearby, the more affluent parts of Western Europe, some of whom are migrant Tunisians, and other francophone sources. Medical tourism has grown slowly in the Middle East, again often assisted by diasporic patients. Jordan serves patients from some parts of the Middle East, and at least in 2005 its low costs made it the main regional medical tourism destination, especially for travellers from nearby Iraq, Palestine and Syria, without the resources to travel to more distant locations. Several thousand also came from developed countries such as the USA and Canada, most travellers from the MiddleEastern diaspora. It was said that in 2007, including some health and wellness visitors, over 250,000 patients from around 84 Arab and other foreign countries were treated in Jordan (Vequist et al., 2009), but no data corroborate this. Jordan’s own data suggest that 220,000 patients from across the world received treatment in the Kingdom’s private hospitals in 2009, compared with 200,000 in 2008 and 190,000 in 2007 (Jordan Times, 29 June 2010) but again there is no statistical support. Political stability and an existing tourism infrastructure have been beneficial. Israel caters for Jewish patients and others from nearby countries and the former Soviet Union, through specializing in female infertility, IVF and high-risk pregnancies. It has also sought to market medical tourism in combination with the perceived therapeutic

The Rise of Medical Tourism

and restorative qualities of the Dead Sea. Egypt and Lebanon, once the major tourism destinations of the Middle East, are seeking to break into this new market, as peace in the latter is established. Making Lebanon the ‘hospital of the East’ is the ambition of the Tourism Council and, according to the Agency for Investment Development in Lebanon, the growth of medical tourism was expected to average around 30% between 2009 and 2011. In 2008 Thomas Cook Egypt and K&M International Health Tourism Lebanon combined to coordinate medical tourism in both countries. Le Royal Beirut Hotel has made partnerships with clinics and travel agencies, and developed a medical package with Middle East Airlines, aimed initially at Arab travellers visiting Lebanon for anything from cosmetic surgery and dental care to intestinal bypass operations, but secondarily at European tourists, particularly from Cyprus and Greece. But ‘Attracting European medical tourists is difficult…. Several European governments, including the UK – whose lead on travel advice most follow – currently advises against all travel to some areas of Lebanon and all but essential travel to other areas of Lebanon’(International Medical Travel Journal, 11 March 2010). Egypt claims to receive 50,000 medical tourists a year from other Arab countries, including perhaps 40,000 from Libya, and seeks to build medical tourism around rehabilitation and recuperation alongside its existing tourism industry (Helmy and Travers, 2009; Johnson, 2010). In Iran the Health Minister stated in 2004 that ‘No Middle East country can compete with Iran in terms of medical expertise and costs’, comparing the cost of open heart surgery at US$18,000 in Turkey, US$40,000 in UK and US$10,000 in Iran so that patients ‘can afford the rest on touring the country’ (Persian Journal, 22 August 2004). However, such arguments have not enabled the development of a medical tourism industry in a country where diasporic tourism is minimal, and political tensions with neighbours discourage regional travel. While Lebanon and Jordan have drawn a small number of patients from the Gulf most medical tourists from there have gone to Asia, or to high-cost European destinations. The

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huge loss of medical tourists overseas has prompted Gulf states particularly to seek to develop national services along similar lines, to redirect the flows of medical tourists. Dubai has built Dubai Healthcare City (DHCC) to capture the Gulf and MiddleEastern market and discourage Gulf medical tourists from going to Asia. Unable to compete on price the Gulf now largely seeks to compete on quality, with Dubai bringing in German doctors to guarantee high skill standards, and Lebanon stressing its many doctors trained in Europe and America. Branding is seen as important: ‘it remains to be seen if DHCC will attract people … if there is a single hospital that had one or two brands that would be good if there was a Cleveland Clinic or a Guy’s or St Thomas’s Hospital’ (Gulf News, 2005). Even high-cost Saudi Arabia has sought to link medical tourism, and especially cosmetic surgery and dentistry, with pilgrimage (hajj) visits to the country, and patients from other Gulf countries (Arab News, 7 July 2005). The Bavaria Medical Group (BMG) has deals with Qatar Airways and the Sultanate of Oman that have taken some patients from Oman to Germany, and led to specialist BMG doctors visiting Oman (Times of Oman, 24 May 2005), which may have reduced flows but not reversed them. In the Pacific Guam has become a regional dental centre for Palau, the Federated States of Micronesia and also Japan, and for Micronesians who cannot afford to travel to Hawai’i (Connell, 2008: 235), but otherwise Pacific island states, despite being tourism destinations, lack specialized skilled human resources and facilities, are costly to reach and too remote from most markets to have ventured into medical tourism. However, a small number of diaspora returnees make use of relatively cheap dialysis services in Fiji (Pacific Beat, 14 August 2009). The limited success of both Pacific and better-placed Caribbean island states indicates that small island states, even with prominent tourism industries, are both disadvantaged in access to global markets, and have some of the greatest deficits of skilled workers. Enthusiasm for medical tourism in this century has resulted in even relatively isolated and high-cost locations such as

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Australia (notably the Gold Coast) and New Zealand examining the potential for medical tourism, at least in the context of marketing certain specialities, particularly cosmetic surgery and fertility, that would compete not on cost but on quality, and might reach a small Asian, Pacific and elite market (Dawson, 2007; Elliott, 2008; Nichols, 2010; Voigt et al., 2010). That such countries are interested and even marginally involved implies merely that: (i) medical services exist; (ii) the rewards are considerable; (iii) other developed countries have succeeded; (iv) profitability is evident; and (v) national economic diversification is always welcome. As a result even the most unlikely players are drawn in.

Transforming the Map Medical tourism has long been concentrated in historic European centres, serving an established elite migration, and having recently grown through cross-border moves within the expanding EU. Elites still travel to the USA, Germany, Switzerland and the UK for expensive but trusted medical care. Many countries have high quality specialized services and other developed countries, such as Australia, have been seen as possible medical tourism destinations where the quality of health care is crucial. However, the most recent growth of medical tourism has been in the middle-income countries of Asia, Latin America, Eastern Europe and the Mediterranean fringe, that: (i) have been able to develop high quality medical services (at least at the best hospitals in national capitals); (ii) have reasonable infrastructure and hotel facilities; and (iii) usually have some connections or association with the tourism industry. Independent of medical tourism, many are also tourist destinations. Other factors that have been influential in creating this new medical geography have been: (i) English-language speaking; (ii) closeness to developed countries and to diaspora populations; (iii) peace and stability; (iv) good exchange rates; and (v) a basic familiarity to a wider world. A particular combination of circumstances has meant that medical tourism has recently

developed in a number of middle-income Asian countries, which have medical care linked to tourism, boosting the attractions of both hospitals and nearby resorts, and integrating medical tourism into the national development strategy. The rise of Asian medical tourism has been exceptional since it has developed at some distance from Western markets, and been boosted by both diasporic migration and cross-border mobility (Chapter 5). Rich-world countries cannot compete on price; and poor countries, especially when remote from major markets, have inadequate high level skills, infrastructure and capacity to develop a medical tourism industry, or market it effectively. Distance has been of considerable significance for medical tourism, as potential tourists have usually tried to minimize distances. Mexico has been a major beneficiary of health tourism from the USA, with Monterrey mounting a strong campaign for American tourists (see below), and migrant Mexicans closest to the border being most likely to return to Mexico for health care (p. 58). In Asia too, proximity has been important. Patients travelling to China have come from nearby Taiwan, Hong Kong and Macau and travelled to Fujian and Guangdong rather than more distant Shanghai or Beijing (Bookman and Bookman, 2007: 58). Russians in Vladivostok cross into nearby China for medical treatment, and of the 20% of sampled residents in the Russian Far East who had been overseas for treatment, the majority went to China (Jego, 2009; Ho, 2010), Bangladeshis go to India and South Africa attracts tourists from nearby states in subSaharan Africa. Cross-border migration for medical care occurs almost everywhere, and short distances are often a function of relative poverty (Chapter 7). Pacific islanders are referred to Australia and New Zealand for care that is unavailable at home (where they travel with relatives, join them and often behave as tourists) although in Fiji cost considerations have meant some travelling to India. Crossborder travel is even more important in Europe. The cities of Strasbourg, Liege and Luxembourg have created a formal network between hospitals in three countries, enabling

The Rise of Medical Tourism

easy patient mobility between them, ensuring that services are used more efficiently. Many lists of the countries where medical tourism occurs exist. Gahlinger (2008) identifies as many as 50 countries where it is regarded as a ‘national industry’, the most comprehensive listing of any of the guidebooks (see Chapter 6). SurgeryPlanet’s website lists 72 countries and other companies identify even more countries. In 2010 Wikipedia listed 24 destinations (two fewer than in 2008), and other attempts at lists have similar or smaller numbers. What all have in common is that they specify no criteria for inclusion. Given the inadequacy of definitions and data on medical tourism numbers (see Chapter 5) and the impossibility of setting lower limits to the point where a country becomes a destination, no definitive list is possible. It is tempting to have a definitive list and map, hence the present study tabulated and analysed the list of countries referred to as destinations by the 820 MTCs (in both source and destination countries) and providers who listed themselves in the Directory on the website of Treatment Abroad as of April 2010 (Appendix I). They listed 75 different country destinations. Arbitrarily selecting those countries referred to more than ten times reduced the list to 26 countries. A small number of other countries, often referred to as destinations (Egypt, Israel, Latvia, Lithuania, Slovakia, Switzerland, Taiwan and Tunisia), fall not far below that cut-off and were also included on the map (Fig. 4.4).

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The inclusion of Cuba just once in the list highlights the political structure of this free enterprise phenomenon, and it too was added. The UK was also added since it gained few references in a directory developed in England. A directory, and thus a map, developed from the USA, or anywhere else, would be somewhat different. While this map is ultimately arbitrary and tautological, it may nevertheless be a reasonable approximation of the geography of medical tourism. Almost all are what Ormond (2008) has called ‘backyards’, close to the sources of medical tourists in richer countries, rather than ‘playgrounds’, a very much smaller number, notably Thailand, where tourist facilities exist. Along with the actual number of references to particular places (Appendix I) this demonstrates the primacy of Asia, central Europe and Central America, the continued significance of West European countries, and the insignificance of sub-Saharan Africa, except South Africa, and small island states other than in the Mediterranean. While many countries are seeking to establish medical tourism those who have already become established are seeking new sources of tourists. For example, at the 17th Moscow International Travel and Tourism Exhibition in 2010, a section of the event, for the first time, was dedicated to medical tourism, increasingly a growing sector of the Russian outbound travel industry. Exhibitors consequently included the Medical Center Rogaska (Slovenia), Center Of Beijing Tibet

Czech Republic Germany

Poland

Austria

USA

Mexico

Cuba

Costa Rica

Latvia UK Lithuania Belgium France Croatia Turkey Spain Cyprus TunisiaMalta Israel Egypt Switzerland Greece

Brazil South Africa Argentina

Fig. 4.4. A geography of medical tourism.

Slovakia Hungary Romania India Thailand

South Korea Taiwan

Philippines Malaysia Singapore

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Hospital (China), Medical Center Chaim Sheba (Israel), Jordan Private Hospital Association (Jordan), Vilnius Heart Surgery Centre (Lithuania), Medical Travel GmbH, University Medical Centre Freiburg, DeutschMedic GmbH, Medcurator Ltd, Medclassic (Germany), Genolier Swiss Medical Network (Switzerland), Premiamed Management GmbH (Austria), and Lissod Modern Cancer Care Hospital (Ukraine). At least nine different countries and even more institutions were seeking access to a new Russian market, again synonymous with the emergence of a more affluent local middle class (eTurboNews, 2010). Destinations and sources are continually becoming more numerous, and international investments have become geographically strategic (Chapter 10). Medical tourism has transformed the map of international health care. Somewhat ironically this has been in substantial part the outcome of migration away from developing countries several decades earlier, and the return of the diaspora – many with good incomes – for medical care, and of some overseas-trained skilled health workers. In the small Mediterranean island state of Malta, patients requiring cardiac surgery had to go overseas, usually to the UK. After 1995 specialist Maltese doctors were attracted back to Malta, new technology was acquired, resulting in both shorter waiting lists and the ability to perform more specialist functions. The savings from not referring patients to the UK were substantial and the process enabled other formerly migrant Maltese patients to stay, taking advantage of better and cheaper services (Blouin et al., 2006). Similar processes have occurred in many Asian and Middle-Eastern states. Korean migrants in New Zealand and Australia routinely return to Korea for medical treatment, which is perhaps only slightly cheaper but takes place in a familiar language and cultural context (see Chapter 5). Indians return to India, Hispanic migrants return to Latin America, South Africans to South Africa. Jewish patients may prefer Israel; Muslims go to Jordan, Tunisia and Malaysia. This reversal of flows of patients, broadly from developed countries to less developed countries, especially sig-

nificant in Mexico and India, demonstrates the cultural context of medical tourism. Economic and cultural factors have combined in this new geography. Thus Mexican migrants in the USA, especially where they are not far from the Mexican border, and who are often uninsured, tend to return to Mexico for medical care. The closer that migrants are to the border the more likely they are to return and the less likely they are to purchase health insurance (Brown, 2008), with a pronounced decline in border crossing more than 15 miles (20 km) from the border for medical care and prescription drugs, and after 100 miles (160 km) for dental care (Wallace et al., 2009). However, half of the parents of insured children still took their children back to Mexico for health care depending on its cost, accessibility and their perceptions of its effectiveness (Seid et al., 2003). Individuals have returned for health care to Mexico due to: (i) unsuccessful treatment in the USA; (ii) difficulty in accessing health care there; and (iii) a preference for Mexican care (Chapter 7). Most migrant societies hold at least lingering beliefs that the content and perhaps quality of care may be superior at ‘home’, while potential returnees have relatives and friends to support them there. Patients returning to their homelands are a key component of the new geographical structure of international health care.

The Diversity of Medical Tourism The outcome of contemporary changes has been an increasingly complex, somewhat hierarchical structure of medical tourism where five overlapping and necessarily crude categories of medical tourist exist. This categorization provides a socio-economic perspective on Cohen’s ‘medical tourism proper’, ‘vacationing patient’ and ‘mere patient’ (Chapter 1). First, there are elite patients from many countries, not least the Gulf, travelling to places like London, New York and Berlin for exclusive and costly medical treatment, continuing a century-long tradition. Secondly, there are rising numbers of patients, many part of the emerging global middle class, or what Bookman and Bookman (2007: 54) call a

The Rise of Medical Tourism

‘second tier of wealthy patients’, particularly travelling for cosmetic procedures, and contributing to the emergence of Central America and Asia as destinations. Alongside them are those who move for cheaper and necessary services, for example when their insurance is inadequate. These are the subject of almost all the literature, the targets of guidebooks and websites and the popular conception of medical tourists. Those who are referred by national governments may also be included here. Thirdly, there are diasporic tourists, who are much diversified in socioeconomic status, from relatively affluent Maltese and Koreans to less affluent Mexicans, returning to their home countries for medical treatment for different combinations of political, economic and cultural reasons. Their numbers are much greater than, by omission, most literature implies. Fourthly, there are cross-border tourists (who include many diasporic tourists), a very long-established group in Europe (e.g. Guerrieri, 1985), who may be seeking cheaper, quicker, more culturally sensitive care or simply seeking reliable treatment, across a nearby border. Some such travellers are clandestine; others are encouraged by national health services. Fifthly, there are the reluctant and even desperate medical tourists, such as those from Afghanistan or Yemen, who are moving at considerable cost, not because it is a luxury or a choice, and who would have preferred local treatment. ‘Medicated tourists’, who meet with misfortune on holiday, and resident expatriates have been excluded. These categories and this typology are necessarily ill-defined, arbitrary and far from homogeneous, especially in the absence of reliable data. Flows are bidirectional; elites may leave as others move in. Geography complicates classification: for example all other categories of medical tourist may also be cross-border travellers (refugees often join the last two categories). A ‘geography of the body’ influences choice of destination for different procedures. Culture (including language) and income further influence destination, some procedures are trivial and others life-saving, relationships with ‘standard’ tourism differ, and rights in destinations vary.

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Much medical tourism has developed without market persuasion. Diasporic medical tourism, such as that to Mexico, Malta and Korea, and many cross-border movements, have needed no advertisement but simply word of mouth and some experience and knowledge of what was there. Moreover, in the Gulf especially, familiarity with doctors and nurses from countries such as India gave the confidence to medical tourists to travel to their homelands in a way that websites might never do. But at the core of the evolving geography of medical tourism have been fundamental economic issues, pulling and pushing patients in new directions. In its various manifestations over barely a decade, medical tourism has boomed and become highly complex in terms of new destinations and sources. Many countries are now involved as sources of tourists, as: (i) privatization of medical care continues; (ii) discontent with public care increases; (iii) cosmetic procedures boom; and (iv) disposable capital is available. Destination countries seek foreign exchange and new means of economic growth. As technology has improved and diffused, and ethical boundaries stretched (Chapter 8), the range of procedures has increased and diversity ensued. Some countries, like Singapore (and the USA and the UK), have become both sources and destinations for medical tourism, and some hospitals have diverse functions: ‘modern well-equipped hospitals in some areas of the world serve the dual role of regional referral centers for patients from poor neighboring countries and, concurrently, function as low cost medical tourism destinations for patients from highly developed nations’ (Horowitz and Rosensweig, 2008: 8). None the less only a few countries have succeeded in developing recognized competence in medical tourism, and those that have succeeded (and their hospitals) have favoured a more generalist approach rather than the specialisms that smaller countries and potential newcomers, such as Georgia, have sought to achieve. A substantial infrastructure, established and recognized skills, and good marketing have been invaluable, but medical tourism has been driven by demand. With growing demand the response has become more

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enthusiastic, and governments have become supporters and promoters, through national development planning and tourism campaigns (Chapter 9). Some governments have taken out equity in particular ventures. Several have established quasi-governmental agencies. Singapore Medicine, for example, is a multi-agency consortium, with funding from several government departments; Israel, Malaysia, Korea and other countries have similar bodies (Reisman, 2010: 134–136) actively promoting this new private-sector development. While medical tourism is growing not all those without medical insurance, or who can make cost savings, or are sick, are necessarily willing to travel. A study of the impact of financial incentives on Americans, entitled ‘Will the Surgical World become Flat?’, showed that almost no one would travel a ‘great distance’ to save less that US$200 on non-urgent surgical procedures and fewer than 10% would travel to save US$500–1000; about a quarter of uninsured people would travel abroad if savings amounted to US$1000–2400 but, even for savings of more than US$10,000, only about 38% of the uninsured and a quarter of those without insurance would travel abroad for care. Despite significant savings from offshore medical treatment ‘the emotional benefit of close access to familiar physicians, friends

and family is considerable’ (Milstein and Smith, 2007: 140) resulting in people being willing to pay substantially larger sums of money to remain at home. A pragmatic reason for immobility may be that in the USA at least accurate and realistic prices have been difficult to obtain and many people have little idea of the costs of particular operations (Herrick, 2007). This phenomenon is not confined to the USA and accounts for new marketing endeavours. Americans may be: (i) more culturally conservative than other national groups, or more loyal; (ii) are less likely to have passports compared with citizens of many developed countries; and (iii) may also have private resources to defray medical costs. Consequently the surgical world has not become flat and for whatever reason many people are unwilling to travel overseas for medical care. Conversely this reluctance to travel explains the significance of diasporic medical tourism, and the desire of many to receive care in a culturally meaningful context. There are both brakes on globalization and potential for increased medical tourism. Irrespective of how and why people have been persuaded or chosen to become medical tourists, many have gone to Asia, hence the following chapter traces the particular rise of medical tourism in Asia, the most significant new regional destination.

5 Medical Tourism and the New Asia

With a combined market share approaching 90%, Thailand, India and Singapore are fueling the double-digit growth rate of medical travel to Asia and making it the fastest growing industry in Asia today. Thailand is the clear industry leader. (The Research Staff, 2009: 42)

The above quotation comes from Medica Tourism, the first (and perhaps the only) issue of a magazine published by the Health Travel Industry of Thailand late in 2009, which not surprisingly is an enthusiastic supporter of medical tourism. The conclusions reached by its anonymous ‘Research Staff’ have no obvious validity, since there are no data to support information on market share, the leading role of Thailand, the rate of growth and therefore the primacy of the industry in Asia. It is a classic example of many statements that boost the industry, and which are then reiterated as an unwarranted truth universally acknowledged. Like most data they have some plausible relationship to the real situation. However, while adequate statistics may be absent, that such a statement can be made at all suggests the prominence of Asia (and the need to constantly boost medical tourism). However, underpinning all that follows is the necessity for better statistics and for more critical examination of the data that exist. The most important new region for medical tourism is Asia. In terms of numbers of medical tourists Thailand is almost certainly

the most important country involved. It became known as a destination for medical tourism as early as the 1970s because it specialized in sex-change operations, and later moved into cosmetic surgery; about 100 foreigners had undergone sex-change operations before 1998 (E. Cohen, 2008: 234–235). Malaysia became involved after 1998 in the wake of the Asian economic crisis and the need for economic diversification, as did many Thai hospitals, when local patients were no longer able to afford private health care. India entered the medical tourism market rather later than South-east Asia but has developed extremely rapidly with shifts in technology and the development of sophisticated hospital chains. Singapore has belatedly sought to compete with India, Malaysia and Thailand, deliberately setting prices just below those in Thailand and even setting up a national stand at the international airport with fliers, information and advice for transit passengers. Other countries, such as the Philippines and Taiwan, are now seeking to be involved. This chapter examines the emergence of Asia and the combination of factors that have given it contemporary primacy.

Numbers from Nowhere Almost all the numbers attached to medical tourism, whether on flows, growth rates or

© CAB International 2011. Medical Tourism (J. Connell)

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income generated, are speculative, based on estimates, without clear definitions and remarkably rounded. Numbers are complicated by diaspora patients, expatriates within countries and short-term drop-ins. It is impossible to determine from most numbers whether some procedures, such as teeth whitening, or local expatriates are included in estimates, but there is a high probability that almost everything is included and numbers are inflated. No countries produce official data on medical tourism, since they have no means of collecting it, and no hospitals release data that has been verified by any independent body. The numbers stated by some countries and hospitals are substantial exaggerations, but inflated figures imply growth and success, and encourage private-sector investment and national support. As one analyst has said: ‘By definition almost every official figure is flawed. They are often badly collected, imperfectly collated and spun to infinity. Some hospitals inflate figures by counting the number of patient visits rather than the number of patients’ (Youngman, 2009; Pollard, 2010a), and by including resident expatriates. Another group of scholars ‘found a lack of hard data on the magnitude of medical tourism, with anecdotes, brokerage claims and theoretical conjectures substituting for more deliberative study’ (Hopkins et al., 2010: 194). Both are entirely correct, and equally true of health and wellness tourism. Although this chapter, particularly, provides some numerical data, most are little more than crude estimates and must constantly be subject to caution and qualification. They have been included primarily to give a crude sense of comparability between countries. Calculations based on data from two Thai hospitals (see below) indicate how overinflation easily occurs in a market context. Since basic data are inaccurate the economic impact of medical tourism is even less easily calculated (Chapter 7). None the less, however unreliable the data, a consensus remains that medical tourism has grown in recent years and continues to do so, and that Asia is dominant. The greatest beneficiary of the shifting geography of medical treatment has been a small number of countries, which have

experienced economic growth, technological change, the return migration of skilled health workers from Western countries, the growth of a middle class who have demanded superior health care and the presence of major international airline hubs and airlines. Increased numbers of expatriates and the new middle class provided key markets for private-sector hospital growth and subsequent medical tourism. As the Chief Executive Officer (CEO) of Bumrungrad International Hospital (BIH) stated in 2006: ‘We are examining new opportunities in South-east Asia – mainly in Malaysia and Vietnam – China and the Middle East, where the number of healthconscious middle class people is growing’ (quoted in Pattaya Daily News, 30 October 2006), a direction reflected in the location of offices and affiliates in those countries. Expatriates have spread information on medical tourism and hosted visitors from overseas. Nearly 20% of medical tourists in Malaysia were there because their relatives had told them about the opportunities (Doshi, 2008: 79), from their own experience or as migrant workers. While such factors were broadly positive, the rise of medical tourism was also a response to the Asian financial crisis of the late 1990s, and the wider globalization of health services. The years since the crisis, as Asian countries sought alternative sources of economic growth, coincided with the growth of medical tourism and the privatization and business orientation of what has become a medical industry. In 1997 the Thailand stock market collapsed, the value of the national currency halved against the dollar and economic turmoil and investor panic spread from Thailand to Indonesia, Malaysia and Korea. The crisis destroyed the savings of much of the emerging Thai middle class, who were no longer able to pay for private health care, hence private hospitals lost their customer base and several revised their marketing strategies to target overseas patients, for whom devaluation meant that prices effectively halved (Turner, 2007a: 115–116; Anon., 2010b), as a more entrepreneurial state emerged. A new low-cost universal health scheme led to the crowding of public facilities and the movement of doctors to private hospitals

Medical Tourism and the New Asia

where there was excess capacity. In both Thailand and India hospitals were given inexpensive loans for investment in superior technology. The global migration of doctors, especially from India, to Europe and North America enabled growing familiarity with being treated by Indians, reducing concerns over the quality of health care. The economic crisis stimulated medical tourism but subsequent domestic economic growth brought new employment structures, local middleclass demand and considerable success. Most Asian governments have consequently promoted and invested in medical tourism.

Thailand Thailand claims to have the largest number of medical tourists, with a million patients said to be from Japan alone in 2003 and a 20%

Fig. 5.1. Cosmetic surgery in Thailand? Illustration by Michele Mossop, with thanks to the School of Fontainbleua (Australian Financial Review, 17 January 2009. Reprinted with permission).

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increase in 2004 and it has even been credited by Singapore with having 800,000 overseas patients in 2003 (Ai-Lien, 2005). Thai hospitals reported that in 2004 some 247,238 Japanese, 118,701 American, 95,941 UK and 35,092 Australian patients were treated, although these figures include locally based expatriates and injured and sick tourists (Levett, 2005). Since many medical tourists are from neighbouring South-east Asian states and from Muslim south Asia and the Gulf, these figures distort the geographical origins. An estimated 632,000 foreigners used Thailand’s health services in 2002, but most were resident in Thailand, contributing about US$477,000 to the economy (Henderson, 2004: 115). The northern city of Chiang Mai has one JCI-accredited hospital, Chiangmai Ram Hospital, and over 80% of the 2000 Japanese residents of the city are said to have used it when they were sick; half of these resident Japanese were business people and half were ‘retired ordinary

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Japanese people’ (Bangkok Post, 12 February 2010: 2). Thailand was said to have treated as many as 1.4 million foreign patients in 2006 (including resident expatriates, holiday makers and medical tourists) and that number was then expected to reach two million by 2010 (Nicholas and Hyland, 2009). In 2009 the same total was quoted but then attributed to foreigners who had ‘travelled to Thailand specifically for medical treatment’ and which had added almost 64 million baht (US$2.2 million) to the economy. About 700,000 were serviced by the 19 hospitals under the Dusit Medical Services umbrella and 400,000 went to Bumrungrad (Bangkok Post, 17 August 2009: B12). According to the Ministry of Commerce in 2002 some 189,000 of an estimated 632,000 foreigners (visiting 33 private hospitals) were expatriate residents in Thailand, 378,000 were staff of international organizations and their family members or visitors from neighbouring Asian counties, and 63,000 were ‘visiting patients’ from Europe and other developed countries. However much these figures vary, and they are inconsistent and disputable, Thailand is the contemporary global centre of medical tourism, and exceeds India both in numbers of patients and in income generated. While many of India’s medical tourists are from the diaspora, almost all of those in Thailand are not of Thai origin. With its early, if specialized, history of medical tourism, and substantial tourism from northern Europe and Australasia, it was well placed to grow in the wake of the Asian financial crisis. As local middle-class demand declined, both Bangkok General Hospital and BIH sought local expatriates, then regional expatriates, followed by the rich middle-class population of the region (Bochaton and Lefebvre, 2009). Thailand was widely seen as less ‘dirty’ than India, free of slums and without its rigid caste system. With its main hospitals, such as Samitivej and Bumrungrad, listed on the Thai Stock Exchange the growth of medical tourism accompanied the privatization of health care. The main medical tourism hospitals have foreign management expertise and are linked to other entities in the private sector, such as Bangkok Airways (see below). Government involvement through the Tourism Authority of Thailand brought hospitals and health care

into the ‘Amazing Thailand’ campaign that began in 2000. By chance the 2004 tsunami disaster that affected Thailand’s southern tourist region demonstrated the considerable capacity of Thailand’s hospitals as they suddenly achieved global publicity (E. Cohen, 2008), and stimulated a Scandinavian market. Medical tourism in Thailand spans a wide range of procedures from various forms of dentistry to cardiac surgery and transplant operations, and the rising importance of medical screening. As in India medical procedures are often linked to standard forms of tourism including a growing number of prestigious spas (Chapter 3), and some of the more prestigious hospitals such as Phuket Hospital and Dusit Medical Services, with hospitals in Pattaya, Phuket and Koh Samui, are located in the main tourist areas. The diversity of patients is reflected in Phuket Hospital’s claim to provide interpreters in 15 languages, and receive about 200,000 international patients a year, while the Bangkok General Hospital has interpreters for 26 languages and a wing specifically for Japanese visitors. BIH in Bangkok – perhaps the single most famous global destination for health tourism – claims to employ 70 interpreters, all its medical staff speak English, and 200 surgeons are certified in the USA. It has a permanently staffed translation centre that specializes in regional Asian languages, including Korean and Japanese, alongside Cambodian, Vietnamese and Lao, and publishes publicity material in several languages, including Arabic. To a greater extent than most other Asian countries, except Malaysia, Thailand has deliberately sought a Japanese market, since some doctors were trained in Japan, and some nurses and other staff have learned Japanese. Thailand has also sought to emphasize medical screening – the routine testing of patients for a wide range of symptoms – and has gained many tourists for such straightforward procedures from nearby parts of Asia, notably Japan and also Singapore, where it is more costly. The translation facilities suggest a high proportion of visitors from other parts of South-east Asia, and the main growth market is regarded as China. The BIH translation centre has translators fluent in 13 languages (Fig. 5.2).

Medical Tourism and the New Asia

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Fig. 5.2. Translation centre, Bumrungrad International Hospital (BIH).

By 1997 Bumrungrad, close to the most popular upmarket tourist areas in the centre of Bangkok, and constructed to comply with US hospital building and safety standards, had become the largest private hospital in South-east Asia, with 12 storeys, 554 beds and 19 operating theatres. It became the first JCIaccredited hospital in Thailand, with a staff of 950 full- or part-time doctors. After the Asian financial crisis it increasingly targeted overseas clients, underselling hospitals in Singapore, placing advertisements in in-flight magazines, encouraging travellers on the national airline, Thai International, to apply frequent-flyer miles to executive physical examinations and offering various discount packages and loyalty cards, so undercutting potential competitors. One of its partners, Diethelm Travel Asia, uses a second-floor office to arrange excursions for patients to local attractions. The hospital was redesigned to look more like a luxury hotel, executive

suites were created and chefs brought in to redevelop menus (Turner, 2007a: 116; Chapter 9). In a sense the contemporary elite medical tourism industry, as it is widely imagined, was born then and there. By the end of the 20th century Bumrungrad was supposedly handling about a quarter of a million patients a year. A decade later it claimed to serve more than 3000 patients a day with average treatment times of 45 minutes and waiting times of 17 minutes, despite half the patients arriving without appointments or a previous case history, and ‘to outperform other hospitals in the region’ and be ‘perhaps the world’s first truly international hospital’ (BIH, 2009: 1). It was said to have treated 360,000 foreigners in 2005, with the hospital having over a million patients in a calendar year for the first time. Since then Bumrungrad has been reported many times as having about 400,000 overseas patients a year. The same claim was again made in 2008, when

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Thailand itself claimed some 1.4 million foreigners visiting for medical treatment. In 2009 it claimed to have served just over one million patients, of whom 400,000 were international patients, with the reduction in numbers in 2009 attributed to the impacts of the GFC and local political turmoil. Dominating the front of its home page, Bumrungrad also claims to serve patients ‘from over 190 countries’, as many are members of the United Nations, though this probably refers to its entire existence. None the less BIH have continued to make claims to global coverage with its Marketing Director stating in 2009 that: ‘Through June this year, we had patients from 191 countries and that’s typical. We’ll top out at a little over 200, which means that at some point in the year we’ll see a patient from every country in the world’ (quoted in Anon., 2010c). A year earlier its CEO had actually claimed 190 nationalities in a day (quoted in Lambier, 2009: 84). International numbers were boosted after the 9/11

crisis in 2001 by the collapse in numbers of patients travelling from the Gulf, Middle East and south Asia to the USA, and by 2005 the number of patients from that region to BIH alone was said to have risen from 5000 in 2000 to 70,000 (Straits Times, 6 November 2006). It has also been stated that of the 400,000 overseas patients a year some 50,000 are Americans (Bookman and Bookman, 2007: 3) and of 435,000 international patients a year 58,000 are American (Turner, 2007a: 117). BIH’s own statistics give much smaller numbers. Bumrungrad’s public statistical data are based on both outpatient visits (in which most procedures, even relatively complex hair transplants, can be completed within a day, hence double-counting is limited) and admissions (recorded once however long a patient may stay). Many procedures may be simple; Medica Tourism featured an American traveller walking in with an ear infection and a rash, with examination and treatment

Fig. 5.3. Bumrungrad International Hospital, Bangkok.

Medical Tourism and the New Asia

taking less than 40 minutes in each case (Leenhouts, 2009), indicating both that throughput can be fast, but with procedures being very different – and much simpler – than those often touted as the core of medical tourism. Most Bumrungrad patients come from South-east Asia, but mainly from Thailand itself which accounts for about 600,000 of all patient visits. Otherwise by far the most important source region is the Gulf (Fig. 5.4). Some Thais may be diasporic tourists (though few live abroad) but most are from Bangkok and visit four or five times a year, hence the overall number of Thai patients is around 150,000. Of the approximately 407,000 patients who are not Thais, about 100,000 are local expatriates and around 100,000–120,000 are primarily tourists who have met with misadventure (‘medicated tourists’) in or near Thailand. As the Medica Tourism example above indicates, some of these (especially expatriates) visit more than once a year hence the absolute number of such patients is fewer than 100,000. The remainder, around 200,000, constitute what Bumrungrad define as ‘fly-in’ medical tourists. Estimates further suggest that almost all those from the Middle East are ‘genuine’ medical tourists, arriving specifically for some procedure, as are the smaller numbers from China and Japan, whereas American, European and Australasian patients are more likely to be accidental hospital patients (Kenneth Mays, personal communication, March 2010). BIH state that the

UK North America 25,934

three ‘highest revenue contributors by country continue to be the UAE, the USA and Oman’ (Bumrungrad Hospital Limited, 2010: 59; my italics). UAE, Qatar and Oman are the major Gulf sources (Anon., 2010c). As elsewhere a significant number of medical tourists cross regional borders, notably from Vietnam, Cambodia, Myanmar and Bangladesh, but the overall number of ‘genuine’ medical tourists is relatively small, especially from developed countries in Europe, North America and Australasia. Bumrungrad has overseas representatives’ offices in Angola, Australia, Bahrain, Bangladesh, Cambodia, China, Ethiopia, Germany, Ghana, Hong Kong, Korea, Kuwait, Mongolia, Myanmar, Nepal, New Zealand, Nigeria, Oman, Portugal, the Seychelles, Singapore, Sri Lanka, Sudan, Taiwan, UAE, Ukraine, the UK, Vietnam, Yemen and in the ‘western hemisphere’, that is the USA, but through Planet Hospital. This list further hints at the principal sources of patients. Somewhat similar data from the Bangkok Phuket Hospital, where the number of foreigners grew from 10 to 25% of all patients over 3 years in the mid-2000s, showed that most of these were resident expatriates, but an estimated 10% were tourists, whose numbers amounted to about 6000 a year. However, only about 500 of these went to Phuket specifically for medical treatment, and then mainly for cosmetic dentistry (E. Cohen, 2008: 246). This kind of analytical process could equally be applied to other Thai hospitals,

Germany

Ukraine

Mongolia

East Asia 24,492 South Korea Middle East China Kuwait Nepal 99,596 Taiwan Bangladesh Bahrain Africa UAE Hong Kong South Asia 14,756 Vietnam Yemen 33,965 Cambodia Sudan Oman Ghana South-east Asia Nigeria Ethiopia Sri Lanka 771,248 Singapore Seychelles Myanmar Angola Oceania 8,246 Australia

Portugal

South America 363

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Europe 25,214

New Zealand

Fig. 5.4. Bumrungrad patients by region. The map records both official BIH data on the regional origin of patients and the location of BIH offices overseas (source: compiled from data supplied by BIH).

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and has obvious parallels elsewhere, were data available. It would almost certainly similarly reveal that the actual number of ‘genuine’ medical tourists specifically travelling to Thailand (and elsewhere) for medical treatment is lower than suggested in most existing estimates. Numbers are invariably fewer than publicized. Bangkok Hospital, the second most prominent destination in Bangkok, claims to receive about 250,000 medical tourists a year. It is part of Dusit Medical Services, the country’s largest private hospital operator, which has 17 branch hospitals around the country, notably in such tourist centres as Koh Samui, Phuket and Had Yai, and owns two hospitals in Cambodia. Its leading international markets are the Middle East, Japan and Europe but in 2009 it saw ‘a rapid increase in customers from China and Australia, due to their increase in income and trade, but numbers from the United States dropped’ (Bangkok Post, 17 August 2009). Samitivej Hospital also claimed that 40% of its patients were international patients from Europe, the USA and Japan; although Samitivej stresses that halal food choices are readily available (Cabrera, 2009a), no real reference was made to patients from the Muslim world. According to the Tourism Authority of Thailand the current source countries for tourists who come with the primary motive of health care are UAE 44%, Qatar 9%, Oman 6%, Japan 5%, Myanmar 5%, Bangladesh 4%, the USA 2.5%, the UK 2.5%, Germany 1%, France 1%, Canada 1% (International Medical Travel Journal, 2010). While such figures are not implausible, and even the briefest visit to the foyer of most Thai hospitals points to the significance of the Gulf compared with European and regional sources (see pp. 115–117), there is no means of collecting or verifying these data. Beyond these formal if crude estimates, substantial numbers of refugees and others cross illegally into Thailand partly for medical care. Some regional variations exist according to the procedure that patients undertake. Gender reassignment patients were mainly from nearby Asian countries including Japan, Laos, Vietnam and the Philippines (Jones, 2009). Cosmetic surgery patients at the Preecha

Aesthetic Institute in Bangkok were from the USA, Korea, Australia, Italy, Japan and Singapore (Bangkok Post, 26 May 2009). However, although Thailand is well known for a diversity of procedures, and perhaps infamous as the centre for gender reassignment, the majority of procedures are actually routine tests without significant surgery or dramatic outcomes, though these are not the more serious procedures usually featured in testimonials, the media and advertising. To a greater extent than in most countries medical tourism has become integrated and embodied into other economic activities in Thailand. Bangkok Airways, Thailand’s largest privately owned airline, is building ‘wellness centres’ for medical tourism, and the national airline, Thai International, has a package including medical check-ups as part of its Royal Orchid Holidays. Bangkok Airways owns three Bangkok hospitals. Patients at the Bangkok Hospital Medical Centre, the Bangkok Hospital Group and Samitivej Hospital can obtain frequent-flyer points for their treatment costs. Bangkok Airways has constructed a wellness centre on a golf course on the edge of KhaoYai National Park, 120 km from Bangkok, to ‘complement our core business in aviation and health care’, and was planning similar centres in China and India (Executive Vice-President Bangkok Airways, quoted in The Nation, 18 July 2008). BIH has a majority 56% stake in Manila’s newest private medical centre, Asian Hospital, has a renal centre in Singapore and manages two other international hospitals in Yangon, Myanmar and Dhaka, Bangladesh. Bumrungrad International Limited, BIH’s international investment arm, has 102 clinics and hospitals in eight countries. In addition to 16 clinics in Thailand, 32 were in Taiwan, 22 in Singapore, 12 in the Philippines, ten in Korea, eight in Malaysia and two in Japan. It has a management agreement with Abu Dhabi to operate Bumrungrad Al Mafraq hospital, a 500-bed public hospital that treats 310,000 patients a year. Bumrungrad’s strategic partners are Istithmar, the investment arm of the UAE government, Temasek (its equivalent in Singapore), Asia Financial Holdings in Hong Kong and the Bangkok Bank. To local partners the ‘strength of the Bumrungrad name’ and

Medical Tourism and the New Asia

‘the unprecedented growth in number of [expatriate] residents in the Emirates’ created a demand for local high quality health-care services. These strategic partners ‘are internationally well known with strong presence in their respective regions, thereby providing important sources of new investment opportunities and referral networks especially in the Middle East and Asia’ (Bumrungrad Hospital Limited, 2010: 58). While referrals may be important these strategic partnerships show that BIH is ultimately a private corporation with an interest in profitability. Construction began in 2007 of a 250-bed Bumrungrad Hospital Dubai to be fully managed by Bumrungrad International Limited, but this was later put on hold during the GFC. The hospital design had a strong Thai influence, using Thai architecture to recreate ‘the exotic atmosphere of a Thai hospital’ (Bochaton and Lefebvre, 2009: 108), since the joint venture partners believed that the hospital should look and feel Thai, as a core strength and point of differentiation for the new hospital. Ironically, as Thai hospitals have expanded outside Thailand, and Thai doctors have migrated to better-paid opportunities there, Bumrungrad itself, with Starbucks and Au Bon Pain in the foyer, has minimal Asian ambience (more closely resembling a corporate office or hotel). The symbolism of globalization can be perverse. As elsewhere in Asia medical tourism has been supported and promoted by the government (Chapter 9). In 2004 Thailand set out a 5-year plan to transform itself into, or ensure that it was, Asia’s preferred centre for medical tourism. While subsequent political strife meant minimal government focus on the strategy it was indicative of the manner in which many Asian governments increasingly saw medical tourism as a development strategy, and sought to promote it in much the same way as other forms of tourism, despite their parallel support for publicsector health care.

India India is sometimes regarded as the contemporary global centre for medical tourism,

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advertising itself as offering everything from alternative Ayurvedic therapy to coronary bypasses and cosmetic surgery. Indian hospitals have upgraded technology, absorbed Western medical procedures and protocols and emphasized prompt, low-cost attention. While non-Indians were ignorant or sceptical of such changes in a country seemingly mired in abject poverty, non-resident Indians (NRIs) were the first international patients. Since economic liberalization and deregulation in the mid-1990s two principal private hospital chains, Apollo and Wockhardt, have expanded and been given government support to import technology and other medical goods with reduced tariffs, so bringing infrastructure in the best hospitals to Western levels. Indian medicine has become involved in assisted reproduction technology, including IVF and surrogate pregnancies. India has also created a special visa, one of only two countries to do so, that doubles the time visitors can stay in the country (up to a year) to receive medical treatment (Chinai and Goswami, 2007). However, most foreigners use a standard tourist visa, because medical visa rules make registration with the Foreigner Registration Office mandatory, and few need to stay long. The links to India’s highly successful information technology (IT) industry have also been advertised as important, and symbolic of modernity. India has benefited particularly from its comparative advantage where prices (both for medical procedures and for tourism) are a fraction of those elsewhere, including other parts of Asia (Chapter 7). Consequently India is known for some rather expensive procedures including cardiac surgery, eye surgery, hip resurfacing and replacements, and also organ transplantation, where cost savings can be greatest. As Indian hospitals improved and salaries increased, so doctors returned from overseas. Many had international qualifications and Western experience that were advertised to medical tourists. The same liberalization brought new structures of corporatization that streamlined India’s notorious bureaucracy and significantly improved administration. The principal corporate hospital chains employ various

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interpreters, though India has benefited because of the widespread ability to speak English, especially by skilled health workers returning from overseas. In contrast to some other destinations, as doctors returned from overseas and greater international accreditation was secured language problems largely disappeared (and were non-existent for NRIs). Diasporic tourism remains important, facilitated by the growth of the Apollo chain of hospitals, one of the more famous transnational hospital chains. The Chairman of Apollo is himself an NRI, other hospitals have been NRI ventures (Lefebvre, 2008) and NRIs have long been the bulk of patients, followed by expatriates from India and neighbouring states such as Pakistan, Bangladesh, Nepal, the Maldives and Sri Lanka, and later by nationals from these countries, and others from America and the Gulf. Long-migrant and second-or-more generation ethnic Indians from countries such as Mauritius and the Seychelles are also significant. Apollo lists 55 associated MTCs on its website, 21 of which are in India and 19 in the USA, with three in the UK, two in Ethiopia and one each in Canada, Japan, Kuwait, Malaysia, Mauritius, the Philippines, Nepal, Saudi Arabia, the Seychelles and Thailand – a distribution that gives further clues to the sources of patients. A very large proportion of India’s medical tourists are of south Asian origin. One recent estimate suggests that 85% of medical tourists in India are from neighbouring countries or are NRIs (Hamid, 2010). Many simply cross to adjoining states so that most medical tourists from Bangladesh, Bhutan and Nepal were in West Bengal (Rao and Zaheer, 2008: 4). Unusually some NRIs return for traditional forms of treatment such as Ayurveda. It was estimated that 150,000 medical tourists arrived in 2002, almost half of whom came from the Gulf (Neelankantan, 2003), and that this number reached about 500,000 in 2005. Many of these were probably NRIs. Another 2004 estimate claimed the annual inflow to India to be between 10,000 and 20,000 foreign patients (Indian Express, 2010). Two other estimates repeat the 150,000 figure (ABC, 2005; Bookman and Bookman, 2007: 3), and it may have grown steadily since

then (Henderson, 2009: 211). One estimate even suggests a growth rate of 30% a year (Aniza et al., 2009). There are few subsequent estimates and these figures are, as elsewhere, optimistic guesstimates. At the start of the 21st century as many as 50,000 Bangladeshis a year were said to travel to India for medical care (Chanda, 2002), while a more recent report suggests as many as half of all medical tourists in India were from Bangladesh, and that proportion would grow if visas were easier to obtain (Business Standard, 20 May 2010). While Apollo has claimed 100,000 international patients, over 5 years in the mid-2000s from 55 countries (Rao and Zaheer, 2008), a second Indian corporate hospital chain, Escorts, claimed that it had increased its number of overseas patients from 675 in 2000 to nearly 3000 in 2007 (Swain and Sahu, 2008: 478), suggesting that international numbers, though growing, may actually be quite small. This crudely suggests that India has fewer than 200,000 medical tourists a year, perhaps half the number in Thailand. Medical tourism is dominated by the Apollo and Wockhardt hospital chains. The Apollo Group, the largest health-care group in Asia in 2008, had 38 hospitals and over 7000 beds across India, a chain of nursing and health management colleges and, as one enthusiastic supporter proclaimed, ‘dual lifelines of pharmacies and diagnostic clinics providing a safety net across Asia’ (George, 2009: 368). In 2010 it launched its 50th hospital. Apollo has become a conglomerate that offers insurance services, while its pharmacies offer a range of medicines and surgical products. In mid-2009, it had a network of approximately 8000 beds and 922 pharmacy outlets. Apollo pioneered orthopaedic procedures including knee replacement and hip resurfacing. Almost 70% of its doctors are said to have trained, studied or worked in Western institutions but it has also sought to integrate Western and Indian traditions, an indication that many patients are NRIs. By 2008 the group was said to have treated 100,000 international patients, many of Indian origin, but there was no indication of time period or supportive data.

Medical Tourism and the New Asia

Like other Asian hospital groups Apollo has expanded offshore, part owning hospitals in Sri Lanka and Bangladesh (with its Dhaka hospital claimed to be ‘a showcase of the synergy of medical technology and advances in IT through paperless medical records’) and with affiliated hospitals in Oman and Nepal. Early in 2010 Apollo was seeking to expand into Libya, Malta, Ethiopia, Yemen, Tanzania and some west Asian countries (Business Week, 2010). The Wockhardt hospital group is a subsidiary of Wockhardt Ltd, a pharmaceutical and biotechnology company. The group was taken over by Fortis Healthcare in 2009. Wockhardt own seven hospitals in India and were intending to open a new one in Goa in 2010 with four more in 2011. Its Mumbai hospital was the first in India to receive JCI accreditation in 2007 and is affiliated with Harvard Medical International. Fortis claim ‘more than 1000 patients annually representing 4 continents and 56 countries’ (Fortis Hospitals, 2010). The New-Delhi-based Fortis, originally set up by Ranbaxy Laboratories, the largest drug company in India, owns other smaller hospital groups, including the Escorts chain and the Pantai Group in Malaysia, but its purchase of a stake in the Singapore company Parkway’s 16 hospitals, with over 3600 beds in Singapore, Malaysia, Brunei, India, China and the UAE, early in 2010 (see below), significantly expanded its scale of operations and its overseas linkages to a total of over 62 hospitals, making it the largest hospital network in Asia. Medical tourism in India is highly localized being centred in a small number of the largest cities, especially Mumbai, within reach of Goa, one of the most popular coastal tourist destinations, and Chennai, declared to be India’s ‘health capital’, which is said to receive about 45% of all international medical tourists. Chennai is the home base of Apollo. India also has a significant domestic medical tourism market, with the key hospitals receiving many inter-state visitors, and Chennai is said to have about a quarter of these. As elsewhere in Asia both the national and the state governments have actively promoted medical tourism and incorporated it into tourist development plans.

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Singapore Within Asia Singapore is a high-cost health service provider, has at least 13 hospitals with JCI accreditation and seeks to compete globally through quality, and regionally, specifically to its populous neighbour Indonesia, through ease of access and low travel costs. Prior to the Asian financial crisis that propelled Thailand into medical tourism, Singapore had the greatest share of international patients in the region, but subsequently was undercut on price (Turner, 2007a). Singapore has acquired a market among expatriates in the region, the Chinese diaspora in other Asian countries, and residents of distant developed countries, because of ease of access (as a global airline hub), cleanliness, political stability and an accessible cosmopolitan lifestyle. The government took a lead in developing medical tourism based on its intention to transform the city state into a ‘biomedical hub’ (or ‘biopolis’) and a leading destination for high-income patients. A joint government– industry partnership, Singapore Medicine, actively promotes Singapore as a destination, but hospital capacity was too limited at the end of the 2000s to enable rapid growth. Singapore claimed an annual 150,000 international patients in 2001, about 80% from neighbouring Indonesia and Malaysia, with others from India, Thailand and Myanmar, with the same total in 2003. It was also said to have had 200,000 medical tourists in 2004, which increased to 374,000 in 2005 (Ai-Lien, 2005; Henderson, 2009) and a reported 410,000 in 2006 (Lee, 2009). This is unrealistic, and numbers are probably yet to reach 200,000, somewhat fewer than in India. None the less Singapore is aiming at over one million international patients by the end of 2012, at least five times its current number, and a large number for a small country, where there is already enormous pressure on infrastructure, including transport, tourist services and housing. If that growth could be achieved it would generate an estimated US$1.8 billion in revenue, create at least 13,000 jobs and even restore economic growth after the recession in the IT industry, but that is improbable. Most medical tourists continue to come from the South-east Asian region,

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especially neighbouring Indonesia, rather than from developed countries (p. 114). That distinction, in a relatively high-cost Asian destination, suggests that even developedcountry medical tourists are substantially driven by economic imperatives for nonessential procedures. Since most medical tourists are from within the region, competing with Thailand and Malaysia is difficult, where costs in Thailand are about 15–20% less than in Singapore (and the cost of living is also less). Cosmetic surgery is expensive and Singaporeans themselves, with access to excellent medical facilities, travel to Thailand because of cost savings for low-level procedures such as check-ups and teeth whitening. Consequently Singapore has stressed its superior technology, and emphasized that Singapore doctors carried out the first Asian separation of Siamese twins and the first South-east Asian heart transplant. In seeking to attract medical tourists to a small country of just five million, Singapore has sought to retain high-level speciality services, and their practitioners, that would not otherwise be possible and so benefit the national population (see Chapter 8). In small countries some services may be used too infrequently for them to be either safe or economically efficient. Despite claims to technological prowess, some Singapore providers have incorporated traditional Chinese medicines and this has drawn in Chinese medical tourists from both India and Thailand (Oon, 2006): a variant on diasporic tourism. As elsewhere in Asia many leading hospitals are part of international chains, typified by Parkway Holdings, the main Singapore hospital chain, with its flagship Mount Elizabeth hospital, which by the mid-2000s had become a regional conglomerate. It owned and managed hospitals, dental surgeries, diagnostic labs and research facilities in several Asian states alongside being engaged in the sale of properties, and diverse investment and trading activities. In 2005, when it claimed that 40% of its income came from foreign patients, it had marketing offices in 15 countries (Khalik, 2006). Five years later this number had increased to 17, with offices in Bangladesh, Brunei, Cambodia, China, India, Indonesia, Malaysia, Mongolia, Myanmar, Pakistan, the

Philippines, Russia, Saudi Arabia, Sri Lanka, Ukraine, the UAE and Vietnam: an indication of market and patient orientation. Reflecting the intricacies of marketing medical tourism, in terms of the balance between Asian countries (including the ‘big four’ of Thailand, India, Singapore and Malaysia), and the efforts of others to break in (see below), international linkages and investment constantly change. India can compete most effectively on price but Singapore must compete on technical ability (quality) and cleanliness, hence there is scope for some complementarity. That became evident in 2010 when the major Indian hospital operator Fortis Healthcare purchased a substantial share Parkway: Indian hospitals are generally much less expensive than those in Singapore or other medical-tourism destinations such as Thailand or the Philippines. For instance, a hip replacement that costs [US]$43,000 in the U.S. could cost [US]$12,000 in Singapore and just [US]$9,000 in India. Convincing Americans to jet off to third-world India is a bit of a harder sell, though. By buying a 23.9% stake in Parkway from U.S. private equity firm TPG for [US]$687 million, Fortis has now positioned itself to become the regional leader in medical tourism, with a strong presence in India (where it has 46 hospitals) for the most price-sensitive patients and a new base in Singapore for higher-end customers aiming for more luxury. Investors are pretty upbeat about the deal: Fortis shares today hit a twelve-month high of 187.4 rupees and are up 35% so far this year. Parkway investors are happy, too. The Singapore company hit a 52-week high of 3.3 Singapore dollars today. (Einhorn, 2010a)

Medical tourism has here contributed to internationalization, new relationships between countries, new forms of private-sector investment and the emergence and growth of Asian-based transnational corporations.

Malaysia Malaysia has been a relatively late entrant into Asian medical tourism but has developed

Medical Tourism and the New Asia

on the basis of high quality hospitals with international accreditation and cultural linkages with other Muslim countries in and beyond the region (though the notion of a ‘harmonious plural society’ is nationally prominent, and also promoted within medical tourism), and near neighbours such as Vietnam and Myanmar. Its origins, as elsewhere, are closely linked to the Asian financial crisis. More than in most countries it has been a part of national development policy, with a National Committee for the Promotion of Health Tourism having been set up in 1998, followed by a Malaysian Healthcare Travel Council. Malaysia went from initially focusing on medical screening to a range of programmes, with cardiac surgery, cancer and eye surgery being in considerable demand. At the end of the last century the number of foreign patients seeking medical treatment in Malaysia was estimated to have been around 400,000, over a 2-year period (Chaynee, 2003) but this was probably an overestimate; it may have been no higher than 75,000 (Reisman, 2010: 175) and 150,000 were reported in 2004 (Chong et al., 2005). Malaysia has variously been reported as having between 130,000 and 200,000 medical tourists in 2004 (Gulf News, 2005; Bookman and Bookman, 2007: 3) and these numbers were said to have increased to 232,000 in 2005 (Aniza et al., 2009). More recently it has been estimated that the number of foreigners visiting Malaysia for medical treatment had increased since 2003, reaching 341,288 patients in 2007, and that the revenue generated from medical tourism was about RM222.25 million (US$68 million) for the first 9 months of 2008 from more than 282,000 foreigners (Bernama, 2010). A majority of medical tourists come from Indonesia, probably about two-thirds of the total, and significant proportions come from other regional states, including the affluent Muslim state of Brunei, Singapore and Japan. Malaysia has concluded an agreement with Singapore for Singaporeans to use their national health insurance in Malaysia and seeks to conclude a similar arrangement with Brunei. One survey in hospitals in and around Kuala Lumpur showed that much the largest group of medical tourists (48%) were from Indone-

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sia (Doshi, 2008: A-21). National data, of doubtful value, suggest that fewer than 8% of medical tourists come from developed countries (Aniza et al., 2009), but that number is very slowly increasing and few are diasporic Malaysians. Medical tourism was also estimated to have contributed some US$103 million to the national economy in 2003 (Henderson, 2004: 114), though a second estimate gave US$40 million for the same year (Arunanondchai and Fink, 2007: 12). The higher numbers are implausible but Malaysia may have a similar number of medical tourists to India and Singapore. Kuala Lumpur is the centre of medical tourism, along with nearby Klang Valley (Selangor), but 30% of patients at the Adventist Hospital in Penang are medical tourists and hospitals in Malacca are also important. As elsewhere in Asia medical tourism is concentrated in the largest urban centres. Malaysia’s Eighth Malaysia Plan (2001– 2005) nominated 44 hospitals to take part in the medical tourism programme, with these hospitals linked to specialist tourist operators who organized tours especially to Malacca and Penang, and a national target of a million patients by 2012 was announced. The subsequent Ninth Plan (2006–2010) further emphasized these strategic directions. Medical tourism is loosely coordinated through Malaysia Healthcare, a ‘one-stop destination’ that provides links to diverse providers, airlines and package tours (Fig. 5.5). Malaysia also promotes itself through a ‘My Second Home’ programme primarily aimed at the lucrative Japanese retirement market, where eligible foreigners can gain a 10-year multiple entry visa. Political stability and Englishlanguage competence, but also competence in Chinese and Bahasa Malay, have been valuable national attributes.

Big and Little Players in Asia The limited ‘data’ available indicate that, however defined, the real numbers of medical tourists are substantially smaller than frequently publicized numbers. Easen’s

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Fig. 5.5. Malaysia Healthcare advertisement, 2009 (source: The Expat, December 2009).

(2009) ballpark figures, in one of the rare comparative accounts, gave the total number of medical tourists in Thailand, India and Singapore as 2.3 million, with 1.2 million in Thailand, 600,000 in India and 500,000 in Singapore, whereas the analysis above suggests that the total for these three countries is likely to be no more than about 700,000 and very probably less than that. It is equally evident that most medical tourists are either diasporic tourists or nearby border crossers, and are often not engaged in complex procedures (see Chapter 7), but that even in just four countries flows are complex and sometimes bidirectional. The benefits have, however,

been considerable and many other Asian countries seek to be involved, and have invested a considerable degree of faith in their ability to compete for medical tourist numbers and for it to be a source of economic growth. Thus far success has largely eluded them. The strongest regional competition to the ‘big four’ comes from South Korea and Taiwan, hindered by relatively high costs and language differences, and from the Philippines. Cosmetic surgery has drawn visitors to Korea from many parts of Asia, though mostly from nearby Japan because of relatively low costs, perceived high standards of care and

Medical Tourism and the New Asia

the rise in Japanese demand. Korea has also been important to the Korean diaspora, many of whom are both relatively wealthy and culturally conservative (Chapter 7). The Korean government has actively promoted medical tourism, mainly targeting Japanese, Chinese, Americans, Russians (from the east of the country) and other states from within the former Soviet Union, and been proactive in encouraging overseas delegations and diplomats to visit hospitals and examine facilities. One such delegate, the wife of the ambassador of Uzbekistan, commented: ‘I don’t smell agents used in hospitals here. Music was playing in the lobby and the smooth mood, luxurious VIP bedrooms and other facilities made me think I was in a six-star-hotel!’ (Korea Times, 2010). Mongolia has signed a memorandum of understanding with three Seoul hospitals, as a growing number of Mongolians arrive for medical treatment. As much as anywhere else in the region, Korea has become actively engaged in promoting medical tourism, and has made particular efforts to attract visitors from China, widely assumed to be a massive future market. Korea was reported to have had 27,500 foreign-based patients in 2008, and that number was said to be steadily increasing. Rather like Singapore the official goal is a million foreign patients by 2020. According to the Korea Health Industry Development Institute, more than 50,000 tourists travelled to Seoul for medical procedures in 2009, mainly from an ill-defined ‘Far East’ and mostly for cosmetic surgery. However, a year later numbers were static or falling and 94% of providers said progress had not met their expectations (Joong Ang Daily, 30 April 2010), though a different source estimated some 60,000 medical tourists (Basit, 2010). The Korea Health Industry Development Institute, established and funded by the Korean government to promote Korean health care and develop a medical travel insurance programme, runs three overseas marketing offices in New York, Beijing and Singapore (Medical Korea, 2010). The city of Seoul opened the Seoul Medical Tourism Support Center in 2009, and its own medical tourism package in 2010, to increase tourism revenue through advanced medical services:

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‘Under the plan, the city government will focus on developing five medical areas, including regular check-up, skin care, plastic surgery, herbal medicine, and dental service, while partnering local medical offices to establish one-stop services where patients can receive comprehensive medical services … In order to develop Seoul as Asia’s leading medical tourism city, we are planning to enhance measures in both quality and quantity while strategizing ways to effectively promote our services overseas,’ said the statement. ‘Medical tourists spend more money and their time of stay is longer than regular tourists, which makes them a very special target audience,’ the statement added, saying that each person spends approximately 3.74 million won ([US]$3,246) per visit, which translates to 70 billion won ([US]$60.75 million) for every 10,000 patients coming through medical tourism packages. (News Xinhuanet, 2010)

Korean hospitals offer a variety of services ranging from comprehensive health screening to cosmetic surgery, which mainly centres on eyelid surgery, rhinoplasty, facelifts and skin lightening. Previously, people went to Korea for less invasive cosmetic surgery procedures, like Botox injections, but foreign patients are now said to seek out procedures developed by Korean surgeons, like autologous fat grafts and facial-bone corrections. While Thailand may be the largest medical tourism destination in South-east Asia, Korea is attractive to young Thais, influenced by the spread of Korean popular culture and seeking the k-pop look of big eyes and white skin. Taiwan, like Korea, has focused on attracting Chinese speakers elsewhere, especially in the USA diaspora and China, but numbers are small. Something of a breakthrough was achieved early in 2010 when a group of Chinese medical tourists were expected: Two high-end medical tourism groups from China will come to Taiwan in April and are expected to bring in substantial revenue … with the average cost for a physical check-up ranging from NT$50,000 (US$1,577) to NT$150,000 (US$4,730), the 64 people from those groups are expected to spend a lot of money during their five- to seven-day visits.

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The medical tour groups were organized by the Guangzhou-based Xian Health and Medical Center, which just opened [in 2010] and is funded by several Taiwanese businessmen operating in China – with capital of 35 million yuan (US$5.1 million). The membership fee for joining the center is 38,800 yuan per year, and every member is entitled to a six-day trip to Taiwan, including a one-day physical check-up service. While southern China’s Guangdong province enjoys the highest GDP [gross domestic product] in the country, targeting its capital city Guangzhou – which has a population of 20 million – to promote medical tourism in Taiwan will bring remarkable business opportunities … as Taiwan has a good reputation for hip replacements and knee and heart surgery, the center can also help introduce those services to potential Chinese clients. (Xinhua English News, 2010)

Taiwan is thus oriented in two geographical and economic directions: (i) seeking diasporic patients from the USA who prefer lower cost care; and (ii) relatively elite Chinese patients from across the Taiwan Strait. The Philippines has based its marketing assumptions and strategy around the notion that its health workers are known throughout the world as both effective and English speaking, and enough have returned for this to be true of the Philippines itself, giving it some expertise in cosmetic and laser eye surgery. However, most returnees have been nurses. A handful of hospitals, notably St Luke’s Hospital in Manila, have sought to become involved. St Luke’s is registered with the Philippine Economic Zone Authority as a ‘medical tourism park’ (Reisman, 2010: 119). Bumrungrad International Limited has a majority share in the new Asian Hospital Inc. in Manila; ‘similar to Bumrungrad International Hospital AHI targets the middle class population’ (Bumrungrad Hospital Limited, 2010: 60). In 2006, President Arroyo started promoting the Philippines as a medical tourism and retirement haven, particularly oriented towards Japan, and involving themes such as the ‘innate hospitality’ of Filipinos, aiming towards around 200,000 foreign patients within a decade to boost tourism into a US$3 billion industry by 2015 (The News

Today, 2010). The constraints to the effective establishment of medical tourism remain the absence of a significant tourism industry, limited familiarity with the Philippines (if not Filipinos) in potential Western markets, concerns over law and order and more established opportunities elsewhere. Once again, as at Medical City in Manila, most medical tourists are diasporic Filipinos, there mainly from nearby Guam and Micronesia, enrolling for check-ups or cancer and cardiovascular problems. Such overseas patients made up only 8% of all patients and contributed just 6% of the hospital’s revenue (Malaya.com, 2010). Otherwise the Philippines has tended to be more involved in the marginal activity of transplant tourism (Turner, 2008). However, nearby Japan, where Filipina caregivers and nurses work, is a significant potential source and, like Malaysia, the Philippines has launched a ‘long-stay’ programme initially to encourage retirement migration (Padojinog and Rodolfo, 2004), which might eventually stimulate medical tourism. While there are distinct prospects of some success for Korea, Taiwan and the Philippines, the challenges are much greater for other countries. Vietnam, for example, has sought to enter the market but thus far has largely attracted only relatively poor patients from adjoining Cambodia (Arunanondchai and Fink, 2007: 13). China is widely seen as the largest future market for medical tourism but it has made some limited inroads as a destination, for the Russian Far East and for unusual and perhaps dangerous procedures such as stem cell therapy. Thus the Beijing Tiantan Puhua Hospital in Beijing caters for international patients, such as those with spinal injuries, looking for experimental stemcell treatments unavailable in the West (Chapter 8). Pakistan would like to emulate India but it is a vain hope for a variety of reasons: While the government of Pakistan seeks to improve hospital quality in the hope of attracting medical tourists … terrorism in Pakistan is scaring away potential health tourists. Professor Tipu Sultan of Bahria University Medical and Dental College argues that Pakistan could offer services to foreigners, especially Americans and

Medical Tourism and the New Asia

Europeans of Pakistani origin, in orthopedic, eye, ENT, heart, and urology treatments besides providing them with investigation facilities in endoscopies, X-rays, MRI, CT scan, cardiology and arthroscopy. ‘Americans of Pakistani origin usually cannot get a visa for India and staying in India is more expensive. Treatment in Pakistan is cheaper than in India because of the downward slide of the rupee in terms of the dollar.’ Sultan says there are good national hospitals that could be used but these hospitals show not the slightest interest in medical tourism. The professor blames investors in Pakistan who want to get returns within a year’s time and therefore they opt for investment in sectors other than health tourism. (International Medical Travel Journal, 18 March 2010)

Even Japan has sought to establish limited medical tourism, a measure of its growing global significance and Japan’s economic strife, the manner in which flows of tourists are multidirectional, the rise of national specialization and the existence of a market for high quality, reliable care. Within Asia constant fluctuations mean that countries, like Japan that have been long-term sources, are seeking to ‘fight back’ via specialization and excellence. Japan is targeting nearby Russia: Anatoly Stolbikov emerged from a health checkup at Kitazato University’s Kitazato Institute Hospital in Minato Ward, Tokyo, with a satisfied look on his face. ‘The examinations took only a short time, and I felt no discomfort. I had no problem talking with the doctors, either, as I had an interpreter,’ said Stolbikov, 56, from the Russian Far East city of Khabarovsk. In February, the Economy, Trade and Industry Ministry invited about 20 foreigners to receive health checkups in Japan as part of a trial that will help hospitals prepare to enter the lucrative health tourism market. The medical tourists paid the cost of their checkups and travel, while the ministry covered the cost of interpreters. In its new economic growth strategy, the government has defined health care and nursing care as fields that are currently hindering growth in this nation. The strategy aims to generate new markets worth 45 trillion yen that would see an additional 2.8 million people employed in these fields. It points out that as society ages,

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medical expenditure is swelling and that this is not just a ‘social cost’ but also something that creates huge domestic demand. (Anon., 2010a)

Despite such numbers, aspirations were more limited. The Japan Tourism Agency simply hoped to boost the number of medical tourists to Japan to 100 a year, a more realistic objective than most countries, oriented initially to China. By early 2010 just 30 Chinese had joined medical package tours organized by a Japanese travel agency, incorporating cancer-detecting PET (positron emission tomography) checks ‘along with the usual sightseeing’. However, the Japanese hospital system has a shortage of doctors, nurses and beds, due to the poor financial condition of many hospitals and the ageing Japanese population. Beyond such fundamental internal problems (resulting in medical tourism from Japan) visas can take 3 months to process, Chinese–Japanese interpreters are few and expensive, ‘quality hospital rooms for wealthy patients’ are scarce and ‘getting Japanese hospitals to treat their patients as customers and not as people who do as the hospital orders them’ will be challenging (International Medical Travel Journal, 4 March 2010). Japan was still expecting to reap some future benefits from cross-border medical care.

Into Asia Throughout Asia the numbers of medical tourists are rising in most destinations, but there are no reliable national figures for any country, that formally count medical tourists, and growth may be much slower than most estimates suggest. However, the success of several Asian states has demonstrated that medical tourism can thrive in diverse contexts, through diverse means. Whereas both Malaysia and Singapore have a medical tourism structure dominated by the South-east Asian region, with Indonesia providing the majority of medical tourists in both countries, Thailand has a more diverse structure and has made a leap from being a regional provider to becoming an international provider. The number of countries seeking to compete

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is growing, though most are middle- or highincome countries, rather than such impoverished nations as Laos or Myanmar. Asian successes have also prompted growing global interest and competition, and optimism is seemingly unbounded but often unfounded. Difficult political situations, high costs, poor infrastructure, unfamiliarity, established intervening opportunities and overstretched medical care systems are all deterrents. A significant part of future growth is widely anticipated to come from the growing middle classes of China, and also perhaps India (despite its national industry), though established sources will remain important. Following the experiences of India, many countries that are seeking to enter the medical tourism market, such as Korea, Taiwan and Pakistan, are seeking to spearhead this through diasporic returnees, those who may be most familiar with progress in their home countries, encouraged by the cultural context and less likely to be discouraged by political problems. Given the potential significance of the Chinese market, which has rapidly become a major part of the ‘standard’ Asian tourism industry, Asia is likely to continue to dominate

as both destination and supply, as flows of medical tourists become more complex. This new structure and geography of health-care provision and international mobility has involved building trust with patients, often online and seemingly impersonally, stimulated by MTCs – key elements in marketing. Their recent growth and their linkages with hospitals, hotels and airlines emphasize: (i) the privatization of medical care within medical tourism; (ii) the construction of new health conglomerates; and (iii) the complex transnationalization of the industry. These are all exemplified in Asia. Like all forms of tourism, marketing the destination and, in the case of medical tourism, marketing very particular services in destinations, and guaranteeing their quality, is highly important for potential visitors who may be quite unfamiliar with both countries and services, and where patients may only meet ‘their medical practitioner’ at the moment of the procedure. Without effective marketing, medical tourism would be little more than small-scale diasporic and cross-border tourism, hence this is examined in some detail in the next chapter.

6 Marketing Medical Tourism

I am so grateful I read that magazine that day and looked up Gorgeous Getaways. They enabled me to fulfill a dream I didn’t think possible. It had so long been such a distant dream, one for movie stars or rich people. Where there is a will, there is a way. I found it with the support of my partner, the skills of a terrifically humble and genuine surgeon and a company concerned enough to bring dreams of cosmetic surgery real for ‘ordinary’ people in a safe and expert environment. I have no hesitation in supporting Gorgeous Getaways in their quest to help people make what seemed to be impossible dreams come true. It does happen, it happened to me. (Quoted in Treatment Abroad, 2010)

The most distinctive feature of medical tourism is that it takes patients across international borders, sometimes far beyond the perhaps comfortable and familiar cultural relationships built up over years between health-care providers, doctors and patients, to places that may be culturally, climatically and linguistically distinct and unfamiliar. Crossing social and political borders for what may be difficult, unpleasant and intimate procedures can be extremely challenging, and accounts for a considerable degree of reluctance, despite cost savings. Medical tourists, other than diaspora tourists, must be convinced to travel, sometimes in the face of opposing advice from their own practitioners, and at least initially through anonymous

websites rather than through personal contact (though word of mouth has a crucial role). Promoting and marketing medical tourism is a considerable challenge. Lack of face-to-face contact in promotion is unusual, but has parallels in other forms of niche tourism, that are the outcome of web searches, brochures and the suggestions and experience of others. Virtually no standard travel agencies market medical tourism (though Thomas Cook has tentatively considered ‘sun and surgery’ package deals in India and has also worked with Lebanon and Egypt to stimulate development, and in Malta, Planit Travel has sought to develop specific medical tourism packages). Otherwise the MTCs that do so are entirely online without a shop-front presence. This chapter examines the marketing of medical tourism, and the particular role of the Internet in this process. More than in any other form of tourism, the Internet plays a critical role, and its utility has done much to boost medical tourism. Somewhat remarkably, after e-mails and shopping for products and services, research on health care is the third most popular use of the Internet, at least among Americans (Cortez, 2008). Other than media stories, that usually draw attention to the drama, incongruities or failures of medical tourism, the only print media advertisements are in in-flight magazines or (usually) small advertisements in English-language

© CAB International 2011. Medical Tourism (J. Connell)

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publications (newspapers or tourist brochures or even occasional street posters), in countries such as Slovakia, India and Thailand (Fig. 6.1), which tend to advertise limited drop-in

procedures. Only recently has the Internet been supplemented with the presence of guidebooks, but websites and guidebooks are interconnected. Marketing and branding in

Fig. 6.1. (a) Dental tourism advertisement (source: Sawaddee, Thai International’s in-flight magazine, April 2010).

Marketing Medical Tourism

Fig. 6.1. (b) Sukhumvit street sign, Bangkok.

various forms have been crucial to the establishment of medical tourism.

Is It Healthy? The single most crucial challenge that medical tourism faces is the need to convince people – who have never been to the possible destinations (and may not normally travel a great deal) – that medical care in relatively poor countries is comparable with that available at home, in outcomes, safety, ‘after-care service’, value for money and perhaps even convenience. For decades health systems in developing countries such as India have been conventionally regarded in the West as inadequate, for India itself let alone for international visitors. That the elite from developed countries travelled to the West for treatment suggested inherent problems. More generally, as an eventual American medical tourist said: ‘When we think of Asia we think of run-down huts, poverty and disease’ (quoted in Russell, 2007). The German radio station, Deutsche Welle, pointed out in the

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mid-2000s that ‘India is not exactly known for health and hygiene’ (22 March 2005) despite its seeking a major market from Germany. Attached to that is the parallel perception that ‘you get what you pay for’: cheap medical care must be inferior and ‘quality doesn’t come cheap’. Cautionary notes have mainly come from professional bodies in source countries, whose members may have to remedy botched procedures and complications. Both the hospitals (and MTCs), who publish positive testimonials, and the professional bodies, who record and repair misadventure, have obvious vested interests. Real rates of success and failure are immeasurable: (i) there is no means of recording this to enable comparisons; (ii) patients’ status changes across borders; and (iii) there are no guidelines against which to measure success rates, especially for cosmetic surgery where disappointments and failures may be more frequent. Indeed cosmetic surgery is never universally successful, even in the best possible contexts, with some infamous examples of failure (Jones, 2008). Outcomes are largely dependent on procedures. Though many so-called ‘smile spas’ in various parts of Europe have no qualified dentists, most do little more than teeth whitening where issues of quality and longevity are less significant. More complicated procedures are more challenging. The focus on botched procedures has largely centred on cosmetic surgery, partly because the media can obtain startling ‘before’ and ‘after’ photographs, or the fewer but particularly challenging transplant operations (see Chapter 8), rather than on more straightforward procedures such as dentistry, where most interventions seem to have been positive. Extreme caution is a large part of the advice given in countries of origin, even for what might seem straightforward procedures. The Australian Dental Association, for example, warns about compromised standards in hygiene and poor techniques and, perhaps more significantly, about adopting the wrong advice and thus procedures. As a representative of the Association suggested: ‘Instead of getting braces, a lot of people are having their teeth capped. But that only lasts a couple of decades. Also, if something goes wrong

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overseas you probably have little recourse for complaint or compensation’ (quoted in Shanahan, 2009: 22). Yet two decades can be a very long time. The media in many developed countries have frequently provided exposés of operations that have gone wrong. In 2006 the Australian Sun-Herald newspaper featured problems in Thailand especially, primarily for cosmetic surgery, under the headline ‘Risky scalpel tours cut into taxpayers’ pockets’ (27 August 2006). A year later the Australian Society of Plastic Surgeons expressed alarm at what they described as dangerous ‘scalpel tourism, often driven by agents offering a package of flights, hotel accommodation, surgery and sightseeing’ (Russell, 2007). A survey of some 68 Australian plastic surgeons recorded that 40 of them had seen patients with complications or poor results and 15 had treated at least one patient after a ‘cosmetic surgery holiday’, most of whom had been to Thailand or Malaysia. Despite their particular interests in pointing to how bad things might be, they recognized that ‘complications could happen to any surgeon’ though overseas there might be no immediate recourse. The Society President pointed out: People are falling for an irresistible, but very irresponsible form of advertising that promises excellent levels of care and monitoring after surgery … While things can go wrong in any surgery, there are huge advantages in being able to get back to your treating surgeon. What we’re finding is that many patients have their surgery in Bangkok, Kuala Lumpur or wherever, then get on a plane and come home. And if an infection develops or you’re not happy with the result of your surgery it’s too late. We’ve had patients come to us in tears saying that when things went wrong there was nobody there for them. Unfortunately there will always be people lured overseas if they think they can save money. We want to remind them that it could end up costing a lot more in the end. (Australian Society of Plastic Surgeons, 2007a, b)

One plastic surgeon commented further that ‘Every procedure is a risk, so we often see these patients coming home with complications which need to be fixed. Of course we

will treat them, but it is not fair to the taxpayer that Medicare then covers the cost of their cases’ (quoted in Metlikovec, 2007). There was no indication of the extent to which Australian surgeons were recognizing genuinely ‘botched’ procedures or whether the complications were trivial (hence only 15 of the 40 treating patients with complications), and no indication of how many women (or men) undertook cosmetic procedures overseas and what proportion of that total the reported 128 ‘problem patients’ might be. The Society issued no subsequent press releases. In the UK it was argued that ‘inadequate arrangements for follow-up care mean that patients routinely present to local plastic surgeons with post-operative complications’ but of 203 surgeons who responded to a national survey, only 76 (37%) had seen patients who presented with complications related to overseas procedures, though they had collectively seen 215 patients in a single year, and a quarter of these required emergency surgery, at some cost to the NHS which became the ‘safety net’. A similar survey in Greater London found that 60% of 35 plastic surgeons had seen complications from ‘cosmetic tourists’. The most popular procedures that required remedial surgery were breast augmentation, abdominoplasty, breast reduction and face/necklift and most patients had been initially treated in Eastern Europe (Birch et al., 2007; Jeevan, 2008: 1423). Since these were also the most popular treatments logically they would result in more problems. The same cautionary statements apply to the British data. Within the industry such statistics are repudiated through the number of successful operations. Thus Yanhee Hospital (Bangkok) alone includes on its website positive testimonials from 376 patients from a range of countries over several years (see below). While failures will not produce positive testimonials, the absolute number of successes compares favourably with the British and Australian numbers on failures. However, here as elsewhere, there is no indication of when testimonials were written, though they usually seem to be produced before patients return home, and before possible

Marketing Medical Tourism

longer-term complications. Some patient statements indicate considerable success: When I returned [from Malaysia] and went to see my doctor, he was furious. He said no American doctor would treat someone who had knee surgery overseas. However he looked at my knee and my X-rays and concluded that they had done an excellent job. He noted that they had left my kneecap in place and that was good because the knee would heal much faster. In the United States it is typical to remove the entire kneecap. (quoted in York, 2008: 101)

Prejudices, perceptions, anecdotes and media sensationalism are more evident than detailed statistics. Overall ‘little evidence exists to indicate that botched operations are a widespread problem in the medical tourism industry’ and anecdotal evidence suggests that where there have been problems this often involved cosmetic surgery patients who: (i) went to facilities that may not have been adequately assessed; (ii) had too many procedures performed simultaneously; (iii) had pre-existing conditions that made success difficult to achieve; or (iv) simply had unrealistic expectations of outcomes and complained over imperfections. Undergoing the so-called ‘mommy makeover’ of full body liposuction, a breast lift and a tummy tuck, for example, offered as a package in such destinations as Colombia, Costa Rica and Mexico, can lead to a slow and painful recuperation and careful post-operative monitoring (York, 2008: 18). In Singapore some cosmetic surgeons have been critical of their own national standards. As one observed: Our health authorities are applying minimal standards, looking mainly at safety rather than the quality of the aesthetic result. This means you don’t have to be a plastic surgeon to perform liposuction as long as you don’t jeopardise the patient’s life, without much regard to how good the result is. (quoted in Nicholas and Hyland, 2009: 22)

Here too, in this elite criticism, there is no real evidence of botched procedures. For more difficult procedures such as IVF success rates can be low. Although hospital

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websites imply high ‘take-home baby’ rates because of the quality of care provided and because hospitals do not have to follow Western guidelines for the number of embryos to be implanted, actual success rates have been excluded and, when queried in India, ‘doctors simply avoided the question’ (Mulay and Gibson, 2006: 88). Formal analysis of comparative success rates for this and other procedures is conspicuous by its absence. Since technology has become much the same as in the West, and doctors are experienced in contemporary techniques, success rates, even for procedures that can have high infection rates (such as heart operations, bone-marrow transplants and kidney transplants) may be comparable to those at some of the world’s best hospitals. Success rates in hospitals, at least in Asian tourism destinations, are probably much the same as anywhere else; several measures of success rates and errors of omission indicate that success rates at good hospitals are little different the world over (Reisman, 2010: 54–56). The quality of postoperative care varies considerably according to location and procedure. Even so, one review of data on clinical outcomes simply concludes ‘relatively little is known about readmission, morbidity and mortality following self-funded medical treatment abroad’ (Lunt and Carrera, 2010: 27). Where some long-term care is needed evaluating outcomes is more problematic since care takes place in different countries. Long-distance travel may itself add complications. Of concern to many potential patients is after-care – what happens if something goes wrong when they return home and their tourism destination and friendly hospital is far away? Usually little goes wrong – patients are not discharged until the signs are good and they will not be rejected by health facilities at home. Medical records can be instantly transmitted electronically to enable after-care in home locations. One reason for the lower cost of health care in developing countries is the often limited possibilities for legal remedies if operations go wrong (and where legal remedies do exist, the difficulty and cost of using these from a distance). It has been argued that, despite Bumrungrad having offices for

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marketing and promotion in 20 countries, it has no office in the USA because having one there would open the way to potential costly liability (Einhorn, 2010b). In many medical tourism destinations laws over medical liability are less strict than those in developed countries hence the ability for effective recourse to legal systems is restricted and, in any event, compensation is unlikely to be substantial. Intermediaries, the new MTCs, are unlikely to be held legally responsible for any failure since they are not themselves health-care providers. However, some providers include coverage and treatment for possible complications in their package prices, and patients may also take out individual insurance policies (Herrick, 2007: 18–19). Organizations such as ISAPS have sought to develop the first international insurance policy for complications arising from cosmetic surgery performed outside the patient’s home country, and to establish an international network of plastic surgeons who would be eligible for protection (Nahai, 2009). How global this might be, or whether it would be linked to a few developed countries, and effectively discourage overseas travel, is unclear. Given the low failure rates of most procedures malpractice is not a major problem, but the fear of malpractice (and both its medical and its financial outcomes) and negative publicity has sparked legal concern (I. Cohen, 2008) and certainly slowed the growth of medical tourism. Inevitable uncertainties surround overseas treatment. Infectious diseases exist in some tropical countries (many of the principal new medical tourism destinations) that are absent in Western source countries, and to which patients have no immunity, and can be caused by pathogens unfamiliar to doctors in developed countries. Deep vein thrombosis may even occur on the way. A worst-case scenario may involve subsequent ‘salvage surgery’ where ‘the procedure or medications may be experimental, and the implants that were used may be unconventional, and removing them may be very difficult [and] atypical to American norms’ (Lundy, 2009: 30). As global surgical techniques converge, and accreditation is extended, such problems are likely to decline, with obscure infections

and diseases unlikely. However, since much medical tourism is for economic reasons it is not unusual for relatively poor patients to leave particular problems until they deteriorate to the point where attention is essential. Many Mexicans returning from the USA for dental treatment left it so late that minor cavities had evolved into major jaw infections before they obtained treatment (Bergmark et al., 2008). Yemeni patients travelling to Jordan and India similarly often arrived too late for cures, and also found that costs were such that they could only afford preliminary treatments (Kangas, 2007: 298). In such circumstances treatment is more challenging and the probability of success reduced. The few surveys of medical tourists after treatment have found that most were satisfied. In a group of European countries the likelihood of going overseas for treatment was strongly correlated with previous treatment abroad (Gallup Organization, 2007). Similarly a British survey found that 74% of those who had gone overseas for treatment were ‘very satisfied’ and 16% ‘quite satisfied’ (Treatment Abroad, 2008), though that still left a margin for disappointment. Other consultancy reports have found similar or higher levels of satisfaction, especially for dental care (Reisman, 2010: 30, 99–100), and anecdotal information supports this. Only the more ‘extreme’ medical tourism (Chapter 8) has lower satisfaction rates. Former Australian patients, when queried on online discussion boards over whether overseas cosmetic surgery (in Malaysia) was safe and how the fears of relatives could be overcome responded overwhelmingly positively, while demonstrating the status anxieties that cosmetic surgery produces. Just tell them that that’s where you are going. You have done your research and the only reason there is bad press is because Australian surgeons are losing money. I had my surgery there and it is 150% FANTASTIC!! Be strong. The risks are the same. And how dare they suggest that they are better surgeons that anyone else overseas. That is ludicrous! I would make a bet that the well known surgeons overseas have had a lot more experience.

Marketing Medical Tourism

Do what is right for you. There is risk with any surgery you have whether it be in Australia or Malaysia. I am in KL now on my second visit & I trust the medical treatment I am receiving. You will find that the training the doctors have received here is no different to the training they receive in Australia. The only difference is the doctors in Australia are paid way too much! I had problems when I came back. My younger sister, by 6 years, had become totally unreasonable and horrible to me, my mother did not speak to me for 10 months. No skin off my nose. I am 59 years old. I don’t need negative people around me even if they are family. My view was I did this for me and I am not here to please everyone. (I had a face/ brow/neck lift and a Boobie lift) I am so happy with the outcome. Do what makes you happy! People who really love you will come around. (Gorgeous Getaways’ discussion board, June 2010)

The image of a country is also absolutely crucial, even where this has no bearing on the health system. Violence and poverty are deterrents – as they are to any kind of tourism – and have reduced the potential of medical tourism in Colombia, Mexico and even Thailand in recent years, whereas Costa Rica and Singapore are seen as particularly stable. Cuba, by dint of being socialist, has largely been excluded from the US market. Terrorism has hampered the establishment of medical tourism in Pakistan (see p. 76) and may threaten India. The extraordinary global success of the film Slumdog Millionaire (2008), set in the slums of Mumbai, not only was resented in India because of its portrayal of slums, dirt and poverty, but it also became a very real disincentive to medical tourism: a throwback to the concerns of Deutsche Welle in 2005. Perceptions, however poorly founded, are critical to all forms of tourism.

Accreditation and Affiliation Crucial to counteracting negative images and to effective marketing is global accreditation. While some chains such as the Apollo Group, based in India, and individual hospitals such as Bumrungrad, have become known in the

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wider world, few have acquired the cachet or reputation of the best Western hospitals – and a hierarchy remains where Western hospitals are perceived to be at the top. Marketing is an exercise in branding. Even the most casual glance at the websites of leading medical tourism hospitals suggests modernity, opulence, comfort and technological prowess (see below). Transferring such images into the positive perceptions of potential patients in distant countries, and providing convincing information on an intangible product, remain critical challenges. While the quality of medical care may vary little across countries real comparability is immeasurable, hence potential patients may be swayed by cautionary tales and the conservatism and self-interest of domestic medical practitioners and their professional organizations. Moreover ‘information on quality is not readily available to patients, and what is available is often difficult to interpret or irrelevant’ while quality varies considerably in most national contexts (Herrick, 2007: 14). Websites promoting medical tourism can sometimes be problematic: a survey of 130 websites on ‘breast augmentation’ concluded that a third contained information that was false or misleading (Jejurikar et al., 2002), though whether this was deliberate was unclear. Rigorous structures of accreditation are highly technical and may mean little to most medical tourists. The Lithuanian dental clinic, Denticija, emphasizes that it is a member of the European Union of Orthodontists, the Lithuanian Association of Maxillofacial Surgeons and the Lithuanian Chamber of Orthodontists (Denticija, 2010), all no doubt worthy but none of which seem at all wellknown. The websites of hospitals delivering IVF and stem cell treatments often provided ‘long, wordy explanations of their procedures which are difficult to decipher [with] a barrage of pharmaceutical and technical terms [that] purport to make the process appear complicated, scientific and, most of all, professional’ (Mulay and Gibson, 2006: 88; Patra and Sleeboom-Faulkner, 2009: 159). To a lesser extent this ‘blinding with science’ is true of other websites. Formal accreditation is of significance to health professionals rather than patients.

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The JCI, originally established to accredit American hospitals participating in Medicare, is the key global regulator of health-care standards, and has been inspecting and accrediting health-care facilities outside the USA since 1999. Its accreditation is therefore sought by many health-tourism facilities, though the JCI works with various overseas medical institutions to help them evaluate, improve and maintain the quality of their health care. Their substantial Joint Commission International Accreditation Standards for Hospitals (JCI, 2007), translated into ten languages, provides the basis for accreditation of all hospitals. However, the JCI, like other accreditation organizations, regulates standards in only the largest hospitals and does not cover such areas as dentistry where small clinics dominate. JCI received its own accreditation in 2007 from the International Society for Quality in Health Care, providing assurance that its procedures met the highest international benchmarks for accreditation entities. A second main accreditation organization, the International Standards Organization (ISO), also accredits hospitals that meet internationally agreed standards. Around 100 countries belong to ISO, one of whose goals is to manage the operational functions of medical facilities, and ensure ‘quality control’, but it examines management efficiency rather than quality of health care. Through this regulation the JCI and, to a lesser extent, ISO (which has played a greater role at the national level) have become increasingly important for the globalization of medical care. A number of independent, non-profit organizations also endorse standards of quality in hospitals and clinics in various countries. In India the National Accreditation Board for Hospitals has signed a memorandum of understanding with the Australian Council on Healthcare Standards for assistance and technical advice towards meeting global standards for health clinics and medication centres. However, many hospitals are actually accredited by the Confederation of Indian Industry. Twelve hospitals in Hong Kong, and others elsewhere, are given accreditation through the Trent International Accreditation Scheme developed by practitioners and managers from within the former Trent NHS Region in the UK.

JCI has worked with health-care organizations, ministries of health and global organizations in over 80 countries. In 2006 it opened regional offices in Dubai and Singapore to cater for growing demand for accreditation in the Gulf and South-east Asia. In early 2010 its website claimed that it had certified ‘nearly 300 health care organizations and clinical care programs in 39 countries’ outside the USA (JCI, 2010). Of the total of 293 some 69 were in Europe (notably Ireland and Italy), 31 were in Latin America (17 in Brazil, eight in Mexico and three in Costa Rica), 117 were in the Middle East and the Gulf (35 in both Turkey and the UAE and 31 in Saudi Arabia) and 71 were in Asia (16 in Singapore, 15 in India, nine in both Taiwan and Thailand, six in Malaysia and three in both Korea and the Philippines). Six of the eight JCI hospitals in Mexico are very close to the US border. Since accreditation was initially aimed simply at ensuring adequate national standards it is unsurprising that many JCI-accredited hospitals have little or nothing to do with medical tourism. Equally, facilities in many countries (including the UK, Canada and Australia) have never sought accreditation. None have been accredited in South Africa, and no Cuban health-care facility has achieved JCI accreditation. The procedure of accreditation and its outcomes have been well described for Singapore: In 2005, the National Heart Centre Singapore (NHC), a tertiary referral centre under Singapore Health Services, became the first heart hospital in Asia to be accredited by JCI and was re-accredited in 2008. This public 185-bed facility is the national and regional referral centre for cardiovascular disease and cardiothoracic surgery, and initially sought JCI accreditation to improve its patient care processes and outcomes. According to a NHC senior consultant surgeon, NHC wanted to ‘reinforce our commitment to quality care for patients as well as ensure a safe environment and continually work to reduce risks to patients and staff’ and decided to obtain accreditation from JCI both because it ‘has been widely recognized as an effective quality evaluation and management tool’ and because ‘the JCI accreditation process is designed to accommodate specific legal,

Marketing Medical Tourism

religious, and cultural factors within each country,’ which is an important consideration for a multicultural society like Singapore. After accreditation NHC experienced numerous positive impacts: increased levels in patient comfort and satisfaction, a safer environment for patients and staff, and improved staff performance … NHC has also experienced a gradual influx in foreign patients. As the first heart centre in Asia to receive JCI accreditation, this designation ‘re-affirms our high standard of care provided to patients, which will help further enhance our marketing efforts in the overseas market.’ (JCI, 2010)

Increasingly the best hospitals have sought dual or multiple international accreditation to ensure wider market coverage and their websites proclaim awards they may have won (see below). Affiliations with hospitals in developed countries are further indications of reputation and respectability, and hospitals in several countries have sought to partner with good hospitals elsewhere, especially in the USA. Harvard Medical International has partnerships with facilities in 40 countries, including the Wockhardt Group, and DHCC. The other large Indian chain, Apollo, is partnered with Johns Hopkins Medicine International. Implicitly such linkages provide accreditation, add prestige and imply global standards. Hospitals in developing countries are branding themselves as equivalent to the very best, and even loose affiliations may mean rather more than JCI accreditation to aspiring patients. Formal accreditation and international linkages are valuable but, again, like some website data, somewhat distant from potential consumers, while a plethora of accrediting bodies can be confusing (Reisman, 2010: 79). However, a profusion of guidebooks in the late 2000s, most oriented to the US market, has enabled a potentially more rigorous and logical search for information (see below). They are more amenable and accessible to aspiring patients: a popularization of more technical data elsewhere, but not without certain biases. To some extent the guidebooks are oriented to Internet-illiterate users of the babyboom generation, offering advice on how to use it to search for medical facilities. Intending

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patients will turn either to guidebooks or to the websites of MTCs and finally to the websites of the facilities where they may go. Before they do that they are likely to have been influenced by media stories, and by word of mouth. Ironically, but inevitably, those most able to initially assist – local medical-care providers – are the least likely to provide advice, while some actively block the possibility by refusing to provide handover notes (e.g. Russell, 2007). Obtaining advice and information is an uncertain and serendipitous activity that often departs far from accreditation.

Media The esoteric and technical nature of formal accreditation has meant that the media have been invaluable to the marketing of medical tourism, followed by MTCs and guidebooks. While some media coverage has been negative it initially drew attention to the existence of overseas facilities in a way that would not otherwise have happened. The extent of media coverage (and the contemporary use of web pages for detailed information) have reduced the need for expensive advertising. Hospitals and MTCs have encouraged past patients to submit positive testimonials and stories, particularly with an unusual ‘human interest’ perspective (see below), that can be recycled to the media. Medical tourism began to boom in the USA in the early 2000s but, apart from diasporic tourism, only after the media ‘discovered’ the new trend and produced stories and television programmes about its significance, and the cost savings that were possible. Overcoming uncertainties about the outside world took longer, because media reports seized upon negative consequences. Some MTCs have actively worked with the media to generate stories. The Australian company, Gorgeous Getaways, has alone stimulated about a dozen articles a year that attest to the positive virtues of medical tourism, primarily plastic surgery, ranging from relatively sober accounts in such newspapers as The Guardian, the Asian Wall Street Journal and the Sydney Morning Herald, to more dramatic features in the tabloids (complete with

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accompanying ‘before’ and ‘after’ photographs). These include such stories as: (i) ‘My Husband Made Fun Of My Body – So I Made Him Buy Me a New One’ (Best, UK, 2009); (ii) ‘Would You Like New Boobs With Your Tan?’ (Marie Claire, UK, 2009); (iii) ‘I Lost 30 Stone And Found The Man Of My Dreams’(Sunday Magazine, UK, 2007); (iv) ‘I had an Apron of Fat – now I have a Taut Tummy!’(Take it Easy, UK, 2006); (v) ‘My boobs went up two cup sizes on my honeymoon’ (News of the World, UK, 2005); and (vi) ‘My hubby left me for a younger woman. So I spent 4,000 [pounds] on a brand new body’ (Take it Easy, UK, 2005). All of these (and more) are posted on the company website (Gorgeous Getaways, 2010). While none shy away from certain problems – surgery may be painful, is not necessarily cheap and can disrupt honeymoons – the consistent conclusion was that it provided value for money, offered new social opportunities, enabled greater self-confidence and could be combined, if sometimes uneasily, with a holiday. Similar stories are common within the popular press and magazines and, as here, almost entirely focus on plastic surgery. Medical tourism has been boosted through television, particularly by support from The Oprah Winfrey Show, and thus especially in the USA, though The Oprah Winfrey Show reaches some 141 countries. The show, and the resident doctor, Dr Mehmet Oz, also promoted ‘A Global Guide to Medical Tourism’ to the extent that there was a joint website with comments from former and potential patients, most of which were positive, including the following from late 2009 and early 2010: Dental medical tourism is a must for me. A few years ago I was quoted [US]$12,000.00 to do some dental work for me. That was out of the question. I had heard that dentists in Mexico were very good and reasonable. I googled dentists and came up with one in Puerto Vallarta (one of my favorite Mexico destinations) and away I went. Got all the dental work I needed at the time for [US]$4500.00 including root implants, crowns, root canals, fillings, and cleaning. And had one wonderful vacation as you can if necessary get very inexpensive rooms there.

In this case at least the link to a familiar tourist destination is evident. Some seem to have been posted out of a sense of desperation: i’m going nex year to Africa to fix me teeth cuz it cost a lot down here but in Africa it’ll cost me not even one thosend .peple think that African Doctor are not good enough but ..hey the African you see on T.V is not the hole picture..people ues poor African to make money..anyways go your self and see the hospitals there..[sic]

That may have been a rather weak recommendation. But patients also have concerns and financial problems and some web postings reveal the challenges to overseas travel and care: I was going to Mexico to get full mouth implants and still the cost is a lot. Not only did a doctor cause me to loss all my teeth I also gained 100pd’s. I need a full mouth implants and have talked to over 47 doctors in Mexico. I still so scared. I don’t trust doctors and I have to trust one in another country, I’m so scared. I just want to smile again. Thank you for your time. Kitty (Oprah, 2010)

Similar issues are debated in other patient testimonials on a range of websites (see below). Otherwise medical tourism has faced the standard problems of distant facilities, but exacerbated by crucial problems of quality. Patients in search of improved treatment (or any treatment at all) must first know that facilities exist elsewhere, either by word of mouth or from the media, and then access guidebooks, and the web pages of MTCs and providers. The media opened the way.

Getting Started A number of websites and, more recently, guidebooks offer advice to potential patients on how to become involved. Medical tourism guidebooks are somewhat distinctive from most guidebooks in not being for people who have already chosen to go away, and the particular destination, but directed at those who are simply considering the possibility. How many potential medical tourists use such information, or any information at all, is

Marketing Medical Tourism

unknown. A 2009 survey of an unknown number of international patients at Bumrungrad revealed that most people found out about medical tourism through friends and very few through books and the media (Anon., 2010b). Diaspora tourists are loosely familiar with what is available at ‘home’ and many others clearly rely almost entirely on word of mouth or good luck, though this depends on the gravity of the procedure (Chapter 7). Some procedures, such as gender reassignment surgery, are rarely advertised. The Internet, however, has become crucial. About a quarter of Bumrungrad patients found out about medical tourism through the Internet and a similar proportion used it for information on country destinations and hospitals (Anon., 2010b). In a general survey of medical tourists, with no information on methodology or sample size, 49% found out about medical tourism through the Internet and 73% sought specific information there, as opposed to through friends, books or MTCs (Anon., 2009). The MTA claim that almost 70% of Americans (some 113 million people) search for medical information online (Health Tourism Magazine, 2010). The implication is that the Internet is invaluable as the primary source for choice of destination yet how people use the Internet, which websites they visit and how they assess the information is quite unknown. What alerts patients to particular Internet sites is unclear but word of mouth plays a role. Whether a ‘digital divide’ discriminates against potential users in some places is similarly unknown (Lunt et al., 2010); guidebooks are probably preferred by the technologically challenged. While newspapers and magazines tend to be of significance primarily for sensationalism, and at least raising general awareness in developed countries, the local media play an important role for citizens and resident expatriates. Thus in Thailand, the Englishlanguage Bangkok Post carries adverts for some cosmetic procedures (Fig. 4.2) and the German language monthly, Farang, contains many adverts for medical procedures. Similar advertising strategies occur in other destinations, where there are both tourism and expatriates, including Malaysia (Fig. 5.5), India and Singapore.

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Websites, guidebooks and MTCs emphasize basic data on both medical procedures and overseas travel. Websites are owned by: (i) ‘utility’ portal sites that provide general information on medical tourism; (ii) companies that market or advise on global destinations (without evident commercial or geographical restrictions) and also on regional and national destinations; (iii) MTCs (some of which are linked to guidebooks); and (iv) health-care providers (mainly hospitals and clinics) but also countries. A few sites are linked specifically to certain procedures, usually cosmetic surgery, such as the Australian site www.cosmeticsurgery.com that has detailed information on many procedures, including cautionary advice. Hundreds of websites exist. A 2009 survey of health providers found 213 websites, notably in Asia (41 in India, 36 in Korea), the Mediterranean basin (34 in Tunisia and 19 in Cyprus) and Eastern Europe (18 in Hungary) (Menvielle et al., 2009) but this was less than a quarter of the total. Utility sites go through a series of basic stages. Thus Ehow, a website offering solutions to multiple household issues (subtitled ‘How to do Just about Everything’) and aimed primarily at US users, observes: There’s a point where people realize that they are simply paying too much for healthcare. For example, one might look at a bill for an MRI and think, ‘I could have taken a two-week vacation for that price!’. With medical tourism, that is exactly what people have decided to do.

It follows this with a seven stage series of directions: 1. First of all, check the cost of the medical procedure that you need to have done in the USA. 2. Using a search engine, locate hospitals overseas that perform that same procedure. Many of them specialize in medical tourism and are very accustomed to dealing with Americans, including speaking English. 3. Once you’ve found a hospital that performs the procedure in a location that you are comfortable with, find out the price of the procedure. Don’t just depend

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4.

5.

6.

7.

on the price listed on the website. Talk to someone at the hospital first. Evaluate whether or not the price difference makes it worth the trip. If you are contemplating a nose job in the US that is $10,000 and the price in India is $800, it probably is. Check the price of accommodations and plane tickets and add those to the cost. Be sure to factor in any recovery time. Set up your appointment, and get your plane tickets and accommodations worked out. Find out what paperwork you will need to bring from your doctor at home. You will have to ensure that you have a passport, etc., just as you would for any other trip. For a good medical tourism experience, consider staying a few days in the country you will be visiting before having the procedure. This way you can have fun without worrying about bandages on your face or whatever. Make sure that your accommodations are comfortable if you will be having time that you need to recuperate. This is not the time to stay in a dormitory-style hostel! (Ehow, 2010)

Such websites usually also offer general comparative data on prices and provide some information on destinations, reliability and security. At least ten companies (and probably many more) take a more-or-less global perspective on the provision of medical tourism. These include Treatment Abroad in the UK, RevaHealth based in Ireland, PlacidWay, SurgeryPlanet, Health-Tourism.com and AllMedicalTourism in the USA. Most other MTCs limit themselves or are limited to particular markets, destinations and procedures (see below). Such global companies provide wide-ranging information on medical tourism opportunities for different procedures, the distinctiveness of particular places and ultimately which can be recommended for what activities (usually including both procedures and tourism). Their websites have multiple linkages to countries, hospitals and clinics, patient stories and testimonials (sometimes in videos), press reports, company policies and interactive sections for obtaining quotations. Some offer virtual tours of facilities. All are commercial sites, complete with

advertisements and linkages, for insurance, hotels, travel companies, sources of finance and regional MTCs. There are no necessary quality controls over site content (widely true of websites) and certain links may be erroneous, inaccurate or incomplete. Yet such sites raise awareness of medical tourism, create a perceived need, offer a range of possibilities, stress the benefits, demonstrate its normality, refer to the pleasant tourism components and encourage potential patients to enquire further. Through 2010 RevaHealth was offering links to a claimed 110,000 providers in 99 countries. Although centred on standard medical tourist procedures such as cosmetic surgery, fertility, dentistry and orthopaedics they also included homeopathy and acupuncture (but both in the UK only). They listed 98 plastic surgery clinics, 214 cosmetic dentists, 125 laser eye clinics (all in the UK) and 16 fertility clinics. Each provider had a link, with patient testimonials, and prospective patients were encouraged to contact them. Thus the Chrysovalantou Cosmetic Surgery Clinic in Cyprus suggests that patients write in along the lines: ‘I am interested in getting breast implants. How much does it cost and when can I have an appointment?’ PlacidWay (under the logo ‘Explore, Customise, Experience’) hosts many articles, covers 59 destinations (including the USA and Switzerland), includes numerous testimonials and provides free quotations. Site users can specify procedures, gain information on what is available in each of the 59 countries, with links to the various providers. It provides basic information on tourism in these destinations: ‘Thailand offers irresistible and breathtaking natural beauty, inspiring temples, renowned hospitality, exotic cuisine and pristine beaches.’ Treatment Abroad covered 54 destinations and listed providers in those countries; their Directory expanded on that (Appendix I). Health.Tourism.com offers information on 31 possible destinations, links users to other sources of information (such as all the guidebooks) and provides details on hospitals and procedures in all those countries. Similarly AllMedicalTourism offers comparative prices

Marketing Medical Tourism

for a range of procedures across multiple destinations (a claimed 65 countries) and for well over 100 procedures, ranging from dental surgery to fertility treatments and major surgery (AllMedicalTourism, 2010). SurgeryPlanet (2010), based in the USA, but with offices in the UK and India, claim that: ‘We provide the most comprehensive, ethical, value added and the best quality overseas medical facilitation services, at the lowest cost to our clients. These services are individually tailored to make the most selective of clients comfortable, healthy and fully satisfied with the entire process.’ They also claim links with over 1000 hospitals in 120 ‘exotic destinations’, and clients can click on procedures linked to a list of 72 countries. SurgeryPlanet hosts a blog site for specific information, books travel and accommodation, offers ‘destination coordinators’ to meet patients, provides loans and offers to obtain private translators, personal chauffeurs and private chefs. On various sites and in the guidebooks (below) potential patients can identify the procedure required and compare prices (and sometimes additional costs) in multiple destinations. On the AllMedicalTourism site (2010) particular procedures can be identified and patients can specify their home country and access a table of comparative prices. Thus in early 2010 inserting ‘Lasik eye surgery’, a surgical procedure that corrects the shape of the cornea so that patients no longer require contact lenses or glasses, and declaring Australia as the home country, resulted in five ‘top destinations’ (with their average prices) and nine more destinations, out of what were said to be 30 countries that performed Lasik eye surgery. In this case the top five destinations were: (i) Croatia (US$3773); (ii) Hungary (US$1244); (iii) Thailand (US$1433); (iv) Mexico (US$588); and (v) Brazil (US$514). AllMedicalTourism (2010) then indicated that their ‘top destination’ was Thailand: ‘Thailand’s combination of English speaking surgeons and nurses, World Class facilities and highly competitive prices, makes Thailand’s capital Bangkok, a strong choice for your procedure overseas’. Selecting a different home country, the UK, gave five rather different ‘top destinations’ (Croatia, South Africa,

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Romania, Mexico and Brazil), another list of ‘other destinations’ but the same ‘top pick’: Thailand. Adopting the same procedure for hair transplants produced an Australian short list of Hungary, Argentina, Turkey, Croatia and the Dominican Republic, with Argentina the ‘top destination’ and, from the UK, Poland and Romania replaced Turkey and the Dominican Republic. Such global MTCs also work with and support national MTCs. Treatment Abroad offers a ‘Perfect English’ service that offers to review and revise English websites (at a cost of around £30/1000 words). Somewhat similarly the trade journal Medical Tourism Magazine occasionally features articles along the lines of ‘Websites – yours may be the joke of the town [or … industry]’ (Piper, 2009) that recommend constructing more effective sites. Some websites, especially in Latin America, retain convoluted English; others have attained high levels of technical sophistication. Occasionally these become combined. Thus Health Travel Guides is ‘a technology and services company that globalizes health care by facilitating the scalability of the medical tourism industry with hosted business processes’ (Health Travel Guides, 2010). Such glitches reflect recent websites and the novelty of MTCs. Many MTCs and websites turn over and become obsolescent extremely quickly, suggesting the transient nature of medical tourism services. Some companies are regionally and nationally based such as Health Tourism In Asia which covers India, Thailand, Hong Kong, Indonesia, Malaysia, Singapore, Japan, South Korea and the Philippines. National sites include www.treatmentinhungary.net and www.medicaltourismofcostarica.com and a host of others. Through www.IndiaCares. com patients can register online, research and select hospitals for treatment, and create and forward personal health records to the hospitals. Singapore’s site www.singaporemedicine.com provides a link to the Singapore edition of Patients Beyond Borders, and provides detailed information on prices, facilities and procedures. It starts ‘In addition to a seamless and timely experience with state-ofthe-art medicine and treatment rendered by

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highly-skilled professionals, patients can also have access to novel treatment options availed by progressive clinical research taking place in Singapore’ (Singapore Medicine, 2010). In a section on ‘What Can I do During My Stay in Singapore’ it points out that ‘Singapore is a vibrant, sophisticated and cosmopolitan city state that delights visitors from all over the world’ and offers numerous tourism possibilities. The Malaysia Healthcare site is much the same, stressing the multicultural heritage of Malaysia, and noting in its promotional video that ‘you’ll find a holistic place that rejuvenates your body and mind’ (Malaysia Healthcare, 2010). A handful of companies have sought different strategies and completely universal coverage, like MediBid that started in 2010 with a main office in California and satellite offices in Canada and New York, advertising itself as an ‘interactive marketplace’ founded on five principles: ‘access, quality, choice, value and privacy’. MediBid was developed to provide access to greater choice and privacy, regardless of insurability, in a completely open market environment, without anyone or anything getting in the way of the decision making process between doctors and patients. MediBid is an interactive marketplace that allows cash-paying patients to seek medical care from doctors, hospitals, and facilities both locally and around the world. More than a physician directory, it is a resource where medical consumers can find a doctor, then actively seek bids for the care they need … Focused on building strong patient–physician relationships, while supporting patients’ privacy rights and choice in the medical market place, MediBid’s goal is to provide the best opportunity for consumers to self-direct their medical care. MediBid puts the ability to make informed healthcare decisions right at your fingertips. You simply post a request for care. It can be anything from a consultation, to a second opinion on knee replacement surgery, a new kind of cancer therapy, or simply an annual mammogram. Then MediBid provides you with a variety of medical practitioners to choose from, listing credentials, costs, treatment program – everything you need to make the decision best for YOU. (MediBid, 2010)

Patients, doctors and facilities could register with Medibid as privatization took another global turn. Bumrungrad and a number of other large providers quickly subscribed. Here is virtual libertarianism – the ultimate unconstrained freedom of choice – in the globalizing private sector.

Medical Tourism Companies (MTCs) One of the most influential elements in developing contemporary medical tourism has been the rapid growth of MTCs (or brokerages) that market medical procedures in distant countries and arrange linkages between patients and hospitals, travel and accommodation and the tourism that often goes alongside that. One industry definition of an MTC, in this case a dental tourism facilitator, is ‘a person or company offering a service to prospective dental patients: to help them navigate the world of international dentistry and find the best quality care abroad, at the same time helping them to realize major cost savings’ (Apton and Apton, 2010). In effect such companies work ‘like specialized travel agents’ (Herrick, 2007: 6), some with branches in different countries and affiliations with hospitals, hotels and airlines. Somewhat more scathingly, Turner describes them as ‘the car dealerships of the global healthservices industry’ (2007a: 127), beyond the bounds of ethics or fiduciary duty, though they are no different from most travel agents. Almost all MTCs have been established in the 21st century, though Surgeon and Safari was established in 1999. Planet Hospital claims to have begun in 2002 but most MTCs are somewhat reticent about their origins since they are so new, and many are short lived. One MTC states: ‘Plenitas is the oldest and well known Worldwide Medical Tourism Organization. It provides medical services and treatments since 2003 and had treated more than 3000 satisfied patients throughout the world since’ (Plenitas, 2010). It covered six destinations: Argentina, Egypt, USA, Montenegro, Romania and Serbia (a relatively unusual set of destinations, that indicates that MTCs market in high-cost destinations, such as the USA, where this is

Marketing Medical Tourism

relevant). Gorgeous Getaways began in Australia in 2003. Plastic Surgery Thailand (an Australian company) publishes testimonials going back to 2006, but make the company sound long-established by saying that the founder was living in Thailand during the 1990s (and probably acquiring local knowledge). Globally there are hundreds of MTCs in both source and destination countries, and numbers have grown exceptionally quickly. Reisman comes up with ‘almost 1000 niche facilitators’ (2010: 70) while Treatment Abroad has a directory of 820 that have registered with them (Appendix I). Since that list included ten from Australia, where there were at least 25 companies, this is far from complete. While many are based in source countries, notably the UK and USA, at least as many have emerged in destinations, notably India and Hungary, some with names that stress the links between health and tourism, such as Surgeon and Safari (South Africa), and Antigua Smiles, that emphasize the pleasures associated with visiting the game parks of Africa and cosmetic dentistry in the Caribbean. Though destination MTCs are more likely to tout the charms of their country, and source country MTCs offer more comprehensive services, there are few differences between them. The novelty of both medical tourism and MTCs is evident in the directions taken to establish markets and connections. Medical Tour International, the one MTC in Japan, states: ‘So far Medical tourism to Japan is not well known, but as many people know our quality standards in the automobile and the electronics are one of the best in the world, and so is our medical technology’ (Medical Tour International, 2010). MedTral in New Zealand similarly seeks a particular kind of market: Are you an American or Canadian who needs non-urgent surgery, is concerned about the cost or waiting time, and is looking for a better option? Why not consider Medical Tourism? The cost of surgery is around 15 to 20% of the cost in the USA. It is a peaceful, beautiful and safe country ideal for Medical Travel recuperation. (MedTral, 2010)

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MonterreyHealthcareCity is a group of ten hospitals in Monterrey, Mexico, which advertises itself as being the closest medical tourism destination to the USA (Fig. 6.2). Finding a place in an increasingly crowded market is the most basic challenge. Most MTCs are small, especially in destinations such as India, Spain and Cyprus, while the few large ones are in source countries such the USA and the UK. Australia has about 25 MTCs centred on cosmetic surgery, and several others with broader objectives. Most cosmetic surgery MTCs were owned by women, with one owned by a transsexual and two by gay men. All the entrepreneurs were cosmetic surgery recipients themselves, either overseas or in Australia or both, hence had close and personal links with the industry (Jones, 2009). Most were passionate and almost altruistic about their work: We’re, I would say pretty much a non-profit organisation … I do it more out of I won’t say the goodness in my heart, I don’t wanna make myself sound like a saint but I care, I genuinely care, and I would just rather them get the right information, right doctor, right hospital, right everything. It’s the most satisfying job I’ve ever done. I feel like I’m helping people, it’s unreal. I’m giving them the chance to have something they couldn’t have; it’s like a dream and people are so grateful, they really blossom, this changes lives. (quoted in Jones, 2009)

The one who saw her function as more akin to a ‘non-profit organization’ suggests the small scale and limited profitability of many MTCs. The Director of the Australian company Global Health Travel started it after her own experience, as others had done: She was living and working in Thailand when one day she suddenly experienced severe pain coming from one of her wisdom teeth. She’d already been quoted approximately A$2,000 from an Australian dentist to have the tooth extracted. Cassandra had some reservations about going to a Thai dentist, but she was amazed at what she found: there was no queue, the dentist was attentive to all her needs and did a great job, and the total cost was less than A$20. Since that experience, Cassandra has had three

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Fig. 6.2. Monterrey, Mexico (source: Medical Tourism Magazine 12, 2009).

further medical treatments in Asian countries. So when we talk about the high quality of medical care available overseas, our knowledge comes first-hand. (Global Health Travel, 2010)

Global Health Travel thus worked with seven Asian countries, including Thailand. Elsewhere

too MTCs have emerged from personal experiences. The American Planet Hospital: started quite by accident in 2002, when our original founder, Ms Valerie Capeloto and her fiancée were visiting Bangkok Thailand and she became sick. Valerie was too afraid to go to what she perceived would be a 3rd world

Marketing Medical Tourism

hospital. However, within moments of arriving, she was met by an Australian educated doctor who … gave her better care than she was used to in California. She stayed at the hospital for three days and was given her own private nurse … A personal chef came by to discuss her daily meal options and brought fabulously prepared meals (and not just Thai food but delicious sodium reduced pastas and steaks). She was discharged two days later with a bill for only [US]$411.By June 2005, the couple had referred over 77 patients to hospitals throughout the world. The company Planet Hospital officially began its website in August of 2005 and has developed a huge fan base of clients. (Planet Hospital, 2010)

The President of Medical Services of Costa Rica (which has links to three JCI-accredited hotels and a range of services) claimed ties to both the medical and the tourism industries: Upon returning to my homeland of Costa Rica in 1972, I paid my way through medical school by earning a reputation as one of Costa Rica’s premier tour guides. I completed medical school in 1982 and now have 27 years experience, both as a practicing physician, and, in my second profession, as a consultant in the field of tourism. (Medical Services of Costa Rica, 2010)

By contrast other MTCs have emerged from wholly commercial considerations as subsidiaries of companies with no links to health. Health and Leisure, which proclaimed itself the largest medical tourism facilitator in the Philippines, with various services and links to several providers, was set up by its parent company, Gulf Express Corporation, which started in the business of airline representation in 1995, and later held agreements with some of the most established carriers in the airline industry, including Qantas, Jetstar and Eva Air. It was further integrated with travel, construction and engineering companies. Similarly Elixir Medical Tours was a product of Lotus Forex Limited, a leading foreign exchange and remittance company based in Hong Kong with offices in the UK, Australia, India, Singapore, Malaysia and Taiwan. Its medical tourism division started in response to strategic diversification plans, with the intention of ‘making forays into the medical

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tourism sector as Health Travel Facilitators’, to promote medical tourism in India. (Elixir Medical Tours, 2010). Origins and geography have influenced size. In the USA where medical tourism is a relatively big business, some companies like Planet Hospital are quite large, whereas in other countries such as Australia, where medical tourism is emerging more slowly and the market is smaller, most companies are parttime operations with no more than an ownerworker and a particular niche (country or procedure) in the industry. European MTCs specializing in dentistry are similarly small. In 2010 a survey of ‘medical tourism businesses’ in over 50 countries found that half employed fewer than five people and a third handled fewer than 50 medical tourists a year (Pollard, 2010b) but this sample was probably biased towards larger companies. Most Australian MTCs are too small to have physical premises, but operate through websites and home offices. Only one of 25 MTCs even had a dedicated office, most were run as part-time ventures and the majority of owners had other jobs. Only two Australian owners had tertiary qualifications in health or business (Jones, 2009). At least one targeted particular clients – in this case brothels – and most relied on word of mouth. One post on the website for Gold Coast Escorts (Queensland, Australia) indicates both such targeting and small size: Hi there, my name is Rachel and I am a former Perth girl, now living in Bangkok for the past 5.5 years. I started a small service for foreigners who want to come to Bangkok for plastic surgery/breast implants as they are so cheap A$3,300 dollars and the hospital are 5star, my service offers accommodation, food, all transfers to and from the airport and hospital, shopping, washing, ironing, 24 hour care and anything else you might need. The girls stay with me at my 3 bed 3 bath condominium on the 31st floor close to the city centre. Because I like to offer a personal service I only take 1–2 persons at a time, I also speak Thai and arrange the surgery using only the International Hospitals (no clinics). My fees are A$72.00 per day with no extra or up front fees, so if you have any of your girls interested please email me and thanks for reading. If two girls

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come together then I will charge A$54.50 per day each. (Gold Coast Escorts, 2010)

Blogs on the site indicated she used Bumrungrad. Many MTCs reflect their owner’s particular cultural ties and geographical origins. In the USA IndUShealth, whose founder and CEO is an NRI who formerly worked as a software engineer, organizes travel to India. In Australia MyMedicalChoices is operated by an Indian migrant and similarly has exclusive ties to India, where she previously worked as a doctor, and could build on previous connections. How many clients companies serve is rarely publicized. A survey of international patients at Bumrungrad revealed that over half (52%) had acquired their knowledge of country destinations and hospitals through MTCs, while as many as 92% claimed to have used an MTC (Anon., 2010b). While that proportion is likely to be particularly high, for a major hospital with many distant patients, it points to the growing dominance of MTCs within medical tourism. In Australia in 2007 some 1499 patients were said to have had overseas surgery organized through national MTCs (Weaver, 2008a). In its first 5 years between 2004 and 2008 the largest Australian company, Gorgeous Getaways, organized travel for about 1100 clients, and annual numbers increased from 40 to 480 (Weaver, 2008b): almost ten clients a week, but growing. Plenitas’ global figures suggest similar numbers. Surgeon and Safari in South Africa received about 30 clients a month in the mid2000s (Witepski, 2005). Other Australian companies have far fewer. The British dental travel MTC sends about 60 patients a month to Hungary (Haslam, 2007). American companies like Medical Tours International and Planet Hospital probably have rather larger numbers. MTCs are usually nationally based, rather than transnational, but with necessary links in source and destination countries. The smallest MTCs (and those in destinations) focus on a single country. In Australia Gorgeous Getaways works almost exclusively with Malaysia (see Box 6.1). Websites tend to suggest a rather greater diversity, and the

larger companies offer multiple destinations. Big companies like Planet Hospital have usually evolved from bilateral relationships with a single country to offering multiple destinations. Planet Hospital sells packages in 13 countries, but most work with providers in no more than six or seven countries. MedRetreat, based in the USA, and whose logo is ‘where smart medicine and exotic travel come together’, offers a ‘menu’ of 183 procedures in seven different countries, crossing several language boundaries: India, Thailand, Malaysia, Brazil, Argentina, Turkey and South Africa (Herrick, 2007: 6). In the following 3 years they added Costa Rica, El Salvador and Mexico to that list. Their response to a ‘frequently answered question’ about why those countries were singled out was straightforward: That is an excellent question since there are many countries around the world that provide medical care at a fraction of the cost in the US. In the future we may possibly add new destination packages to our network. However, in selecting these destinations, we took several important factors into consideration. First and foremost, we selected countries with the most established, most experience and highest quality in the global medical tourism sector. Next we selected countries that are investing immense resources into building up their medical tourism infrastructure. This means that in addition to their healthcare facilities and technology, they also have built advanced transportation and communications systems. Then we reviewed their healthcare standards, professionalism and quality of their doctors. (MedRetreat, 2010)

MediTravel focus on eight countries: Costa Rica, Czech Republic, India, Korea, Malaysia, Mexico, the Philippines and Singapore (with Thailand and the UAE as ‘other countries’), and list four or five healthcare providers in each of them. WorldMedAssist list six countries: Costa Rica, India, Korea, Belgium, Turkey and Mexico. Healthbase. com (under the slogan ‘Healthcare Beyond Boundaries’) has partners in 14 countries, most being JCI-affiliated hospitals, and was negotiating with 11 more countries early in

Marketing Medical Tourism

2010. Specialization on a small number of countries reduces costs and enables companies to develop more complex links and expertise there, which may also make it more difficult for ‘new’ countries to emerge as significant destinations. Several larger MTCs have operations spanning the source country and sometimes multiple destinations, although their overseas presence may be limited. Some organize local transport and accommodation, mobile phone services and airport transfers, but this is usually left to local, affiliated, companies and hospitals. Thus MedRetreat are typical of numerous MTCs: We’ll guide you, step-by-step, through the entire process. Within a short period of time, you’ll receive very valuable assistance from our U.S. Program Managers to help facilitate the planning of your medical retreat. Once you have arrived in your destination, you are greeted at the airport by your Destination Program Manager (bilingual host) who understands American culture and wants to make certain that you are comfortable. Not long after your arrival and discovery of the finest accommodations you may have ever experienced, you are escorted to a world class medical facility, where you meet Englishspeaking, western-educated professionals who provide an initial examination and answer questions. Then, according to your medical retreat itinerary, you’ll return at a predetermined date to receive your medical procedure. Afterwards, recuperate in peace and quiet and return home spending less money on your entire trip than you would have in the USA for the procedure alone. (MedRetreat, 2010)

More comprehensively, MediTravels, based in St Louis (USA), and with the logo ‘Sun Sand and Surgery’, promise that: Our global partners network are world best accredited healthcare outsourcing facilities. Our packages are specifically designed to provide not just the basic health cover, but also a wide range of benefits providing peace of mind for you, your family or your personnel. We take care of all your medical travel needs, our Offshore medical teams are the most caring and gentle-loving people in the world. Have peace of mind as we arrange your medical travel with only the best and

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most reputable service … We have made alliances with top healthcare institutions in India, Thailand, Singapore, etc. Some of the top healthcare institutions include Apollo Hospitals, Wockhardt Hospitals, Escorts Heart Institute and Bumrungrad Hospitals … MediTravels has also made alliances with leading tour operators around the globe to make your stay easy and comfortable without any hassle. We can also arrange tours to exotic locations within the destination country including trips for alternative therapies such as dermatology, spa treatments and massages. (MediTravels, 2010)

IndUShealth are linked with the air ambulance company, Air Escort, which ‘offers highly-trained licensed medical escorts who can provide in-flight medical monitoring and care, including ventilation, sedation and pain management’ (IndUShealth, 2010). On an equally comprehensive but smaller scale, Dayo Dental, based in Phoenix, Arizona, provide weekly chartered vans to take dental patients to partner facilities in Los Algodones, Mexico, where treatment is normally completed in a day (Hyo-Mi et al., 2009). Destination MTCs work in similar ways. Ageless Wonders in Panama provide information on various national services, especially dentistry, offer lengthy testimonials, have links with tourist companies (offering city and canal tours), can provide finance and offer mobile phones and Panama phone cards. Ageless Wonders are also linked to Home Watch Care Givers, an American company specializing in after-care or post-surgical recuperation, with more than 170 franchises in the USA and others around the world. In Australia DestinyMediTravel in 2009 was coordinating the visit of representatives (and one of its plastic surgeons) from Phuket International Hospital to Melbourne, Sydney and Brisbane to conduct information sessions with potential clients interested in travelling to Phuket for surgery, enabling them to meet the surgeon beforehand (DestinyMediTravel, 2010). Gorgeous Getaways enable people to choose their own flights (but recommends low-cost carriers) and accommodation in Kuala Lumpur (and provides advice on both, with comparative prices, and suggestions

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and discounts for recuperation at the Mines Wellness Hotel, outside Kuala Lumpur), meet them at the airport and drive them into the city, and accompany them to all medical appointments and the operation. After that: You will be visited for the first 3 days by Gorgeous Getaways assistant nurses to change the dressings on your wounds and just ask if you need any help. If you are on our Extra Care or Platinum package, then you will have a helper to assist you in making meals, shopping and showering. When you feel better, you can start with other programs – massage, pampering, or very gentle exercise. As you recover, you can enjoy more options – such as tours and travel, or you may prefer just to relax longer and enjoy the pampering and many other activities available at the resort. There is always the fantastic shopping where you can pick up great bargains! On your last day in KL, our driver will pick you up from the airport approximately 3 hours before your flight departs. A few weeks after you return home, you will receive our Welcome Home email with your before/after photos on it. We also welcome you to join us at home at our ‘Get Togethers’ that we host around Australia and NZ. (Gorgeous Getaways, 2010)

Most MTCs target individuals, as do travel agents, but in the USA MTCs also target small businesses, corporations and health insurance companies that seek to reduce their health costs. By contrast, in Canada MTCs are more likely to stress the problem of waiting times as much as costs. Timely Medical Alternatives: was formed in 2003 to help Canadians, on long medical waiting lists, to take personal responsibility for their own medical care and ‘Leave the queue’ … Our mission is to provide Canadians from every province with information about the medical waiting lists in Canada, options for Canadians unable or unwilling to wait for care and finally, referrals to hospitals, clinics and diagnostic imaging facilities. (Timely Medical Alternatives, 2010)

Its website enabled potential users to access the waiting times in each Canadian province for 12 different procedures (and also resolved such ethical questions as ‘Isn’t jumping the

queue against the Canadian way?’). While the MTCs primarily focus on cost and quality issues they sometimes therefore addressed other reasons for medical tourism. MTCs generate their income from referral fees that are built into the cost of treatment, or from patients registering for their services. Companies may claim to offer the lowest prices since, as MedRetreat suggest: ‘We have negotiated more favourable pricing due to high volume patient flow. You will not be able to receive a better price even by going direct … We receive compensation from our overseas partners for our role in the process. So in essence our services are completely free to you’ (MedRetreat, 2010). This is a somewhat disingenuous approach to commercialism. Like several other large MTCs, MediTravels include a category on their website for potential investors in the company. Early in 2010 Internationalhealthcare.com were offering to sell their domain name. All MTCs stress safety and reliability, usually by referring to accreditation, the credentials of staff and the testimonials of recent patients. Some address this in global terms. Thus the Texas-based Medical Tourism Corporation refers to global success rates: For example, Escorts Heart Institute and Research Center in Delhi, India performs nearly 15,000 heart operations each year, and surprisingly the death rate among patients during surgery is only 0.8 percent. This is less than half the equivalent rate in most major hospitals in the United States. (Medical Tourism Corporation, 2010)

Other MTCs do not even hint at even a 0.8% chance of failure, but assume that success is assured. Some companies screen patients to ensure they are well enough to travel, digitize clients’ medical records and place them online to enable doctors in destination countries to review them in advance, and arrange conference calls with doctors in potential destinations to allay fears about procedures and other matters. The MTCs validate themselves, and their effectiveness, by claiming years of experience (despite their recent origins), and direct firsthand links with reputable overseas hospitals (usually by stressing their JCI accreditation).

Marketing Medical Tourism

In response to the ‘frequently asked question’ of ‘What if my family doctor advises against a medical procedure abroad?’ MedRetreat are an example of how an MTC responds to such claims: Such advice is certainly to be expected. Rest assured that the US is not the only country that has rigorous healthcare standards and strong patient rights. In fact, you may be surprised to learn that your local hospital has lost accreditation due to poor quality standards. Many hospitals throughout the world are accredited by the JCAHO or Joint Commission International, a US based hospital accreditation organization. Check to see if your hospital is accredited by the JCAH. (MedRetreat, 2010)

Many MTCs stress that they have inspected facilities (hospitals and hotels) used by medical tourists in their recommended destinations and, as in the case of MedRetreat, ‘Only the best hospitals, hotels and destination program managers have met our stringent criteria and have been chosen to participate’ (MedRetreat, 2010; my italics). Likewise, in terms of medical care itself, ‘many of the doctors in our network were educated in the US. Some have even practiced in the US for years and remain Board Certified in the US’. MedRetreat, who also publish the guidebook The Complete Idiot’s Guide to Medical Tourism, stress that: through our travels overseas to find and qualify medical institutions, we have declined affiliations with over 50% of the healthcare providers we visited. Because we have performed our due diligence on your behalf, you will be the recipient of receiving great care from the highly qualified hospitals within our network. (MedRetreat, 2010)

Yet guidebooks and MTCs are not independent but are linked to some tourism and health-care providers. Procedures are advertised and promoted in ways that make them acceptable and not challenging. Gorgeous Getaways have packages labelled Yummy Mummy, Fabulous Facelift, Zap the Fat and even Designer Vagina (Weaver, 2008a). Many MTCs encourage

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contact between aspiring and former patients, sometimes at forums (Box 6.1). As Global Health Travel point out ‘Once you decide to move forward with Global Health Travel, we will happily refer you to past clients that have had the procedure that you are seeking. In return, we appreciate your referrals once you return from your medical treatment’ (Global Health Travel, 2010). Contacts with doctors are also made possible. Like several other MTCs, the Canadian company Worldwide Medical Partners states: ‘Prior to your departure we will arrange for a video conference with your Doctor for last minute questions, directions and guidance’ (Worldwide Medical Partners, 2010). Centred on several MTCs, online communities have also emerged enabling potential clients to query past patients and potential providers, and discuss issues with other potential patients, reinforcing notions that they are not alone and that others’ experiences have been positive. Beyond ubiquitous coverage of price and reliability, the third focus of MTCs is tourism, often linked into a package. Combining medical treatment with tourism inevitably makes it more attractive and exotic than it might otherwise be and may counter conventional images of hospitals and medical procedures. The merits of particular countries (and their peoples) as tourist destinations are usually covered. Thus MedRetreat state: ‘Imagine travelling to exotic locations like Thailand, Malaysia, India, Argentina and South Africa in perfect anonymity with a personal assistant at your side’ (MedRetreat, 2010). One Indian website advertisement stated that many patients were pleased at the prospect of combining their tummy tucks with a trip to the Taj Mahal. MTCs, anxious to gain clients, stress the tourism possibilities much more than the health providers. MTCs have sometimes been in conflict with health-care providers, most of which have many independent clients. The President of one MTC has argued that Thai medical tourism lacks effective marketing and promotion since hospitals have been unwilling to cooperate with MTCs and have not settled adequate commission rates for them. ‘Tour agents view that 3–6% commission rates offered by hospitals are too low while

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Box 6.1. Gorgeous Getaways Get-together (Kirstie Petrou) Arguably Australia’s largest MTC, Gorgeous Getaways has sought to personalize the impersonal face of Internet-based business. By hosting meet-and-greet sessions around Australia (Sydney, Melbourne, Canberra, Gold Coast, Cairns, Perth) and New Zealand (Auckland, Christchurch, Wellington) over 4 years, Gorgeous Getaways has offered past and potential clients a face-to-face forum in which to ask questions, air their concerns and fantasize about future procedures. Held in carefully selected central business district bars at an hour usually associated with after-work drinks, conversations on topics that might be difficult elsewhere are lubricated by complimentary wine and finger food. Media stories featuring past patients are displayed prominently, as are a selection of ‘before’ and ‘after’ photos showing the transformations that are possible (Fig. 6.3). Fliers for related businesses, such as medical finance companies, are available. The company manager personally greets all guests and, after ascertaining what procedure an individual is interested in, provides information and answers questions. Potential patients are then introduced to others who have had similar procedures, to encourage mingling and provide direct information. Past and potential patients from similar age groups are paired together. There are no formal presentations or ‘hard sell’ and though e-mail addresses are taken, no obvious follow-up. One such meeting in Sydney, in March 2010, was attended by some 20 individuals, predominantly women, most between 40–50 years. Some brought male partners, most of whom were planning to accompany them to Malaysia, taking advantage of ‘bring a friend’ discounts. Two significantly younger women were also present, friends in their late 20s. Many of the women present expressed dislike for their post-pregnancy bodies, and justified cosmetic procedures as a way of dealing with this. Five were past patients, armed with their own before and after photos and eager to share their experiences. At such a sponsored event, their stories were inevitably positive and, while many spoke of their trepidation beforehand, there was an emphasis on how pain-free major surgery might be. Past patients shared their stories. In her late 20s, Sarah had undergone a breast augmentation in Malaysia in 2008. A major factor in her decision to travel was the price difference: she could travel to Malaysia with her partner, and enjoy a holiday, for less than the price of the surgery alone in Australia. While Sarah was nervous about using an Internet-based company, attending the meet-and-greet session helped allay her fears. Though she had not visited Malaysia before, having lived in America for a period she was no stranger to international travel. Sarah decided to undergo the procedure first, and holiday afterwards without the looming distraction of imminent surgery. Having been active in the Gorgeous Getaways online community prior to leaving Australia, she was able to meet up with another woman of a similar age who was undergoing the same surgery on the same day. They provided each other with moral support throughout the experience. Five other Gorgeous Getaways patients were staying in the same hotel and the company organized a group excursion for them to the aquarium, providing welcome social support for those who had come alone. Sarah experienced minimal pain after the surgery, but was careful not to strain herself during her holiday. While her partner went out clubbing, Sarah stayed at the hotel for fear of accidental bumps to her chest. She had a fabulous holiday in Malaysia, and enjoyed the shopping immensely. The familiar sight of common American chain stores in Kuala Lumpur was a great comfort to Sarah, reminding her of her time in the USA. Subsequently, though Sarah had recommended Gorgeous Getaways to many friends, that they had to travel to Malaysia was a significant deterrent to most. However, at the meeting Sarah was accompanied by her friend Kate, who was planning her own trip later this year. Sarah planned to go back to Malaysia with Kate, but couldn’t decide what to have done, describing the number of choices as being ‘like a candy shop’. She now wishes she had known about ‘smaller procedures’ such as dental work when she had previously gone. Had she done so she would have capitalized on this while getting her breasts done. Similar stories were told by other past clients. One woman in her 50s talked of having a facelift, eyelift and breast augmentation in a period of 3 weeks. Then, towards the end of the stay in Malaysia, she decided she was ‘bored’ and booked herself in for a ‘designer vagina to go’. Various participants expressed concerns, including those of friends and family, about having surgery done in a different and ‘dirty’ cultural context, but Sarah emphasized how Western Kuala Lumpur felt, describing this as positive.

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Fig. 6.3. Gorgeous Getaways flier, 2010.

hospitals are confident they already have their own markets and need not depend much on tour agents’ (quoted in Chinmaneevong and Theparat, 2010; see also E. Cohen, 2008: 248). The rise of MTCs is thus both a challenge to providers, wary of the need for them, and a support for them.

Guidebooks In a similar flurry of growth, five guidebooks have been published since 2006 on medical tourism: four from the USA and one, the first, from the UK (Hancock, 2006; Schult, 2006; Gahlinger, 2008; Woodman, 2008; Marsek and

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Sharpe, 2009). Despite their detail and global coverage they are not well known and have played only a limited role; only two out of 121 medical tourists in Malaysia found their hospital through a guidebook (Doshi, 2008; Anon., 2010b). The most successful has been Woodman’s Patients Beyond Borders that has gone into two editions and at least six country-specific versions (for Korea, Malaysia, Taiwan, Thailand, Turkey and Singapore, the last also covered in an Arabic edition). Basic and pervasive themes are evident from the subtitles splashed across the covers: three have the word ‘affordable’, one ‘low cost’ and the other ‘inexpensive’; similarly two mention ‘quality’, one ‘top quality’ and a fourth ‘world class’. They are likewise oriented (the ‘complete idiot’s guide’ and ‘everybody’s guide’) to straightforward global overviews. The guidebooks have similar perspectives to those of the global MTCs, and there is little difference between them and exploratory websites such as Ehow, other than the greater detail in the books, and more exhaustive accounts of particular countries and their tourism potential. Unlike most guidebooks that deal with a single country or region, medical-tourism guidebooks seek a more-orless global coverage of relevant places and offer advice on choices of destination. Each assume that readers have minimal knowledge of: (i) medical tourism (what procedures are possible, how much they might cost); (ii) the destinations; and (iii) how to get there. They are aimed at relatively unsophisticated readers in developed countries, with some reasonable ability to pay, rather than diasporic travellers. The single most distinctive characteristic of the guidebooks is that they are all enthusiastic supporters of medical tourism, subject to appropriate research and precautions. At least two of the authors, Hancock and Schult, write from their own experience, and others have obvious connections with the industry; Marsek runs the MedRetreat MTC, Gahlinger has a medical background, and Woodman is described as ‘an outspoken advocate of global consumer healthcare and medical travel’. Each of the guidebooks initially discusses what medical care is possible and the normality of undertaking procedures overseas.

The first has ten separate chapters on different possibilities ranging from cosmetic surgery to gender reassignment and transplant surgery (Hancock, 2006), but the main focus is on cosmetic procedures. Affordability, value for money and safety are discussed in detail. Several provide comparative tables of costs, which are regarded as crucial, as is budgeting to ensure that travel is feasible. All also discuss fares, choosing an MTC, recuperation, and how to balance choice of destination according to health or tourism. The guides assume that potential patients have had little experience overseas and offer advice on packing, climate and language of some banality, but directed at first-time travellers. ‘Often the customs and traditions overseas may be very different from what you are used to at home’ (Marsek and Sharpe, 2009: 87). Most provide advice on obtaining passports and a range of travel precautions, and point out that many others are involved. There are ‘100,000 fellow travellers – or more’ (Schult, 2006: 2), and ‘Most people in the US can travel to almost any country for less than two weeks’ wages and it doesn’t take long’ (Gahlinger, 2008: 8–9). They also argue that there is no reason to be alarmed by travel to different places. ‘You have heard these countries referred to as “the third world” or “underdeveloped”. So you think poverty, crime, poor transportation or a lack of amenities [but] you can generally choose the degree to which you want to be insulated’ (Schult, 2006: 111). Woodman notes both that ‘most health travelers are met at their airport gate and whisked to an American-style hospital or hotel’ and that many people outside the US are afraid to travel there because of fears of violent crime: ‘it’s easy to forget that most other countries enjoy far lower crime rates than ours’ (2008: 27). Nor are perceptions like reality; Costa Rica is not at all like Jurassic Park (Schult, 2006: 16). Crime is avoidable with sensible precautions, but Schult’s observation that sewing cash into undergarments can be a wise precaution (2006: 15) may counteract benign observations on crime rates. None the less of a claimed ‘500,000 Americans who traveled overseas for medical treatment in the past five years, not one has died as a result of violence or hostility’ but then ‘as a

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medical traveller you’ll be too busy achieving your health goals to be booking risky nights out on the town, hazardous wilderness tours, or adventurous side trips of uncertain outcome’ (Woodman, 2008: 121, 122). Quality is critical but it may be worse in your home town (Schult, 2006: 59). Gahlinger makes the striking (and inaccurate) argument that since ‘fully one third’ of doctors in the US were trained overseas, especially in Mexico and the Caribbean, where medical schools are vastly inferior, and ‘almost all’ doctors at major medical tourism hospitals were trained in the US, surgery overseas is consequently better (2008: 31). Schult similarly states that Indian doctors are trained in the West (2006: 200). Quality thus translates into transferring skills from the West. But quality varies and idiosyncrasies exist: ‘Brazilians approach procedures more artistically. They believe in sculpting the form and creating the curves and lines of the female shape’ (Schult, 2006: 56). Doctors may also be more accessible, sometimes providing mobile phone numbers to patients. Safety and quality lead into recuperation and the role of tourism. Each book assumes that tourism is a secondary concern but that it is not unimportant, and at least one has relatively detailed tourism advice for travelling companions. ‘Think of your medical journey more as a business trip than a leisure junket’ (Woodman, 2008: 31). The guides vary in suggesting going to a place where a particular procedure has been successful or where long-held tourist dreams exist, and also in whether or not they provide standard tourism information about particular countries, such as what to see and do. They err on the side of caution – that tourism is not the principal objective, tourism should be gentle, perhaps undertaken before the procedure, and exclude activities such as rock climbing, too much sunshine, but involve ‘light sightseeing and window shopping near your hotel’ (Marsek and Sharpe, 2009: 12). Only Woodman recommends also taking a standard guidebook along. Most guidebooks recognize that they are just one means of obtaining information, and most encourage the use of the Internet and Google searches to delve deeper into compa-

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nies, hospitals and countries, and to use e-mail to get more specific information. Gahlinger, however, argues: ‘when you use the Internet to research overseas healthcare, you will not necessarily find the top clinics. You will find the top marketers, promoters, advertisers and hustlers’ (2008: 9), but then goes on to recommend a range of sites. Schult (2006) too offers a host of websites, encourages independent research and explains how to use Google and e-mail effectively. Each similarly argue that their books are starting points for more detailed and specific information, that much information and claims can be bewildering but that adequate knowledge is crucial, and that there are certain key questions on affiliation, accreditation, expertise and so on. Most recommend engaging an MTC to advise further on destinations and become their comprehensive travel agent. While most guidebooks provide basic information on the more likely destinations this is often simplistic and directed to the ease and normality of travel. Thus in Costa Rica not speaking Spanish is no real inconvenience since everywhere people speak English ‘One can expect similar circumstances in any metropolitan area sophisticated and pragmatic enough to be courting North America tourists and their dollars’ (Schult, 2006: 111). Indeed any foreign hospital worth considering must ‘offer comprehensive English speaking, American-friendly staff’ (Marsek and Sharpe, 2009: 34), so that ‘If a hospital or clinic that you’ve contacted can’t furnish English-speaking doctors, don’t be embarrassed. Politely thank them and move on’ (Woodman, 2008: 30). Climate is never a challenge, though tropical climates require lightweight clothes. Avoid tap water and streetvendor food; take your favourite snack foods. Currencies are easy to understand and credit cards and ATMs are ubiquitous. None of the books are prescriptive about destinations but stress that this is a function of: (i) costs; (ii) available procedures; (iii) preferences about climate; (iv) language and cultural diversity; and (v) what tourist activities are preferred and how they might be combined with medical care. But ‘the farther you get away from the USA the cheaper it will be’ (Schult, 2006: 113) but this is a trade-off with airfares and comfort. Schult’s own preference

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was for dentistry in nearby Costa Rica rather than travelling another 12 hours to a cheaper destination. While each guidebook stresses the range of country possibilities several have slight preferences. Gahlinger offers the ‘top ten’ centres (beginning with Bumrungrad, then Jinemed in Turkey and the Barbados Fertility Centre), but discusses 45 countries. Gahlinger is the lone guidebook to include Cuba. Woodman covers 21 countries, Marsek and Sharpe review 12, whereas Schult concentrates on three that are convenient to Americans – Brazil, Costa Rica and Mexico – alongside the ‘Far East’ (which turns out to be Thailand, Malaysia and India) and the book concludes with a two-page ‘Afterword’ by the CEO of Bumrungrad. Country destinations and their providers are discussed in positive or neutral terms, but influenced by: personal experience; links to MTCs; and a preference for places closer to home. In the midst of neutral accounts on 12 countries one guidebook notes: ‘many of my clients have been so thrilled with their experience in Malaysia that they’re considering buying a second home there’ (Marsek and Sharpe, 2009: 316; my italics). Only exceptionally are places perceived negatively. Gahlinger refers to political instability in Syria, and suggests nearby Turkey, Jordan and Iran, but elsewhere observes that in Jordan ‘many arriving medical tourists have been defrauded, abused and otherwise taken advantage of’ (2008: 283, 229). He also criticizes dubious procedures in Mexico, air pollution in Mumbai, and hookers in Singapore. Schult has a low regard for the Dominican Republic and is wary of the border towns of Mexico. Otherwise travellers must make up their own minds. The better guidebooks are handbooks that offer massive amounts of common sense, encourage potential tourists to examine all options, but all are extremely enthusiastic about medical tourism.

Trade Journals and Associations MTCs have moved towards their own versions of accreditation. Healthcare Tourism International started in 2006 with the goal of

upholding and improving the reputation of the medical tourism industry, and accrediting the non-clinical aspects of medical tourism, such as language issues, business practices and false or misleading advertisements. Based in Los Angeles, but with offices in India, Singapore and Ecuador, and through its associated Healthcare Trip Inc. it has assumed accreditation responsibility for many of the major groups involved in medical tourism including hotels and has sought to claim NGO status as a body that protects patients’ rights and provides ‘a “United Nations” roundtable for the health tourism industry in order to establish health tourism standards and principles for credentialing purposes’ (Healthcare Trip Inc., 2010). Somewhat similarly, the MTA is a (self-designated) independent group based in Florida with offices in Seoul, San Jose (Costa Rica), Dubai, Tel Aviv, Istanbul and Buenos Aires. It claims to be the ‘first international non-profit association’ that promotes itself as objective, and medical tourism as positive, and links hospitals, MTCs, insurance companies and governments ‘with the common goal of promoting the highest level of quality of health care to patients in a global environment’ (MTA, 2010). The MTA has established a Medical Tourism Certification programme, but this provides information rather than regulates the industry. The International Medical Travel Association (IMTA), based in Singapore, has focused rather more on improving international patient care. IMTA has similarly sought to integrate providers, patients, employers, insurers and third-party brokers. One goal was to establish a Patients’ Bill of Rights. In 2008 Treatment Abroad, a member of the MTA and of IMTA, developed a voluntary code of practice for medical tourism to encourage the development of best practices among MTCs and health-care providers, in terms of quality of care and accreditation. By April 2010 just ten MTCs, including eight in Europe, one in South Africa and one in India, had signed the Code. Treatment Abroad also developed a Venice Declaration on Medical Travel (launched at the European Medical Travel Conference in Venice in May 2010) that centred on:

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The right of citizens to travel to access healthcare services or to access a higher standard of health services; the need for healthcare systems worldwide to respond better to the healthcare needs of citizens who travel for healthcare and who wish to obtain the best quality, most timely, most costeffective and most conveniently located medical treatment and services available in Europe and throughout the world; and the need for better integration of health and tourism services and for investment in resources to improve quality, customer orientation and the healing competency of health services. (European Medical Travel Conference, 2010)

No organizations have suggested any need for a right not to have to travel overseas for medical care. The MTA supports two online magazines. The Medical Tourism Magazine, subtitled ‘Your Guide to International Medicine’, is an industry publication that began in 2007; oriented to potential patients it extols the virtues of new technology and diverse destinations. Articles enthusiastically support the industry, are usually written by industry participants and may start from a disinterested perspective, such as ‘The Role of the Facilitator – Dental Tourism’ which explains how MTCs operate but concludes with an invocation to visit Panama (see p. 50), the destination used by the MTC of one of the authors (Apton and Apton, 2010). In 2009 the MTA launched a complementary bi-monthly online magazine, Health Tourism, subtitled ‘Your guide to health and medical wellness’. The weekly International Medical Travel Journal is published online by a subsidiary of Treatment Abroad and distributed to a broad spectrum of businesses involved in the medical travel (health travel) sector, in over 40 countries. It too is directed to industry rather than patients. Despite the creation of industry organizations and magazines and even the promotion of a code of practice, such activities offer only a potential regulatory and advisory role for MTCs. Voluntary codes have no effective teeth. Such large organizations as the MTA contribute to the global integration of the market, perhaps to the particular benefit of the largest global players, rather than to the

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medical tourists who are unlikely to be aware of its existence.

Hospitals on the Web: Training, Technology and Reliability Sooner or later intending patients are likely to turn to the hospitals and clinics, whose websites are centred on available procedures, reliability, quality and cost. The last is somewhat downplayed, except in Asia (where prices are lower), on the assumption that most potential patients have already discovered that element. Some hospitals formally advertise prices; more frequently websites stress value for money, or provide mechanisms for patients to enquire about prices. Many of the larger and more prestigious Asian hospitals claim to ‘offer a better level of care than the average community hospital in the United States’ (Herrick, 2007: 14), and post such information on their websites. Yet for most potential patients, the websites, like tourism brochures, are an imperfect and biased source of information. Images of modernity, via technology, cleanliness and apparent efficiency are dominant. Elegant websites, in English (but occasionally in other languages) feature the range of possible procedures, costs, accreditation and affiliations, smart staff, lavish wards and accommodation, patient testimonials and diverse language competence. Vejthani Hospital in Bangkok has a website in Thai, Japanese, Arabic, Bengali, German and English, and many other sites are multilingual. Some sites include videos of reassuring doctors, procedures and satisfied patients. As with MTCs, however, others are quite basic and evidence of competence can be lost in translation. Others are more detailed. Bumrungrad’s site has four objectives: (i) factual information on doctor biographies, lists of specializations, descriptions of procedures, accreditation and treatment costs; (ii) testimonials from journalists, patients and bloggers, with links to YouTube; (iii) visual experiences through photo galleries of rooms; and (iv) access for enquiries and requests (Anon., 2010c). Such broad objectives are more or less replicated elsewhere.

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Hospitals primarily stress various facets of quality, which is invariably linked to modern technology and the qualifications of the staff, but also to the accommodation: State of the art, professionally managed Dentzz Dental Care Centres located in the prime areas of Mumbai (Bombay) were established with the sole intent of providing ideal and comfortable dental care for all its clients. Whether you are based in India or any other part of the world you can be assured of receiving the finest in dental care at Dentzz. With its highly skilled and reputed panel of specialist dental surgeons spanning across all fields of dentistry, an array of dental procedures, right from one sitting root canals to advanced smile makeovers, dental implants and full mouth rehabilitations are all performed under one roof. (Dentzz Dental, 2010)

Samitivej Hospital in Bangkok states: Our commitment to quality care and innovation has been recognized by UNICEF and WHO, being the first hospital in Thailand to be awarded the Mother and Baby Friendly Hospital status in 1999. Other notable awards include the Prime Minister’s awards for Most Recognized Service in 2004 and accreditation by Hospital Accreditation Board in Thailand. (Samitivej Hospital, 2010)

Bumrungrad notes that it was regarded by readers of Wall Street Journal Asia as one of the ‘most admired Thai companies’, voted Thailand’s most innovative company, given the ‘Best Website of International Travel Award’ and also secured design awards. How ‘notable’ or meaningful such awards may be, and whether patients take any note of them, is uncertain, but the same themes recur again and again. While JCI accreditation is invaluable, for many potential patients it is somewhat abstruse and technical, hence hospitals and MTCs routinely advertise the skills and accreditation, usually Western (especially American) where possible, of their staff. Many post detailed curricula vitae (CVs) online. The SP Clinic in Phuket, Thailand, which specializes in plastic surgery, alongside a photograph of a soberly suited surgeon, emphasizes that:

Dr. Sompob Sansiri is a certified board of International Academy of Cosmetic Surgery (IACS). He is a certified cosmetic surgeon and a member of American Academy of Cosmetic Surgery (AACS). He is a certified board of American Academy of Aesthetic Medicine. He is a member of American Society of Hair Restoration Surgery (ASHRS). He also has a diploma in aesthetic medicine by American Academy of Aesthetic Medicine. He is well recognized as one of the best doctors who performs cosmetic and liposuction surgery. Dr. Sompob Sansiri has performed liposuction for over 10,000 patients in Thailand. These patients also include foreigners from oversea [sic]. Beside of liposuction, Dr. Sompob Sansiri also perform other cosmetic surgery procedures such as face lift surgery, nose surgery, tummy tuck, breast lift, breast augmentation, sex change surgery, hair transplant, penile enlargement, etc. (SP Clinic, 2010)

Similar CVs and biographies outline the credentials of doctors and surgeons, and potential patients have access to much more information about them than about their own doctors, especially where new procedures are involved. Technological prowess is rarely ignored. Samitivej Hospital states: ‘The hospital’s range of high-technology medical equipment, complemented with its skilled team of caregivers and specialists has successfully performed complex surgery from open heart to liver transplant. The hospital is well equipped from digital imaging to the latest 64-slice CT Scan’ (Samitivej Hospital, 2010), though the latter may sound challenging. The Challeng’eHair Paris hair-grafting clinic, advertising in the Air Mauritius in-flight magazine, provides ‘before’ and ‘after’ photographs of their European clients and stresses: One of the five most advanced clinics in the world is located in Mauritius. The international medical team consists of one Plastic Surgeon, a Laureate winning doctor from the faculty of Paris and an anaesthetist, all members of the Medical council … This clinic, set up to European standards and approved by the Ministry of Health is equipped with state of art technology. (Islander, December 2004: 38)

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Parallels may be drawn with other contexts: Facial extreme make over as you’ve seen in Korea. Korea is one of the most famous countries where facial extreme make over is usually operated. SP Clinic has adapted and use the same techniques. The patients will experience extreme result and the miracle changes to their life! (SP Clinic, 2010)

Cuba asserts that the professional quality of plastic surgery and dentistry is ‘unquestionable as shown by the health indices given by the World Health Organization’ (Cuban Health, 2010). Many providers make quite comprehensive claims: Dr. Sunil Dental Clinic is a unique dental clinic in Thailand with team of 15 certified professional Thailand dentists who have a passion for science of dental with art of cosmetic dentistry. Our goal is to provide optimal dental health within our state-ofthe-art facilities in the relaxing environment. We have served thousands of clients all over the world including celebrities. Our team of dentists and dental specialists at Dr. Sunil Dental Clinic are experienced and highly qualified, accredited both locally and globally including UK and USA. Our specialized team of doctors is well spoken in several languages like English, Indian, Arabic, Japanese, Thai. We also provide interpreters on request in languages like German, French, Spanish. We provide a wide range of dental services such as laser teeth whitening, dental implants, crown/porcelain veneers and bridges within 24 hours, bonding, gum lifts, aesthetic dentures, and tooth color fillings. (Dr Sunil Dental Clinic, 2010a)

A context of technological excellence is important. Singapore hospitals claim various Asian ‘firsts’ (Chapter 5), while Bangkok Hospital advertises itself as the only hospital in Thailand with a gamma knife for neurosurgery (Turner, 2007a: 121). The Wockhardt hospitals in India are the only ones in the world to perform COPCAB heart surgery (Dunn, 2007). Like JCI accreditation these can be important claims but they mean little to patients seeking quite different experiences. Caring is sometimes stressed. Vejthani in Bangkok offers ‘the finest clinical integration

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while respecting the needs of the human spirit’ (Vejthani, 2010). Fortis Hospitals in Mumbai are ‘proud of our tradition of compassionate patient care and the advances that we continue to generate’ (Fortis Hospitals, 2010). Yanhee has ‘800 caring, considerate and compassionate nurses and staff at your service’ (Yanhee, 2010). The implication of caring is more evident in the large numbers of attentive nurses in many photographs. Wockhardt Hospitals’ website has a smiling nurse subtitled ‘Wockhardt helps me fulfil my dream of caring for people every day’ (Wockhardt Hospitals, 2010). Even trade publications are not averse to stressing the significance of the ‘angelic nurses’ of Asian hospitals (The Research Staff, 2009: 43). Quantity and reliability are, however, attached greater significance. Tourism is more distant in hospital websites, though they often stress comfortable accommodation (and its amenities, such as Internet connections), and links to hotels and other tourism providers. Websites certainly stress the hotel-like quality of the hospitals – the two are elegantly combined and nothing is lacking – and Western amenities, such as restaurants, and services such as airport transfers and visa extensions (Chapter 9). Perhaps as significant in influencing the undecided as the formal data on reliability, quality of service and low cost is the fact that many websites are modern and sophisticated, emphasize the latest technology and portray doctors as every bit as handsome and youthful, and nurses as beautiful, as on the television soaps. Little is left to chance. Staff look both professional and caring – and even global – in promotional photographs, with one of Bumrungrad’s more iconic images being that of a Thai doctor balancing a globe in his manicured hand. The home page of Bangkok Hospital manages to combine a helicopter landing, two beautiful nurses making a respectful wai gesture, and other images of caring bedside manners. It is unsurprising that certain themes recur: ‘world class’, technological expertise, caring and clinical excellence, especially where they are combined as Apollo Hospitals suggest: At Apollo Hospitals, India, we unite exceptional clinical success rates and superior

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technology with centuries-old traditions of Eastern care and warmth, as we truly believe the world is our extended family – something our 16 million patients from 55 countries can warmly affirm. (Apollo Hospitals, 2010)

The websites of providers are nothing if not predictable in content and effusiveness.

Patient Testimonials Common to most websites of MTCs and hospitals are testimonials of success, most from ‘ordinary’ people who have benefited from medical procedures. Testimonials take predictably standard forms, covering precisely what providers are also seeking to demonstrate: (i) quality; (ii) costs; and (iii) personal attention and care. Dentzz is made up of a highly professional team whose knowledge and expertise instantly put one at ease. My special thanks go to the doctor whose knowledge of specialised dentistry, her incredible attention to detail and her calm and ever-reassuring manner meant that even the most challenging dental problems were solved. The clinic’s administrative staff also went to great lengths to ensure my comfort, convenience and well-being. The whole process was efficient, personal and I felt very cared-for throughout my experience (Diane Curran, UK). (Dentzz Dental, 2010)

The Yanhee Hospital (‘destination beauty’) in Bangkok features a series of testimonials – literally handwritten and scanned onto its website. An Australian patient, after a breast enlargement operation, wrote: The Yanhee Hospital is fantastic. Everyone is so calm and friendly. I felt as if I was in very safe hands the entire time. All my questions were answered and if I needed help the nurses looked after me in a matter of seconds. The hospital and staff are very well presented. I highly recommend this hospital to anyone and I will definitely come back here for any future treatments. The nurses are so beautiful and friendly and are constantly checking to see that you are being cared for. I

want to thank everyone here at the hospital for making this experience as enjoyable as possible. (Yanhee, 2010)

Other facilities post similar handwritten testimonials. The Dr Sunil Dental Clinic in Bangkok has both video testimonials (common on several sites) and handwritten notes where English sometimes comes to grief: ‘I am afraid of dentist. After know you I am not any more. Thank you’ (Tomas, Italy. 22 June 2007; Dr Sunil Dental Clinic, 2010a). Comments at Bumrungrad included: I felt more like a travelling dignitary in a 5-class hotel than a simple patient in a hospital. This hospital disgraces any hospital I have ever visited in any country. (Bumrungrad, 2010) I spent 3 days at Bumrungrad Hospital and aside from the discomfort (worse pain in my life!) associated with this procedure, my accommodations at this seemingly 5 Star resort, was wonderful. I had my choice of rooms and was graciously upgraded to a mini suite on the 6th floor with a garden outside my picture window overlooking Bangkok. My food choices ranged from Western to Mediterranean and I must say that the staff was friendly and cooperative. Unfortunately the health club was off limits this time around. My recommendation is an overwhelming, YES. I know it’s only a hospital but even after being discharged, my friends and I went back for our meals and to enjoy the opulence of the place. (Travelblog, 2010)

A degree of exoticism, a brief experience of the ‘other’, was often welcome, especially where it pointed to greater attention and service: This was our third visit to Bumrungrad International Hospital [BIH], so we knew to show up early for our routine health exams. When the doors opened at 7 a.m. on Tuesday, we were there. The friendly nurses at the registration counter were dressed in starched white uniforms, complete with neat little hats. Other female staff members wore pale green silk uniforms with their hair pulled back into chignons; the men wore pants and jackets of the same classy fabric. Everyone greeted us with a

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smile and a slight bow with hands in prayer position. (The Guide Hog, 2010)

Occasionally testimonials come from less ordinary people: I was always keen to do something new & trendy. Being a Miss India World I had a great smile but wanted to enhance it further. Based on a few recommendations, I decided to get some cosmetic dental work from Dentzz. The doctors made me feel very comfortable and recommended the best treatment alternative for me. The atmosphere within the surgery was very soothing and comfortable and I am very happy with the outcome. I would happily recommend Dentzz to anyone (Sayali Bhagat, Miss India World (2004–05), Bollywood Actor). (Dentzz Dental, 2010)

Similar endorsements recur constantly, and it is unsurprising that testimonials, and many journalists’ stories, are positive. Most focus exclusively on the positive impacts of overseas surgery, there is little scope for dissent on monitored sites and few variations on the form of endorsement. Enthusiasm is positively encouraged and reinforced. As the web page of Gorgeous Getaways states: We have many opportunities for our past clients to help and advise others who are considering a surgery holiday in return for payment. These opportunities are available for our clients: 1. Being a Case Study and Referral (requires photos to be shown) This is simply writing up an account of your experience in Malaysia – this can be anonymous if you prefer. If you have had body shots, we can crop your head out of the photos and change your name. Unfortunately it can’t be anonymous if you have had a face procedure of course! Also just a few times we will give your name to others who are considering the same surgeon or procedures for them to ask questions, this can be done by email or phone, on your request. In return, we will pay you A$100 for your support in doing this. … 3. Media Interview Journalists are always looking to interview people who have had surgery. These are

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usually just short telephone interviews and in some cases there may be a photo shoot. Depending on how strong your story is, you will be paid from A$500. We have had clients paid up to A$3,000! But this is only for very strong and compelling stories e.g. massive weight loss, unusual surgeries, mother and daughter or surgery bought as a present. These are just examples, if you have anything unusual then do let me know – the more unusual and stronger your story, the more you will be paid! Also, please send through photos of you socially, with makeup, smiling so we can have some better after photos now. Stories normally run on photos, so the better your photos, the more chance of getting paid more for your interview. (Gorgeous Getaways, 2010)

Patient testimonials posted on hospital websites are always positive, just as are the ‘case studies’ in the guidebooks, but blogs and more personal websites reveal a greater diversity of experiences. Just as positive testimonials are to be expected so too are negative ones, but negative blogs and independent critical websites are rather harder to find, and are less ‘professional’ than the multiple websites of MTCs and providers, with their ubiquitous success and incurable optimism. They do, however, exist: Bumrungrad – I wouldn’t touch them with a 20 foot pole (although handy as a shortcut to Soi 1). There are much better (and much cheaper) hospitals within spitting distance of that place. Less money on marketing I’m sure but better care and more empathy in the experience of the only person I know who has ever used them. (Thai Visa Forum, 2010)

Samples of one are unhelpful. A few disappointed patients play with the ‘bum’ component of the name. The most vituperative criticism of Bumrungrad has been on an evocatively titled website (www.bumrungraddeath.com/index.cfm) where an American claimed that the hospital had ‘murdered’ his son. But alternative websites took a more balanced approach, emphasizing that unusual deaths occur in all hospitals (http:// medicaltravelsite.com/blog/2006/10/09/ disturbing-press-releases-regarding-a-death-

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at-bumrungrad). British medical tourists to Tunisia posted two unflattering perceptions on their return: I just wanted to add that also be very wary of so called packages on the internet, that offer an ‘english speaking assistant’ … mine offered that. I was horrified when a cigarette smoking man in a dirty old van picked me up at the airport, his knowledge of the English language was roughly 2 words, he made me feel very uncomfortable, then dumped me at the reception of the clinic where not a single person spoke English. It was a complete nightmare, and a terrible stressful experience, please be very careful, do not believe the flashy web sites and fake pictures, take it from me, it’s a lie! Please don’t make the mistake I did, I went to Tunisia for a mini face lift, and was left with terrible scarring, I lost 2 inches of hairline above my ears, and I have excess tissue as a result on my face, and my ear lobes have been stretched down, having it put right is going to cost a fortune, I wish I had not opted for cheap surgery, it’s just not worth it. (Tourism-Review.com, 2010 http://www.tourism-review.com/article/ 95-medical-tourism-brings-hard-cash-to-tunisia)

Unfortunate events, distraught relatives and customers disappointed enough to vent their frustrations in web pages are very uncommon and no general conclusions can be drawn from such incidents and accidents.

The Normality of Travel Some patients may never have previously made overseas journeys and, at what may be a difficult time, it is necessary to emphasize the normality and ease of travel, and perhaps its ubiquity. Bumrungrad, for example, stresses the wide variety of countries from which patients have come – ‘over 190 countries’ (a claim that is, however, unproven) so that, as the website continues, ‘I’m not the only one who travels for surgery’ (Bumrungrad, 2010). Many sites have ‘frequently asked questions’ one of which invariably refers to travel and tourism issues. On one Filipino MTC website such a question is ‘Tell me where the Philippines is located, its cul-

ture and languages spoken?’ Part of the answer is that ‘The Philippines is located in South-east Asia. The Filipino people are known to be hospitable to a fault and visitors are always welcomed with open arms’ (Philippine Medical Tourism Inc., 2010). Distant locations pose problems of unfamiliarity and greater cost of access, but their peoples are noted as unfailingly helpful. To ease travel most MTCs and some providers offer extensive concierge services and airport meeting and greeting (even before passport control). Some hospitals offer airport limousine services and passport and visa assistance. Medical tourism may conceivably be fun. Yanhee’s website provides a video tour and discussion with native Englishspeaking employees partly to the background of the Beach Boys’ ‘I Get Around’. And it need not be challenging or expensive. As one American MTC states: Pre-trip planning includes selection of a medical tourism package that fits your needs, direct consultations with the physician before your trip, arranging your passport and visa, making travel arrangements, etc. At the destination country, right from the moment you arrive at the airport, we provide you an agent who will take care of all your needs during the visit and make sure your stay is comfortable. Also, you will have access to a mobile phone and internet that will allow you to stay in touch with friends and family. You save money on your travel expenditure. We work with one of the biggest discount international airline tickets consolidators. We also help facilitate deep discounts on car rental and lodging. (Medical Tourism Corporation, 2010)

As one American company points out: ‘Worldwide Medical Partners and its family of companies have helped thousands of patients throughout the years travel seamlessly through international borders.’ Beyond that a complimentary concierge will act as ‘your personal aid; your local companion will arrange your Airport Pick-up and Drop-off, accompany you to, and facilitate your doctor’s visits, take you sightseeing and guide you to the best dining and shopping in town’ (Worldwide Medical Partners, 2010). Bangkok

Marketing Medical Tourism

Hospital notes that ‘Our medical campuses provide special amenities from concierge services, deluxe accommodation, translation, visa assistance, shopping and dining designed to significantly enhance your visiting experience’ (Bangkok Hospital, 2010). Food is designed to be culturally specific, whether McDonald’s or halal. In such ways, should they choose to, patients need spend little time outside the ‘safety net’ of a Western-style hospital and its accoutrements. A degree of segregation may be encouraged. Patients experience English-speaking staff (and many hospitals have other language speakers) and may be in entirely foreign wards. The Bangkok International Hospital is exclusively for international patients, and within it there are Arab, Burmese and Japanese wards, with design elements with distinct cultural components. Reassurance over common languages, but above all of English speaking, is common, and several Bangkok hospitals have recruited Filipina nurses primarily for their English-speaking ability (Jones, 2009). The staff on many websites appear both caring and seemingly familiar to Western visitors.

The Language of Success and Competition No other health-care sector is as competitive and consumer-oriented as medical tourism. After all, some procedures do not have to be undertaken at all, and most can be undertaken in many countries, usually including home countries. Marketing is the most critical challenge. Even beyond obvious information about price differentials and quality of care, the discourses of medical tourism have taken on diverse themes that accentuate the ambience and even opulence of care. Hospitals have

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even been advised (and some may have responded) to develop ‘green’ credentials: (i) serving organic food and drinks; (ii) providing views of nature and greenery; (iii) using natural light and green cleaning products; (iv) recycling water; and (v) becoming more energy efficient (Bagwan-Paragas, 2009). Technology, skills and care are much vaunted. Longevity is featured where it can be. Yet though websites may be comprehensive, they are branding and marketing tools as much as sources of information and it is impossible to assess their ‘success stories’ in a vacuum. Over time, although dependence on the Web has intensified and diversified, the experience of friends and relatives has become more important, while the Web and personal perspectives are more important than the formal backstop of JCI (or other) accreditation. Some MTCs consequently run get-togethers where former patients can talk about their experiences and potential patients talk to them. Word of mouth and human perspectives have become probably the most effective do-it-yourself forms of accreditation. Marketing medical tourism is, despite the pun, a massive contemporary operation, developing an export industry that was largely unknown in the 20th century. It has had to convince patients to abandon uncertainty and fear, even xenophobia, and trust overseas hospitals and health workers in different cultural contexts (even though diasporic tourism led the way), and at a time of personal uncertainty and even crisis. From a focus on obvious quality and cost issues, and global accreditation, the new MTCs have tended to add elements of tourism and pleasure while hospitals have promoted technology, reliability and certainty. Who have responded to these blandishments, and the extent to which an economic rationale is dominant, can now be examined.

7 The Economics of Medical Tourism

a Mercedes product at Toyota cost (Bumrungrad Hospital Marketing Director, quoted in Nicholas and Hyland, 2009: 23) Cadillacs at Chevy prices (Bumrungrad CEO, quoted in Anon., 2008b: 71)

It is remarkably difficult to know who the majority of medical tourists are, where they have come from and gone to, and just why they are there. Measures of the flows of medical tourists vary enormously, partly because this defies easy measurement: are they simply the patients or are they accompanying family members? More importantly, while ‘business’, ‘convention’ or simply ‘tourism’ are familiar descriptions on most arrival cards, where they exist, there are no distinct categories for tourists who may be medical tourists, despite Egypt listing ‘Medical Procedure’ as one option and India having a special visa for long-staying medical tourists. Even were there to be such a category on arrival cards there is a reasonable presumption that many medical tourists would ignore it, and specify tourism rather than risk referring to health problems. This chapter seeks to examine who medical tourists are, where they come from, why they became medical tourists, where they go and what impact this has had on (mainly) destination countries. As with previous chapters there are concerns 112

with the accuracy of much of the data, in the absence of specific surveys. ‘Standard’ mere tourists (for whom a minor cosmetic procedure may be part of a holiday) and clandestine migrants are excluded from the following discussion which is centred on deliberate medical tourists. All data on flows of medical tourists are based principally on extrapolations from hospital records, themselves usually unavailable for scrutiny, at best selectively released, and then usually to boost future activities. This can be modified by examining the testimonials on websites, though these too are limited by some obvious selectivity, their English-language content (though some hospitals such as Yanhee in Bangkok post many testimonials in Japanese) and by their use in public-relations campaigns. Much of what follows must therefore be subject to some doubt and debate.

Who Are the Medical Tourists? Global flows Beyond ‘temporary’ medical tourists undertaking minor cosmetic procedures it is usually assumed that there are two distinct tourist groups: (i) those from more developed countries, unable or unwilling to pay substantial charges and/or wait long times for

© CAB International 2011. Medical Tourism (J. Connell)

The Economics of Medical Tourism

complicated medical procedures, and who are not the elite in such countries; and (ii) the emerging elite from ‘developing countries’ – those countries where medical standards may be poor and who prefer to pay to avoid such national facilities in favour of high quality care elsewhere. However, these flows, often assumed to be the core of medical tourism, may be numerically dominated by diaspora medical tourism, about which little has been written, websites ignore and which is not the target of marketing, hence any typology is more complicated (Chapter 4). Only crude data provide comparative figures on global flows, and these data are worse than those on destination numbers. Globally it has been suggested that anywhere between 50,000 and over five million people annually are medical tourists, but most estimates are mere ballpark figures. A much-cited McKinsey consultancy report suggested that the number of medical tourists in 2007 was somewhere between 60,000 and 85,000. That study excluded ‘medicated tourists’, resident expatriates and ‘wellness tourists’ travelling for massages or acupuncture. Significantly the report also excluded ‘patients who travel in largely contiguous geographies to the closest available care’ thus excluding substantial cross-border mobility. Omitting such groups revealed that the largest single segment, with 40% of medical tourists, were patients seeking high quality care in destinations like the USA and who mainly came from the Middle East and Latin America. The second largest segment (with 32% of tourists) were those seeking better care than they could receive in their less-developed home countries. Three remaining segments included those who were avoiding long waiting times, and those seeking lower costs for either medically necessary procedures or discretionary procedures (Ehrbeck et al., 2008). It thus challenged basic assumptions about the main medical tourism categories. The McKinsey report did not explain how their numbers were derived and how they were allocated by sector, though they probably excluded analysis of providers without JCI accreditation. An industry commentator challenged the assumptions and definitions of the McKinsey report and, by including non-JCI accredited

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providers, patients who were not in-patients (including many dental and cosmetic surgery patients) and cross-border patients, argued that the number was more likely to be a ‘conservative estimate’ of over five million (Youngman, 2009). However, this number included an unspecified number of ‘wellness tourists’, on the grounds that their objectives were no different from those of other medical tourists, and accepted largely uncritically several Asian estimates. At the same time Deloitte Consulting estimated that 750,000 Americans alone had gone overseas for health care in 2007, the year of the McKinsey report, and projected a tenfold growth in the following decade (Deloitte, 2009). That report was much welcomed in the industry but, again, the methodology was unstated. The discrepancies are considerable even within international consultancy reports, being based on industry and national estimates. If 750,000 Americans did go overseas for medical treatment in 2007 then the USA would be the world leader in numbers. Somewhat fewer may have been citizens. Industry sources put the number of UK patients making personally funded medical trips to Europe alone in 2006 at over 50,000, almost half of whom were dental patients (Treatment Abroad, 2007) a total that is more plausible than the US one. However, as the analysis of the Bumrungrad data indicated (Chapter 5) numbers can easily be exaggerated to boost the industry, and destination figures would have been much greater had that number of people left the USA. These data do little more than suggest that flows are probably dominated by mobility from developing countries, and that developed countries remain important destinations. Regional flows Despite the qualitative literature centring on the movement of medical tourists from developed European countries, especially the UK, the USA and Australia, the majority of medical tourists almost certainly come from neighbouring countries (and, in most statistics at least, include people already in the destination countries, as workers or tourists) and from the Gulf. While accounts of medical

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tourism in the Western media emphasize transcontinental journeys most movements are intra-regional. The projected image of medical tourism, in the media and on websites, is rather different from reality. Geography and culture influence mobility. Australians and New Zealanders are more likely to visit Thailand and Singapore, countries that they are more familiar with, rather than travel further to India. Within most continental regions there are very significant differences in the costs of treatment and hence considerable mobility. In the EU region, somewhat ironically as skilled health workers – nurses and doctors – migrate westwards (to the UK, Sweden and Germany), patients migrate in the opposite direction (to Hungary, Poland and Latvia). In Latin America similar regional moves occur, and Mexican-Americans dominate movements from the USA to Mexico. Most of those who travel to Cuba come from nearby Central and South American (but also Andean) states. Africa and the Middle East also exhibit regional movements within the Levant, the Maghreb and in sub-Saharan Africa. Libyans, followed by Algerians, dominate movement to Tunisia, as they also do to Egypt. In Jordan, the leading destination in the Middle East, medical tourists mainly come from other Arabic-speaking countries where the doctor: population ratio is lower, and the medical skills of doctors are perceived to be lower, such as Yemen, Sudan and Libya (Smith and Puczko, 2009: 163). About 84%, 84% and 87% of overseas patients in Tunisia, Singapore and Jordan, respectively, come from neighbouring countries, and 89% of Thailand’s patients in 2002 were said to be local expatriates or Asian nationals (Lautier, 2008). Since most medical tourism is a response to a lack of finance or insurance cover, either absolutely or for certain popular procedures, it is largely funded from personal out-of-pocket expenditures. This favours short distances and low costs. Insurance companies too are rarely anxious to fund distant travel, unless procedures are inexpensive. Culture modifies geography where diasporic tourists, from Korea, Malta, Taiwan and elsewhere, choose to travel longer distances for the familiar comforts of ‘home’.

Data from destinations shed some light on the geographical origin of medical tourists. In 2005 those who came to Singapore for medical treatment came mostly from neighbouring countries, especially Indonesia (52%) and Malaysia (11%), with other significant sources being the USA/Canada (5%), the UK (4%), Japan (3%) and Australia/New Zealand (3%) (Khalik, 2006). Singapore has, however, seen a shift of its market from Indonesia to the Middle East, alongside greater numbers of ethnic Chinese from a diversity of sources. Rich Javanese tend to make the short flight to Singapore, while Sumatrans go by ferry to Malaysia. There is further differentiation in Singapore: richer Indonesians go to private hospitals and the poorer go to public hospitals. Regional arrivals were more likely to come for checkups and minor treatments and those from developed countries for more intensive procedures (Khalik, 2006). Most medical tourists in Singapore continue to come from nearby developing countries, despite the high costs, rather than developed countries, and 2005 was the first year in which Bangladesh and Myanmar had enough medical tourists there to be among the top ten countries. In Malaysia a survey of 121 medical tourists at five hospitals in and around Kuala Lumpur revealed that almost half of them (48%) were from Indonesia, with smaller numbers from Australia (ten), New Zealand (seven), Philippines (six), India (four), Sudan (four) and the UK (four), with fewer from Japan, Romania, Nigeria and Oman, and just one patient from each of China, the Netherlands, France, Germany, Kiribati, the Maldives, Montenegro, Saudi Arabia, Switzerland, the UAE and Ukraine (Doshi, 2008: A-21). This geographical spread, where the methodology favoured literate English speakers and the response rate was low, suggests a much wider geographical distribution and, by implication, parallel situations elsewhere in Malaysia. While most of this sample of medical tourists in Malaysia were from neighbouring Indonesia they were not necessarily relatively poor. Of 112 for whom data were available just eight had only completed primary school education and 69 had received a college or university education (Doshi, 2008: A-23). Most were neither very young (only ten were

The Economics of Medical Tourism

aged less than 20) or very old (only 11 were aged more than 61) with half being between 31 and 50. At Bumrungrad most medical tourists were from other parts of South-east Asia and from the Middle East. However, testimonials on its website paint a different picture. From 98 testimonials over the 5-year period 2005–2009 where a nationality was given, some 33 were from the USA, 16 from Thailand, ten from Australia and seven from the UK. No other countries had more than three testimonials; the remainder came from Asia (Bangladesh, Cambodia, China, Hong Kong, Indonesia, Japan, Malaysia, Nepal, Singapore, Taiwan), Europe (Germany, Ireland and the Netherlands), and also the UAE, Canada and New Zealand. Since many patients at Bumrungrad are from the Gulf this unrepresentative sample may represent the products of a more effusive culture, language issues, or a marketing ploy for custom from the USA. Indeed the cover of the principal promotion document has a group that is primarily Caucasian, and also young and seemingly healthy (Fig. 7.1). A larger sample of 376 patient testimonials from Yanhee Hospital’s website early in 2010, where cosmetic surgery is dominant, recorded 143 from Australia, 40 from Japan, 39 from the USA, 29 from New Zealand, 22 from the UK, 12 from Singapore and 12 from Sweden. Just two were from the UAE, and none from elsewhere in the Middle-East region. The average age of the Yanhee patients was 34. In both hospitals such testimonials, and brochures and web pages, may represent an idealized geographical distribution rather than the reality. Testimonials on the websites of the two main Indian chains indicate that most patients are actually from India itself, but otherwise there is a more global spread, which is probably indicative of the Indian diaspora. At Fortis Wockhardt, after 54 testimonials from India, there are three each from the UK and the USA, and one each from Afghanistan, Australia, Bangladesh, Ethiopia, Israel, Nigeria and Sri Lanka. By comparison, out of 40 Apollo testimonials, just seven were from India and 12 from the USA, followed by Canada (five), Nigeria (five), Seychelles (two) and one each from Australia, Costa Rica, Mauritius, Pakistan, Spain, Switzerland, the

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UK and Uzbekistan. Rather earlier one Chennai (Madras) hospital claimed patients from Oman, the UAE, Bahrain, Qatar, Saudi Arabia, Mauritius, the Seychelles, the Maldives, Sri Lanka, Bhutan, Nepal, East Africa, Germany, Australia, Canada and the UK in 2005 (Times of Oman, 11 June 2005). Many are likely to have been NRIs. Most major medical tourism destinations in Asia attract significant numbers from the Gulf, primarily the UAE (especially Dubai), Oman, Qatar and Kuwait. As one blog noted: A middle-aged Arab couple, the man in white robes and the wife in a burka, plus an elderly lady in a wheelchair, probably one of their mothers. The wife was chatty, a bit loud, a bit heavy. She had a half-face mask, heavily kohled eyes, smelled very strongly of perfume and walked with a slight limp that I’ve noticed on other women in burkas. Bumrungrad attracts a large number of customers from the Middle East and the Gulf states, including many burkaed women, which seems to phase [sic] nobody. Though it is interesting to note how something that is so deliberately unrevealing can be customized – a discreet black sequinned trim, an embroidered edge, hot pink painted fingernails, a pair of very hip black sneakers peeking out from below. There were others running here and there: A saffron-robed monk (and not the fake triad-y ones you see in Hong Kong). A small black boy who was lost. Enormously obese Westerners. Dozens of languages spoken. Bumrungrad has quite good medical care, but its best feature may be the people watching. (http://joycelau1.spaces.live.com/blog/ cns!DFE95C9AB5B43908!186.entry)

Its CEO has effectively concurred: ‘If you come into our lobby, it’s sort of like going to Terminal 3 at Heathrow airport’ (quoted in Anon., 2010c). In the mid-2000s some 70% of medical tourists from the UAE went to Singapore (Gulf News, 2005). By contrast India was said to be the preferred destination of Omanis (Times of Oman, 11 June 2005). In Asia the number of Gulf tourists was boosted after 9/11 in 2001 and it remains a major source of medical tourists for South-east Asia. As the manager of one group of Malaysian hospitals has said: ‘since 9/11 people started looking to the Eastern world for holidays and we are

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Fig. 7.1. Bumrungrad International Hospital brochure (source: Bumrungrad International Hospital, Bangkok).

The Economics of Medical Tourism

trying to capture a fraction of these people. The Middle East is a huge market for us. Abu Dhabi Company for Onshore Oil Operations sends its 36,000 employees to us for checkups’ (Gulf News, 2005). There are niche markets within medical tourism, while cultural sensitivity is particularly important in a health context. Testimonials from Clinica Biblica in Costa Rica indicate the predictable dominance of the USA; 33 of 36 testimonials came from there, with two from Canada and one from the UK. In South Africa, despite the most famous destination MTC being Surgeon and Safari with its obvious elite connotations, the majority of medical tourists are African nationals from countries such as Botswana, Ethiopia, Zambia, Angola, Nigeria and other sub-Saharan states, who turn to South Africa because medical facilities, equipment and skills are lacking in their own countries (Witepski, 2005; Easen, 2009). Patients of Surgeon and Safari itself did, however, come from greater distances, mainly from the UK followed by the USA, were aged between 45 and 65, usually single, and stressed economic factors (Witepski, 2005). Significantly, with only rare exceptions, in destination hospitals in every country by far the majority of patients are locals, medical tourists make up less than half of all patients and most are from nearby countries.

What Procedures? Beyond Cosmetic Surgery Much of the literature and many assumptions about medical tourism suggest that it is primarily concerned with cosmetic surgery, yet it is very much more diverse. Available data are again unhelpful. Medical tourism is centred on a limited range of surgical procedures (including such minor procedures as teeth whitening) partly because many illnesses are too serious to allow mobility which would be injurious to health. Dentistry probably dominates medical tourism, but prices are lower hence cost differentials are less dramatic while the outcomes rarely attract media attention. Teeth are unexciting. This is equally true for

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diaspora tourism and regional cross-border movements which may be about something as inconsequential as check-ups or as necessary as eye surgery. Media attention is invariably focused on either cosmetic surgery, where costs are greater and outcomes, good or bad, are more photogenic, or on some minority procedures where ethical issues are paramount (Chapter 8). The web pages of hospitals and MTCs, indicating what is available, and the testimonials of patients shed some light on the range of procedures that are involved. However, testimonials, like most media reports, tend to relate to relatively complex procedures, hence check-ups are absent. Despite the great differences between procedures, from bariatric surgery to infertility treatment, and from breast augmentation to gender reassignment, which are very different in terms of costs, duration of stay and cultural consequences (let alone pain), useful quantitative differentiation is absent. Cosmetic surgery is certainly significant but check-ups and other low-key procedures are much more likely to be typical rather than more dramatic, and sometimes glamorous, procedures. According to the National Coalition on Health Care about 40% of Americans who have travelled abroad for health care went for dental work (Apton and Apton, 2010). In Europe dental treatment was marginally more significant, accounting for 43% of patients in 2007, with cosmetic surgery undertaken by 29% and other surgery, scans and diverse treatments accounting for the remainder (Treatment Abroad, 2008). An even higher proportion might be true of the UK and, since dentistry is rarely life threatening, more patients may travel independently rather than use MTCs. International patients at Bumrungrad came mainly for orthopaedic procedures, followed by cosmetic surgery and dentistry (Anon., 2009). In Singapore patients mainly undertook general surgery, followed by general medicine, cardiology and gynaecology (Khalik, 2006). The greatest proportion (23%) of medical tourists in Malaysia were there for routine procedures, such as consultations with specialists, and a further 15% were having check-ups; 21% were having plastic surgery of various kinds (notably tummy tucks, facelifts, nose jobs and

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liposuction) and 19% were having other surgical procedures, including cancer treatment (Doshi, 2008: 80). At least two-thirds of the patients received treatment for between 1 and 5 days but more than 11% stayed longer than 6 days (Doshi, 2008: A-24). This rare survey of patients, which probably has wider validity, indicates that most procedures are brief and uncomplicated, and few patients stay for long, which perhaps also indicates the potential for accompanying ‘tourism’.

The Rationale for Medical Tourism The main global influences on the growth and structure of medical tourism have been economic, whether for local moves or longdistance travel, for drop-in procedures or extensive surgery, or for Europeans, Asians or elites in a range of countries. An overly repeated phrase is ‘First World care at Third World prices’ (though where waiting lists are long, ‘First World’ care has its limitations). If medical tourism is primarily a function of economic change, social factors – the desire for cosmetic surgery and cultural connections – have stimulated and directed flows, while waiting lists, insurance constraints, quality of care and desire for privacy all play roles in decision making. When medical tourists in Malaysia were queried over their reasons for choosing their hospitals and destination, the five most important reasons were: (i) ‘clean and hygienic physical environment’; (ii) ‘modern and up-to-date medical treatment’; (iii) ‘reputable medical services’; (iv) ‘excellent track-record of medical services’; and (v) ‘wide range of medical services’. By contrast the five factors that were least important were: (i) ‘amenities offered for medical practices’; (ii) ‘halal food is easily available’; (iii) ‘relatives and friends are here’; (iv) ‘cultural similarity’; and (v) ‘availability of tourist attractions’ (Doshi, 2008: 69). While that might suggest that economic and cultural factors are of minimal importance, and tourism irrelevant, these were most likely to have been so central to decision making as to be implicit. None the less they indicate the primacy of medical care.

While most medical tourists are not wealthy, few are very poor; even so many merely cross nearby national borders, or travel within the same continent. Portuguese women cross the Spanish border for abortions, Mexicans travel from the USA, Indonesians move to Singapore. Short distances can be a measure of poverty; poor Cambodians cross into Vietnam rather than Thailand, and poor Polish women travel to Ukraine and Moldova whereas their richer compatriots travel further and westwards and pay more. Even patients who cross nearby borders rarely travel far; ‘dental towns’ in Hungary are close to borders, Bangladeshis often travel no further than West Bengal and Mexicans in San Diego (USA) travel either to the border town of Tijuana or to their own home towns (Chavez et al., 1985). Perhaps surprisingly, given many assumptions about wealthy medical tourists, they are rarely as affluent as health and wellness tourists, for whom such tourism is very much an optional extra, the rewards of a good life. Because of the demand from uninsured American patients, border crossings and the return of the diaspora, a significant part of medical tourism involves the movement of the relatively poor, and in California at least the poorest (Laugesen and VargasBustamante, 2010), across nearby borders. Movement from very poor countries, such as Yemen, may also involve some of the poor, although few can afford to travel, while clandestine migration into Australia, Thailand and elsewhere, is of the poor and often desperate. However, high levels of poverty (often associated with recent migrants with illegal status) reduces the likelihood of migration for medical care, especially where it may jeopardize residential status. Moreover, the very sick (who may also be the very poor) are unlikely to be able to travel at all. Yet medical tourism has been particularly attractive to elites, especially in developing countries. Nigerians, for example, are said to spend as much as US$20 billion/year on health costs outside Nigeria, and an estimated 18,000 wealthy Nigerians go overseas each year for medical treatment (Easen, 2009). Other economic and political elites in developing countries similarly go overseas

The Economics of Medical Tourism

reflecting a clear hierarchy of resort to medical care. Most Nigerians who go overseas for medical care are relatively well off, as are medical tourists from many other parts of sub-Saharan Africa. However, where local facilities are particularly poor, less well-off individuals and households may choose, or effectively be forced, to travel in search of adequate care. Medical travel from Yemen is relatively common, with estimates suggesting over 40,000 people a year, since facilities for some critical problems are absent. Mumbai (India) is the cheapest destination and the most popular with poorer Yemenis, some of whom are forced to sell land, livestock, jewels and property, and take out loans, to finance travel for necessary medical care (Kangas, 2007). None the less each patient spends about US$3000 on medical treatment abroad; collectively therefore each year as much as US$120 million may leave one of the poorest countries in the world. Similarly in Bangladesh ‘a significant number of patients are forced to travel abroad at considerable financial and logistic costs to seek medical advice/care’ (Rahman and Khan, 2007: 144). Even, or perhaps particularly, in devastated Afghanistan medical tourism has begun, despite unfamiliarity with foreign cultures and inadequate health literacy for informed decision making, since local health care is dismal (Mohmand, 2009). Many others make similar moves at great cost. Yet all must have the resources to travel beyond national borders, and pay for care and accommodation, and their expenditure is significantly greater than that of ‘standard’ tourists. Since cancer and cardiovascular services are absent in Yemen, mobility for health care occurs across the socio-economic spectrum, although most resented having to travel. While the majority travelled to Jordan or India, relatively cheap and familiar destinations, Iraq and India were the two cheapest options, while Jordan and Egypt were a little more expensive but also popular, partly because the language was the same and expensive translators were not required. Moscow offered possibilities but Yemenis were discouraged by crime and the hostile environment, while Saudi Arabia, seen as comparable

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to Jordan and Egypt, was inaccessible for political reasons. Above them in the hierarchy was Germany, seen as providing excellent but expensive care, while the more desirable UK and USA were accessible only to a few welloff businessmen or senior government officials. Choices were further influenced by knowledge of particular places, past experience, cultural practices and beliefs and family migration histories and connections: classic patterns of chain mobility. They were also influenced by a ‘geography of the body’ where particular countries had reputations for some procedures: (i) Russia for eye care; (ii) India for kidney care; (iii) Jordan for cancer; and (iv) Egypt for psychiatric medicine (Kangas, 2002). From the same country, elites and the poor made different choices in negotiating a variety of options and a hierarchy of places. The USA, with so many of its population uninsured or under-insured but able to pay for some procedures (as Suzanne Rakow’s case, below, indicates), and close to some Central American providers, is the single greatest national source of medical tourists. Other developed countries are significant sources, but without the ‘insurance push’ and the high costs of the USA, though fewer medical tourists seem to come from Scandinavia, which may reflect more adequate medical insurance, affordable and equitable health care and shorter waiting times. However, despite the significant flows from the USA, little more than a third of Americans would move overseas even if there were substantial savings (see p. 60). A poll of 3000 Americans in 2008 found that older people were less likely to be willing to travel (if they could save half the cost and quality was comparable), with only 37% of [baby] boomers being willing to travel compared with 51% of Generation Y (those less than about 35) while Hispanics and Asians were most likely to be willing to go, compared with Caucasians and African-Americans, and men more willing to go than women (Deloitte, 2008: 5). By contrast Europeans were much more willing to travel, influenced by quality of care and reduced waiting times rather than reduced costs, but poorer residents of East European states were less likely to envisage mobility. While 53% of all EU citizens were willing to travel overseas proportions varied

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from 88% in Cyprus to just 26% in Finland, where most people professed themselves satisfied with local services. Language barriers, financial constraints and lack of information limited willingness to travel; older people, women and unskilled workers were the least willing to travel (Gallup Organization, 2007). Certain groups were reluctant to travel even where substantial cost savings are involved, and some may simply forgo medical care. A further random survey of 5050 Americans found that no more than 29% would consider going abroad for medical treatment, such as heart bypass surgery, knee replacement, plastic surgery and diagnostic procedures; ‘alternative’ medical treatments overseas elicited the greatest interest whereas cosmetic procedures attracted only 10% of respondents. Not surprisingly those who did not have health insurance were more likely to consider going abroad for medical treatment: for example, 37% of respondents without health insurance would seek cancer care abroad as compared to 22% with insurance. Their greatest concern was over adequate quality; consequently when asked whether they would consider treatment abroad, assuming ‘the quality was the same and the costs significantly cheaper’ the percentage saying they would consider medical treatment outside US borders increased by 12% (Khoury, 2009). Almost twothirds of Americans would not consider seeking overseas medical treatment even with cost savings and where ‘necessary procedures’ were required (Deloitte, 2009: 10). Responses varied regionally. In more conservative parts of America such as the Midwest (followed by the South) people were least willing to consider obtaining treatments outside the country; in the West they were the most willing. However, even American college students were generally unfavourable to medical tourism, again centred on uncertainties about quality of care that largely resulted from limited knowledge (Reddy et al., 2010). Distrust, unfamiliarity and the certainties of home and family pose significant barriers, as they do for other forms of mobility, and thus moderate fundamental economic factors. Despite social, cultural, political and psychological factors all being influential, at least in the USA medical tourism has been so

pervasively associated with cut-price procedures overseas that is has been ridiculed by high-income observers as the province of the ‘bargain shopper’ (Burkett, 2007: 226). The New Republic magazine commented ‘What next – cruises to Cuba for surgery performed with the more affordable aesthetic of Havana rum?’ (quoted in Milstein and Smith, 2007: 137). However these are interpreted (and whether or not transport costs, etc. are also significant), price differentials underpin choices in favour of medical tourism and of particular destinations.

In Praise of Cost Differentials Costs are higher in developed countries for a number of reasons, including that wages and salaries are high (and these equal more than half the operating costs of hospitals): (i) doctors in middle-income countries earn less than half the salaries of those in developed countries; (ii) nurses and allied workers (radiologists, etc.) earn perhaps a third of comparable salaries; and (iii) unskilled workers (such as hospital cleaners) earn very low incomes (Herrick, 2007; Connell, 2010).Whereas in the USA labour costs account for 55% of total hospital costs, in Singapore it is 44% and at Bumrungrad 18% (Reisman, 2010: 25). In Mexico medical equipment and imported supplies are the major costs (Hyo-Mi et al., 2009). Since costs of technology vary little, reduced labour costs are critical, which also means that more health workers can be hired and patients may have better access to nurses. Technological change has introduced new procedures, which are very costly, but in demand by the ageing baby-boom population. Bureaucracy is less important and bureaucrats fewer. In most developed countries markets tend to be constrained as insurance companies, governments or even companies pay a substantial part of health care, and do not search for the lowest and most competitive prices so that health-care providers do not compete on prices, compared with countries where personal out-of-pocket expenditure is more significant. Marketing by distant providers competing for discriminating markets ensures that prices are kept relatively low. While

The Economics of Medical Tourism

hospital technology has become much the same as in the West, and doctors are experienced in Western procedures, most labour costs remain very low and insurance is less costly. Medical-care providers in developed countries, especially the USA, may build into their costs coverage for possible malpractice litigation, whereas in countries such as India and Thailand a liability insurance policy costs about 4–5% of that in America. Thailand does not compensate victims of negligence for non-economic impacts, and malpractice awards are much less than in the USA (Herrick, 2007: 12). Fewer regulations governing medical care, hire of skilled workers, occupational health and safety and so on further keep costs down in relatively poor countries. The theme of insurance has been emphasized by at least one MTC: Although many countries have imitated our world-renowned health care system in terms of quality and technology, they have not adopted our legal system completely. Doctors in the US are required to pay medical malpractice insurance that usually cost over [US]$100,000 annually. Foreign doctors are required to pay medical malpractice insurance as well, but their costs are as low as [US]$4000 annually. In addition to this insurance, certain economies are at different stages of development than the US. This absolutely does not mean that their healthcare technologies and institutions are behind the US. In fact, most of the private hospitals in our network use exactly the same equipment and instruments as the most advanced hospitals in the US. (MedRetreat, 2010)

In something of an attack on the structure of American health care MedRetreat added other factors that contributed to reduced costs outside the USA, including: lower real estate values, lower construction costs (to build hospitals), favorable exchange rates, lower government taxes, no accounts receivable collections issues with medical tourism patients (cash/credit card payment before release from hospital), no emergency room bad debt, less administrative paper shuffling, less bureaucracy/red tape, cheaper medical supplies/equipment/medications. (MedRetreat, 2010)

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Some of these are also present in other developed countries. Conversely, as IndUShealth have pointed out: Although the leading Indian centers are equipped with same state-of-the-art technologies as the premier U.S. medical centers, they are able to charge far less than U.S. counterparts because the pay scales are lower and the patient volumes much higher. For example, a typical magnetic resonance imaging scan (MRI) costs [US]$60 at Bangalore compared to more than [US]$700 in New York. There is also a dramatic difference in the malpractice environment – a New York heart surgeon pays more than [US]$100,000 a year in malpractice insurance, while his New Delhi counterpart pays only [US]$4,000. (IndUShealth, 2010)

Such differences inevitably translate into substantial price differentials. Data on price differentials vary within countries and over time (and advertised data rarely include all costs, often excluding essential transport and accommodation costs, which in any case frequently change). Numerous attempts have been made to depict cost differentials, many by MTCs and in the guidebooks. IndUShealth, for example, an MTC which exclusively links the USA and India, posts a set of comparative economic statistics on its web page (Table 7.1) and explains the inclusions and points out that these may not be final: The hospital costs shown include hospital stay, operating theater costs, doctors’ fees, anesthesiologist fees, pre and post-surgical diagnostics, medications, nursing care, and rehab. The combined costs shown also add the typical costs of passport/visa fees, air travel, local transportation, hotel stay and meals. Please note that in certain cases, costs may exceed those shown due to special needs or constraints established by the patient’s medical history or condition. (IndUShealth, 2010)

As in this context many cost differentials are so substantial that smaller differences in hotel costs and the need to obtain passports, etc. are inconsequential. Arguments have been made by opponents of medical tourism that the initial and obvious costs may not be all, and the costs of any complications and

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Table 7.1. Comparative prices (US$) of procedures, March 2010 (source: IndUShealth, 2010).

Type of procedurea Hip replacement/resurfacing Knee replacement CABG (heart bypass) Heart valve replacement Heart pacemaker/defibrillator PTCA (angioplasty) with stent Spinal fusion Gastric bypass Laparoscopic surgeries (gall bladder, hysterectomy, etc.) aCABG,

Median US cost (US$)

Typical Indian hospital cost (US$)

Combined travel and treatment cost (US$)

50,000 45,000 100,000 125,000 60,000 70,000 75,000 45,000 20,000–60,000

7,000–9,000 6,000–8,000 6,000–9,000 7,500–10,000 4,000–6,000 4,000–7,500 5,000–8,000 8,500–10,000 1,500–5,000

9,000–14,000 8,000–13,000 8,000–14,000 9,500–15,000 6,000–11,000 6,000–12,500 7,000–13,000 10,500–15,000 3,500–11,000

coronary artery bypass surgery; PTCA, coronary artery angioplasty.

post-operative costs may have to be met in the patient’s home country, hence there are disparaging comments that this is ‘fly-in flyout’ or ‘itinerant surgery’. Yet the cost differentials are evident. Other tabulations reveal similar situations. Comparisons from two other American MTCs, TourNCare (Table 7.2) and SurgeryPlanet (Table 7.3), for six and five countries, respectively, reveal very similar patterns but significant differences in the ‘actual’ costs quoted, according to how these are calculated. Overall multiple price comparisons (repeated in the guidebooks and on numerous other websites) reveal, unsurprisingly, that price differences are greater for more complex and demanding procedures and that differences are particularly great between the high-cost USA and several Asian countries, especially India. Indeed these three tables alone demonstrate the hierarchy from the USA (and other developed countries), through Central America to Asia (with a significant gap between Singapore and India). For complex surgery economic differences are particularly great, absolutely and relatively, and anecdotal data confirm this. In 2003 a small child in the USA with a hole in her heart was faced with a bill of around US$70,000 there, but the operation was carried out in Bangalore, India at a cost of US$4400 (Neelankantan, 2003). Open heart surgery in the late 2000s cost about US$70,000 in Britain and up to US$150,000 in the USA

but in India it cost between US$3,000 and US$10,000 depending on how complicated the procedures were. Heart valve replacement in India is less than 10% of what it might be in the USA. A colonoscopy that is about US$2260 in the USA costs US$602 in Thailand (Butler, 2009a). Dental, eye and cosmetic surgery costs about a quarter of that in Western countries, and heart bypass operations in India are about a sixth of the cost in Malaysia, hence India has cornered a substantial part of the market for expensive procedures. Price differentials for cosmetic surgery are considerable since cosmetic procedures are not usually covered by insurance. A facelift in Costa Rica costs about a third of that in the USA, and rather less in South Africa, though subsequent possible complications must be paid for in the patient’s home country. Tunisia has attracted patients from Europe since it is relatively close, hence transport costs are low, and because such plastic surgery procedures as breast augmentation and liposuction are said to be 40–50% cheaper than in Europe (Tunisia Online, 2 February 2010). Relatively popular procedures such as hip and knee replacement (where insurance may also be limited) are significantly cheaper in some destinations: Colombia, for example, undertakes knee replacements for about US$5000. The relative provision of insurance cover influences both the choice of procedures undertaken overseas and their location.

The Economics of Medical Tourism

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Table 7.2. Comparative prices (US$) of procedures, May 2010 (source: TourNCare, 2010). Country Treatment for Angioplasty Heart bypass Heart valve Hip replacement Hysterectomy IVF Mastectomy

Costa Rica

India

Mexico

Thailand

Singapore

USA

11,000 29,000 18,000 13,500 5,000 No data No data

10,500 11,000 12,000 10,500 5,000 5,000 9,000

16,500 26,500 21,500 17,000 7,000 No data No data

14,500 13,000 11,500 13,000 5,000 No data 10,000

14,500 22,500 15,500 13,500 7,000 9,500 14,500

61,500 127,000 170,000 44,500 20,000 14,000 24,000

Table 7.3. Comparative prices (US$) of procedures, April 2010 (source: SurgeryPlanet, 2010). Country Surgery CABG (heart bypass) Heart valve replacement Hip replacement Knee replacement Spinal fusion Hysterectomy (vaginal) Economy travel costs (from USA)

USA

Costa Rica

Singapore

Thailand

India

152,000 180,000 101,000 66,000 104,000 32,000 0

25,000 29,000 11,000 12,000 16,000 5,000 1100

32,000 23,000 16,000 19,000 21,000 10,000 1,400

23,000 22,000 13,000 12,500 10,000 4,000 1,200

8,000 12,000 8,000 7,500 8,000 3,500 1,800

Routine procedures such as colonoscopies and obstetric examinations are much cheaper and more affordable (and less demanding of recuperation time). Similarly, while price differentials for dentistry are usually not so substantial, complex procedures can be expensive and insurance coverage is rare. As one Australian patient in Manila phrased it somewhat graphically, after 5 days of treatment: the final bill is compensation: two porcelain crowns, six fillings, 20 X-rays, half a root canal (on the house) and enough painkillers to kill Keith Richards, for only a fraction over A$1100. Add to that my budget airline and the total cost is less than having one pure porcelain crown done in Australia. (Shanahan, 2009: 22)

Overall, depending on the location and procedure, the relative cost advantage from medical tourism ranges from about 28% to 88% (Deloitte, 2008: 13), at least when patients move from developed to developing countries.

A reasonably typical account of the dominance of economic factors in medical tourism is that of a Californian patient with breast cancer: When Suzanne Rakow was diagnosed with breast cancer, doctors recommended a mastectomy followed by two months of radiation. Underinsured and retired, the 59-year-old Californian was shocked when she heard the hospital bill would total [US]$100,000 or more. She had already received a [US]$10,000 doctor’s bill for a second opinion and a 25-minute needle biopsy, and her insurance wouldn’t cover any of it. ‘I am not poor and I am not rich’ says Rakow ‘I didn’t know what I was going to do. If I spend all of my money now, what if the cancer comes back? I have to live on something’. A friend she met recommended she call Planet Hospital, a medical-travel company that connects patients with 32 hospitals in 18 countries. Within 36 hours she was on the phone with a surgeon at Mount Elizabeth Hospital in Singapore. Planet Hospital scheduled her medical procedures and found hotel

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accommodation, as well as a local concierge. Her total bill, including the surgery, radiation, airfare, hotel, concierge and a two-week side trip to Bali, was under [US]$30,000. She paid it out of pocket. (Butler, 2009a: 51)

While many uninsured but potential patients would baulk at these costs, and Suzanne is towards the high-cost end of much medical tourism, this vignette indicates the financial benefits from some of the more demanding procedures. The websites of MTCs and providers, and the pages of the travel guides, include many similar stories and testimonials to cost savings. Discussion boards demonstrate that while medical cost differentials are reasonably well understood, since the prices of particular procedures are formalized, knowledge of associated costs can be slight, especially where patients are unfamiliar with destinations. A post on Gorgeous Getaways’ discussion board early in 2010 stated: I’m looking at GG [Gorgeous Getaways] and seriously thinking of heading over next month to have breast reduction/lift, full tummy tuck and wanted a thigh lift but I think I will settle with the first two. Can anyone tell me who have been over how much spending money you would need on day to day things? I have never been overseas so have no idea what money I need to have other than my money for surgery, hotel, etc. I plan to go over by myself, and not do anything else other than surgery and back at the hotel – probably because I would be scared of getting lost and not knowing my way around.

Uncertainty and unfamiliarity, with cultures and costs, can be brakes on medical tourism and, as in this case, indicate the problem and uncertainty of calculating costs. That uncertainty is a deterrent to travel to distant places. Even though economic factors are critical, though less relevant in elite Western destinations, other factors influence particular choices of destination. A tourist from the USA in South Africa considered similar economic factors: If I’d had the treatment in the United States it would have been performed in a day clinic and I would have been sent home shortly afterwards. As a single person, I would have had no-one to look after me in case things did

go wrong [and they did go wrong, since she contracted gastric flu] I was extremely impressed by the way the matter was handled by Surgeon and Safari – I was taken to an emergency clinic and given very considerate care. If I had fallen ill at home the situation would have been vastly different – I would have had to phone medical services myself and there would have been a long debate about which medical facility I should go to. I would have wasted hours for someone to attend to me and paid hundreds of dollars for the entire experience. (quoted in Witepski, 2005)

Another client of the same company noted: I had been interested in having a face lift for many years. I had the money to have the procedure done on Harley Street but I’d become aware of the South African option through my research on the subject. I found the idea of having the procedure done here, rather than in the UK, compelling due to the fact that the costs covered more than just the surgery; it included round the clock care and attention. (quoted in Witepski, 2005)

As in both these cases, and in Malaysia (p. 114), other factors, such as the perceived quality of care, can be crucial while familiarity with destinations and personal recommendations are almost as important. Ultimately price differentials have primacy hence MedRetreat, after 7 years’ experience, offered their own simple economic rule, though that too was mitigated by other factors: The $6000 Rule. Medical tourists can now obtain essentially any type of medical or surgical procedure within reason. However, there is a simple rule we follow to determine if it makes financial sense to travel abroad. We call it the ‘$6000 Rule’. If your procedure would cost [US]$6000 in the U.S., you may not realize any financial savings. Although the surgery would only cost about [US]$1500 abroad, by the time you add the airfare, post-op hotel accommodations, ground transportation, and the other essentials of overseas medical travel, you may only realize a break-even scenario. This being said, many people still choose to travel abroad to achieve complete privacy and anonymity, peaceful recuperation, and the avoidance of daily hometown distractions. (MedRetreat, 2010)

The Economics of Medical Tourism

Although this makes implicit sense (at least for medical tourists from developed countries such as the USA), MedRetreat point to psychological factors (such as fear, worry, doubt and anxiety) that may discourage those who could afford it from actually becoming involved. Similarly the McKinsey report concluded that the required savings would have to be as much US$10,000 before mobility occurred (Ehrbeck et al., 2008). There are no empirical data to support either assertion. However, the average cost savings of European dental tourists was £3200 in 2007 (Reisman, 2010: 99–100) and this was then about US$6300. Many medical tourists make substantially smaller savings. Nor is economics alone any guarantee of becoming a medical tourist, with many Americans, for example, refusing to have treatment abroad at almost any cost savings. Economic factors are never absolutely dominant.

A Culture of Medical Tourism While many medical tourists are from developed countries such as the USA, the UK and Australia, they are not necessarily originally from those countries. Hispanic migrants in the USA return to Latin America for medical care for economic reasons (including inadequate insurance) but also because of: (i) cultural barriers to health care; (ii) discrimination; (iii) a preference for health care in a familiar cultural context; and (iv) the opportunity to catch up with friends and relatives. Such people have been making these journeys for several decades with numbers increasing over time as diasporic populations grew and became wealthier, and services improved in their home countries. In countries like Mexico and India they have played a crucial role in the genesis of medical tourism, their word of mouth has instigated chain mobility, and over time the concept spread from this diasporic culture to neighbours and workmates. Economic factors thus spill over and enmesh cultural factors that include a simple familiarity with languages and processes (for example, in Korea, patients’ unconstrained choice of providers, and for Mexicans in the

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USA, the ability to spend longer periods with a doctor) among migrants who carry with them ‘perceptions and expectations generated in their homeland’ (Lee et al., 2010: 109; see also Bergmark et al., 2008) which may find a more culturally adequate response there. Cultural reasons can complement and overwhelm economic factors. Only a minority of Mexicans who returned there for medical treatment did so because they had a serious illness that required high-cost treatment. Most returned to see their families or for other reasons and to ‘take advantage of their time in Mexico to seek medical care’ and especially dental care. Some believed that: (i) treatment at home was less likely to be turned into an experiment; (ii) they would experience less discrimination; (iii) medicines in Mexico were more effective because they were more likely to be concentrated and made from local medicinal plants; and (iv) treatment would take less time so that they could return to work more quickly (Bergmark et al., 2008). Rather differently Koreans in New Zealand, beyond obvious language issues, chose to return to Korea for medical treatments since they: (i) preferred Korean diagnostic practices; (ii) believed that Korean doctors were better qualified; and (iii) simply felt more ‘at home’ in Korean hospitals where they felt included (Lee et al., 2010). Indians, Pakistanis and Brazilians do much the same. In India the majority of medical tourists are part of the Indian diaspora in the USA, the UK and elsewhere, despite a gradual shift to a more diverse patient population. Koreans routinely return to Korea for medical treatment just as Taiwanese in America go back to Taiwan. For Koreans returning from New Zealand, although more expensive than remaining in New Zealand, the quality of care is comparable and the cultural context enables ease of communication and comprehension of complex procedures while enabling patients and their families to visit friends and relatives (Lee et al., 2010). Both Korea and Taiwan, neither of which is a lowcost destination, have sought to develop large medical tourism industries from this familial starting point. Cultural factors may be important in other contexts, for example in Yemen where

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families pay for relatives to go overseas for medical care to prove that they did everything possible for them. Yemenis also chose their destinations according to economics, language, health problem and existing migration and cultural ties and therefore where social support would be most forthcoming at a time of considerable expenditure and vulnerability (Kangas, 2002, 2007). Similar extended family support systems are widespread, emphasizing how culture, good health and family ties are inseparable (e.g. Andrews, 2009). Travel thus becomes a marker of social status, a means of acquiring cultural capital and a route to good health. Certain procedures, such as IVF treatments, may lend themselves to a form of diasporic tourism. A British Indian couple who were unable to conceive a child, and were placed on a waiting list for fertility treatment in England, travelled to Gujarat and found an Asian donor-surrogate for half the British price (Martin, 2009). The website of the Mumbai Test Tube Baby Clinic states that it caters specifically to Muslim couples since IVF will be performed according to Sharia laws (Mulay and Gibson, 2006: 89). A Japanese couple seeking IVF, since it is illegal there, travelled to Hawaii, since it was both the nearest part of the USA and had many Asian and Asian-American donors, though they rejected those of Korean ancestry (Thompson, 2008). Culture dominates many such intimate procedures. Language too is important. South Africa has been a major beneficiary for tourism from anglophone states in sub-Saharan Africa, and for visitors from the USA and the UK. Similarly language ties routinely take francophones from sub-Saharan Africa in the opposite direction to Tunisia or to France. Libyans travel east and west but remain in the Arabic-speaking Maghreb. Spaniards travel to Colombia. Russians and Ukrainians go to Israel where many doctors speak Russian. India and the Philippines stress their English-language credentials, just as many websites of hospitals feature translation facilities, or the training of staff in, usually, English-language contexts. Mexico has sought to train bilingual English-speaking nurses. Indonesians travel to Malaysia where

Malay is comprehensible, and also to Singapore, but to the larger private hospitals where Indonesian is likely to be spoken (Chan, 2007). Where language differences exist there is some evidence of less adequate treatment (e.g. Guerrieri, 1985), and the guidebooks consistently advise against treatment in an alien linguistic context. Culture may be significant for stimulating markets. The Muslim state of Malaysia has sought to attract Muslims from elsewhere, mainly from the Gulf and the Middle East but also from Brunei and Indonesia, while Singapore has attracted ethnic Chinese from a range of countries in the region, such as Vietnam and Malaysia, where they are generally minority populations. Thailand has deliberately sought to build cultural bridges with Japan in order to boost patient numbers from there. Malaysia has promoted itself as the most appropriate destination for Muslim patients from the Middle East, stressing its halal food and the ability of Muslim doctors to say prayers before operations (Straits Times, 6 November 2006). In each case countries and hospitals have stressed culturally appropriate contexts of health care, dietary provision and so on. In complete contrast some medical tourists seek to escape the cultural complications of care in their home countries. In Saudi Arabia and Yemen patients are often sheltered from the truth about life-threatening illnesses and may prefer the greater frankness of Western care (Kangas, 2002; Albers, 2008). A quite different culture may also be welcome for those seeking anonymity, peace and quiet.

Getting There: Personal Ties and Words of Mouth While geography, cost and culture are important, many choices of destination (and also procedures) are made on little more than hearsay and friends’ recommendations, though they usually align with costs, geography and language ties. Evidence for idiosyncratic choices is mainly anecdotal. As one Australian recorded for the Philippines: Before I went to the Philippines to have my teeth fixed, I had only a vague understanding

The Economics of Medical Tourism

of what dental tourism was all about . . . Many would-be tooth tourists opt for the Philippines because its dentists have a good reputation and their qualifications are recognised in the US. . . . I chose the Philippines because I wanted to visit a friend in Manila . . . Arriving in the Philippines it suddenly occurs to me that I have no idea how good my dentist will be – I have a recommendation via a friend of a friend of a friend who lives locally, but is that enough? . . . Suddenly I’m struck with the fear that my snap decision to have dentistry in the Philippines is a dangerous folly. (Shanahan, 2009: 22)

The eventual outcome was successful, after a range of procedures, though he eventually concluded: ‘Book the dentist not the destination; this isn’t a holiday’, despite participating in a number of tourist activities (Shanahan, 2009). Chance meetings may be catalysts. I’d been thinking about cosmetic surgery for a while after having my 3 children. I went to a plastic surgeon in Melbourne for a consultation. He spent 15 minutes with me and I was slapped with a A$150 consult fee. The cost of a breast lift and tummy tuck was going to cost me A$22,000. I’d heard having cosmetic surgery overseas was cheaper but had seen too many horror stories on A Current Affair and Today Tonight to even consider it. Then one day when I was at the supermarket I ran into a friend I hadn’t seen in a while. She looked so different, not just physically but there seemed to be a new found confidence about her. I asked what her secret was for looking so fresh and rejuvenated. She said 3 words. ‘Face Lift Thailand’ and put me in touch with Global Health Travel. Four months later I was on an airplane. (Global Health Travel, 2010)

A similar sort of process occurred for a resident of Norfolk Island, an Australian territory in the western Pacific: A long-term resident of Norfolk Island, Anne Howe used to travel to Sydney once a year for her annual dental check-up. A few years ago, however, she got more than the scale and clean she bargained for: her dentist said her jaw was going out of alignment and she needed major work. ‘The price I got was quite horrendous and being a Norfolk Island resident, we don’t get any benefits like Medicare. And I remembered reading about

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someone who had gone to Thailand or somewhere to have surgery and so I thought “I’ll have a look on the Web and see what I can find”.’ Her net surfing led her to Specialist Dental Group, a clinic attached to Singapore’s highly regarded Mount Elizabeth Medical Centre and Hospital. She’d visited Singapore before, mainly on stopovers en route to Europe and had always come away impressed by the island’s cleanliness and air of efficiency. A few emails later and it transpired another trip was a real option. For about the same price as a hospital stay in Sydney, she could travel to Singapore, complete her dental work and still have money left over after accommodation and air fares. ‘My experience couldn’t have been better’ she says, back home and problem-free. ‘I was treated exceptionally well, the doctor I saw was highly qualified, ticked all the boxes, and my husband who ended up going with me, ended up going along to the dentist for a check-up too.’ (quoted in Nicholas and Hyland, 2009: 22)

Many similar examples exist of friends, partners and relatives going along ‘for the ride’, to provide moral and physical support, to have a holiday, and then deciding themselves to take advantage of medical services. Potential medical tourists are often fearful of some aspects of destinations, from security to the quality of care, and simply boredom if they must recuperate alone in a strange place, much preferring to travel with others for social and moral support. Online communities and discussion boards, such as that of Gorgeous Getaways, provide means of avoiding that. Early in, 2010 two women posted such a request: I am looking to have breast lift and augmentation and face lift first time and am nervous because every time I tell someone they say don’t do it overseas. I have looked here in Australia and could never afford to have it done here. I was hoping that there is maybe someone else who like me is a bit nervous and maybe we could give each other some support. I am a 48 year old woman. I am thinking of going for surgery approximately end of July. Would love to meet some-one who is also going at that time. I am feeling very nervous and would like to give and receive some support to another person while I am there [Kuala Lumpur].

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Maybe we could go shopping etc together. I am in my late 60s but bright with a good sense of humour.

Both requests gained positive responses and several offers of support and shopping. Many others have posted similar requests. While most medical tourists travel with family and friends, the inevitable uncertainties of medical tourism in distant places both deter some and encourage others to network and acquire new friends. The Internet is invaluable. These examples, that of Suzanne Rakow (above) and a host of others scattered through websites, demonstrate that chance and personal contacts play a considerable part in basic knowledge about the world and about medical tourism, and that the media contribute selectively to this. Choice of destination is as likely to follow the experiences of friends and relatives as the disembodied suggestions of guidebooks and websites. Health-care providers in the home country (mainly Australia in these examples) provided no advice or assistance, nor initially did MTCs, while the Web and telephone calls enabled most arrangements to be made. As the example of the Australian travelling to the Philippines suggests, in contexts where care may be less critical, such as for dentistry, self-help is more common and choice of destination less important. Family and friends are influential, in offering support and finding contacts, and thus contributing to informal accreditation. Word of mouth provides the ‘personal’ contacts that websites or guidebooks cannot. Previous experience is invaluable, and perhaps also accounts for the dominant role of former patients within MTC organizations (Chapter 6). The Kreativ dental clinic in Budapest treated about 16 British visitors a month in 2004 but by 2007 that number had tripled solely by word-of-mouth recommendations, with similar growth occurring from other northern European nations. Kreativ no longer apparently found it necessary to advertise (Haslam, 2007). The largest group of medical tourists in Malaysian hospitals (some 57% of 121 patients) were there because their friends or relatives had told them about it, or lived nearby; MTCs, who

accounted for 15% of the tourists, were the only other significant influence (Doshi, 2008: A-22). Providing ‘meet-and-greet’ sessions and online discussion boards for aspiring medical tourists, as Gorgeous Getaways has done (Chapter 6), creates, builds on and extends such personal contacts. Few branches of tourism and even fewer of medicine are so reliant on the Web as a source of information. Many medical tourists learn of opportunities overseas from media stories and from the recommendations and advice of friends and acquaintances but, as interest increases, through Internet websites. Surfing the net reinforces vague information from friends. Most websites of MTCs and providers further reinforce and extend the advice of friends, providing formal information and hosting a range of personal stories portraying satisfied tourists. Most have a similar structure and format and emphasize economic and social factors and also personal serendipity. WorldMed Assist, a growing company in the expanding industry of medical tourism, helped save Kevin Stewart’s life. Last November [2006], Stewart’s liver started to fail, and by February, he had to endure hospital visits every two weeks to have his belly drained of fluids his liver would no longer process. His doctor said that without a liver transplant, he would die. Worse, there was a four-month wait for a transplant, and no one was sure he had four months. He also was told it would cost about [US]$350,000. Stewart, a retired owner of a landscaping business, had no health insurance. Stewart now has a newly transplanted liver, courtesy of his sister, Jo-Ann Hall of Ottawa, Canada. On Friday, he lands at Miami International, arriving home from Apollo Hospital in Delhi, India, where the procedure was performed. Total cost of surgery and hospitalization there: [US]$55,000. ‘Having this surgery in the U.S. would have wiped me out,’ Stewart said. ‘Having someone help me get the transplant I needed in India – with top-notch doctors in a great hospital, at a fraction of the cost – saved me so much money that I flew my girlfriend and Jo-Ann’s husband to India to help us recuperate – and still saved [US]$275,000. The surgery has given me back a life I thought was lost.’ That life looked pretty bleak when he got his diagnosis and the price tag. ‘In early June, I hit the Internet, and eventually

The Economics of Medical Tourism

landed on the term Medical Tourism. I searched several firms, saying, “I need a liver transplant.” Several responded, but I kept coming back to WorldMed Assist,’ Stewart said. ‘By late June, they had me on my way to India, and my surgery was finished on July 11. Pretty amazing. I heard I was the first American to have a liver transplant in India.’ (WorldMed Assist, 2010)

The Internet abounds in similar stories that end successfully, through the predictable ability of MTCs to provide the support required. The media replicate similar themes: Liz Danforth has always been healthy, so the fact that she didn’t have medical insurance never really worried her – until 2004 when she was gripped with terrible abdominal pain. After undergoing a series of tests her doctor gave her the bad news. She had gallstones. Removing them would cost about [US]$12,000 – assuming there were no complications. Danforth, now 55, an illustrator and game developer in Tucson, Arizona, was concerned: ‘I had savings and I could have paid for it but it was a lot of money’ she says. Then a friend suggested she get the operation abroad. Danforth was intrigued by the idea, known as ‘medical tourism’, and began researching possibilities. What she found amazed her: vast networks of hospitals in destinations such as India, Thailand, Singapore and Costa Rica that catered to cash-strapped, under-insured or uninsured Americans looking for expert medical care at reduced prices. After conducting her own research Danforth ultimately chose Bumrungrad International Hospital in Bangkok – a five star facility accredited by the Joint Commission International. She spent two days – as opposed to the six or eight hours allocated in a US facility – in the hospital, and then recuperated at a hotel around the corner. The entire procedure cost [US]$320 plus [US]$800 in air fare. (Ellin, 2009)

Evident again are the economic benefits of medical tourism, the potential for longer hospital stays (and thus more effective after-care) and the social and instigating role of friends and relatives. Some procedures can only be undertaken in particular places, ensuring that patients who seek rare services (whether stem cell therapy or suicide) must go there irrespective

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of economic factors. For some procedures medical tourism becomes literally a last resort where cost is almost irrelevant (Chapter 8). For every procedure treatment is likely to be most successful where doctors are familiar with the particular conditions: My unscheduled visit to Bumrungrad taught me an old lesson — and a new one. For decades, Americans have known they could obtain cheaper health care abroad, and have slipped off to Mexico for small surgeries or Canada for prescription drugs. But more and more people now recognize foreign hospitals can deliver not only cheap but also highquality health care, and are considering medical tourism even for serious health problems. When I returned to the United States, in fact, I found myself longing for Bumrungrad. On a follow-up visit to an American doctor, I waited in a small room after telling him about my dengue fever diagnosis. After a while, when he hadn’t returned, I poked my head into the hall, and discovered him thumbing through a book to find information about dengue fever. (Kurlantzick, 2007)

On the other hand the epidemiological transition has meant that doctors in developing countries are thoroughly familiar with lifestyle diseases, such as cancer and obesity, emanating from the West, which no longer has distinctive health problems. Familiarity with local and regional circumstances and cultures, however, explains why much medical tourism simply crosses nearby borders. The wider social context of health care is also influential. Several testimonials and blogs from the USA commented on the satisfaction of seeing and using the Starbucks café in the foyer of Bumrungrad, and on other aesthetic pleasures the hospital offered: They’re growing a culture of whatever was eating my throat up, and I’ll be back at Bumrungrad (gotta love that name) again Saturday. Did I mention the other reason it’s my favorite hospital? There’s a Starbucks in the lobby, and the nursing staff are . . . how to put this delicately . . . a bit more aesthetically pleasing than in any hospital I’ve been in back in the States. *cough* (http://blog.hackingbangkok.com/2008/ 11/two-weeks-ago-i-caught-somemutant-drug.html)

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A version of the placebo effect may thus be important for some, but the familiarity that comes from well-known cafés and home languages is valuable. Having Starbucks and McDonald’s investing in the hospital may offer independent prestige and accreditation, for visitors from many countries, and enables some to have accessible food without stepping outside their comfort zone. The redesign of the atrium of Bumrungrad to include Starbucks, McDonald’s and Au Bon Pain, ‘had a powerful effect on lower-income and middleincome Americans [who] discovered that they could afford posh “VIP” services reserved for only the wealthiest clients at private American hospitals’ (Turner, 2007a: 116). The effect on visitors from the Gulf, Eastern Europe and other parts of Asia, where such outlets are particular symbols of modernity, is probably even greater. Diverse cultural factors may have unpredictable impacts on choice of destination and eventual satisfaction.

Institutional Interests and Networking While medical tourism has largely been seen as an individual phenomenon, like so many other components of tourism, where individuals and households make decisions about destinations, durations and what activities to engage in, it has become increasingly an institutional phenomenon. Medical tourists have been seen to be moving away from the sometimes rigid constraints of national health-care systems, and their perceived inadequacies, particularly in the USA but also in Europe. Increasingly there has been a degree of collusion within state systems, as patients are encouraged to move within Europe to take the burden off some national systems, insurance policies provide for the bypass of national systems and some companies ‘export’ workers for health checks rather than trust inefficient national systems. In the future Western insurance companies may well encourage overseas treatment to reduce their own costs. In the mid-2000s the British NHS was sending patients to Europe to cope with a backlog of cases, but

restricting them to places within 3 hours flying time (such as France and Spain), and within the EU market area (Carrera and Bridges, 2006). Changed circumstances might lengthen such distances. Insurance companies are also opting to send patients overseas to reduce their own costs. One Kolkata (Calcutta, India) hospital has signed an agreement with the British-based transnational insurance company Bupa, for the transfer of privately insured patients to India. In the USA an insurance company has teamed up with an MTC, Companion Global Healthcare, to send patients overseas. Through this process, for example, a South Carolina man was sent overseas for hernia surgery in San Jose, Costa Rica, for a total cost of US$3900, which the insurance company entirely covered; had the surgery been undertaken in the USA, the bill would have been US$14,000 of which the patient would have had to pay US$10,000 and the insurance company the remainder (Butler, 2009a: 51). Both company and patient were economic beneficiaries. Japan has been a perhaps reluctant pioneer in such institutional developments. It has always been unwilling to accept immigration hence, as the population ages, has a health-care system that is under considerable pressure, without access to migrant health workers as in most developed countries (Connell, 2010). Japan has consequently taken particular distinctive advantage of medical tourism. Some Japanese companies have sent their employees to Thailand and Singapore for routine examinations, as the savings on medical fees and high quality medical care make the airfares and accommodation costs inconsequential. For provincial Japanese companies the cost is little more than that of travelling to Tokyo, reports are done in Japanese and images sent electronically to Japan. Moreover at least one Bangkok hospital has an exclusively Japanese wing and there are many Japanese nursing homes in Bangkok. Such medical connections have diversified, with spectacles being made in Thailand from measurements taken in Japan and then flown there. It is likely to become increasingly common for companies and mainstream health insurers, at least in the USA, to include

The Economics of Medical Tourism

foreign providers in their networks of health-care providers (Bookman and Bookman, 2007; Herrick, 2007). The Blue Shield insurance company of California, for example, has developed a health network scheme, Access Baja, enabling people who so choose to get health care in Mexico, though most of those who have enrolled in the scheme are Mexican nationals. In a less culturally defined context, in 2006 Blue Ridge Paper Products of North Carolina offered their employees incentives to have emergency surgeries undertaken in India and offered to pay airfare, extra sick leave and a US$10,000 bonus (Burkett, 2007: 223). A month after offering their package, union pressure, focused on lax overseas medical malpractice laws, resulted in Blue Ridge withdrawing it. Concerns were also raised over individuals’ ability and freedom to choose. A year later Blue Cross Blue Shield of South Carolina added BIH to its network of providers, although early after inception no patients had taken advantage of this option (Herrick, 2007: 21) preferring domestic medical care. Blue Cross later concluded similar agreements and by 2010 had agreements with seven overseas hospitals, in Singapore (three), Thailand, Turkey, Ireland and Costa Rica, and in India, Apollo and Wockhardt both seemed likely to become partners (Einhorn, 2010b). Variants continue to reappear: Douglas Carneau is preparing to travel to India for two partial hip replacements and back surgery. Because its costs will be much lower, Regence BlueCross BlueShield of Oregon is willing to send Carneau to India, put him up in hotel, and pay for operations there. Carneau, a long-time truck driver for Safeway and a member of his local Teamsters Union, has health insurance. In fact, he calls it ‘a Cadillac plan,’ and it does provide top-of-the-line coverage through Regence BlueCross BlueShield of Oregon. Carneau isn’t going to India to save money. Instead, he is taking the idea of shopping around for the best health care to a new level. And in the process he is becoming among the first in this country to go overseas for discount surgery that will be paid for by his insurer. (Korn, 2009)

Some US companies have independently explored the possibilities of overseas medical

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care for their workers, to avoid high domestic costs. Such proposals have been strenuously opposed by unions, such as United Steelworkers – the largest union in North America – who criticized the manner in which company profits might be increased in this way, and raised issues of legal liability overseas and job losses in the American health-care industry if health care was outsourced. In 2008 a supermarket chain based in Maine began paying the entire medical bill for employees, with a companion, to travel to Singapore for hip and knee replacements (McGinley, 2008). Employers in southern California particularly have developed insurance plans where their employees go to Mexico for routine care. By early 2010 more than 200 employers in 21 states covered treatment overseas for their employees and some, like the Maine supermarket chain, included airfares for two people. Small companies in the USA consequently became the ‘early adopters’ (Milstein and Smith, 2007) of the off-shore provision of health care for their employees, though Japan had set partial precedents. Such institutional linkages are equally valuable to MTCs like Companion Global Healthcare and Planet Hospital, which developed or sought to develop, with insurance companies, low-cost schemes for overseas health-care provision that would reimburse patients the same amount for each particular procedure independent of where it was undertaken. The intention was to initially develop the scheme with El Salvadorians living in the USA, who would travel to El Salvador for major medical needs, and then follow this with similar schemes for countries such as India and Mexico (Herrick, 2007). Once again the diaspora led the way in the consolidation of international institutional linkages. In other countries similar institutional affiliations have been established. Thailand has gained contracts from the UAE’s police department and the Oman government (for the Royal Guard of Oman) both of which were previously linked to Europe (Levett, 2005). Several Asian countries have organized trade missions to South-east Asian countries, such as Myanmar and Vietnam, and Gulf states, in search of additional formal ties, to

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ensure a steady and substantial flow of patients, rather than merely be the beneficiary of individual decisions.

The Economic Impact Where medical tourists either come from developed countries or are elites from poorer countries, and stay for significant periods in destinations (as recuperation sometimes demands), their contribution to local economies can be substantial. However, there is little data and, once again, estimating the numbers of medical tourists, let alone those who travel with them (and would not otherwise have travelled) is problematic. Existing estimates fail to indicate whether the assumed economic impacts are based solely on health expenditure, or on travel and tourism, which are not easily distinguished (although most data seem to refer to health expenditure). Consequently estimates of the economic impact of medical tourism are usually at best ‘back-of-the-envelope’ calculations, derived from inaccurate numbers, which have minimal basis in hard data and rigorous economic analysis. Even the dimensions of the ballpark are imprecise. Various country estimates exist but none have more than relative utility. Recent data from Thailand suggest that it earned over US$2 billion from medical tourism in 2008, and that 2009 would be somewhat down on that, on medical services alone (Bangkok Post, 30 March 2009). Another estimate was that medical tourists in Thailand spent US$1.6 billion in 2003 (Taffel, 2004), while medical tourists in South Africa were estimated to spend between US$30 and 40 million in the same year. Medical tourism in Cuba has been said to generate US$40 million a year, and US$27.6 million in Malaysia in 2004, while medical tourists from Latin America spend up to US$6 billion a year overseas (Bookman and Bookman, 2007: 3). Alternative estimates suggest between US$40 million and US$103 million in Malaysia in 2003, US$420 million in Singapore in 2002 and about US$482 million in Thailand in 2003 (Arunanondchai and Fink, 2007: 12). Cuba is elsewhere said to

earn US$30 million from 25,000 foreign patients, or US$40 million from 20,000 foreign patients, and Israel US$30 million from 20,000 foreigners (Reisman, 2010: 102). A recent estimate has Israel earning just over US$100 million a year (Haaretz, 22 June 2010). In Jordan where medical tourism is ‘considered one of the main contributors to the national economy’, it is said to bring in revenues that reach US$1 billion annually (Jordan Times, 29 June 2010). Two juxtaposed estimates for India range from US$433 million in 2005 to US$17 billion a year earlier (Reddy et al., 2010). Singapore has claimed that its estimated annual 150,000 international patients in 2001, about 80% of whom were from neighbouring Indonesia and Malaysia, stayed for an average of 5 days, spending about US$1500 per head. Crude calculations suggest this adds up to about US$220 million. Another version has the average expenditure of standard tourists in Singapore at US$144/day and the expenditure of medical tourists at US$362/day (Turner, 2007b: 314). Equally wildly fluctuating estimates have been attached to the global income generated from medical tourism, but there are no reliable data. Not only is there no basis for any of these claims, and no hints of methodologies, but given the various discrepancies, notably for Malaysia, they are barely even crude indications. How fast expenditure has grown, in which countries and from which sources, and who are the major beneficiaries, are all impossible to assess. A small number of studies offer slightly more rigorous data. Some relative newcomers, like Tunisia where medical tourism is said to be growing exponentially, have made substantial gains. In 2009 medical tourism was said to be worth some 5% of all Tunisia’s service exports, significant in a country where ‘standard’ tourism is considerable. Moreover these export earnings were said to account for 24% of the turnover of private clinics, amounting to ?175 million (U$219 million) (Tunisia Online, 2 February 2010). In Tunisia the direct expenditure of medical tourists on health alone (clinic costs, doctors’ fees and pharmaceuticals) was estimated at US$55 million in 2004, about a quarter of the total earnings of all private clinics, and thus a substantial input to the

The Economics of Medical Tourism

health sector (but entirely to the private sector, in the two largest cities). While overseas visitors pay more than Tunisians this raises some questions about the role of private clinics in serving the national population (Chapter 8). Adding to that the total expenditure of patients and relatives in the hotel, food and transport sectors (based on an average length of hospital stay of 3 days and outside stay of 2 days, and about 1.5 relatives per patient) brought the overall expenditure figure to US$107 million (Lautier, 2008). Almost exactly half of all expenditure was therefore outside the health sector, and half the jobs created were also outside the health sector, broadly within tourismrelated service sector activities. Every estimate suggests that medical tourists spend more than standard tourists, and usually about twice as much, as in Singapore (despite the second Tunisian estimate above), because of the high costs of medical services. Another estimate for Tunisia suggests that medical tourists spent between ?2500 and ?4000 compared with the ‘usual tourists’ who spent ?300–400 (TourismReview.com, 2010), although the latter figure seems unusually small. It has been said that an Indian medical traveller spends US$7000 compared with other tourists who spend US$3000 (Reisman, 2010: 102). Costa Rica has declared medical tourism to be in the ‘national interest’ since the Costa Rica Tourism Board believes that, from 2006 data, medical tourists spend, on average, twice or three times as much as a traditional tourist does; that is to say, US$400–600 (¢228,000–342,000) as opposed to US$200 (¢114,000) (Costa Rica Views, 2010). In Korea too medical tourists stayed longer and spent more money than other tourists (Chapter 5). Assuming that the cost of medical treatment is included most medical tourists will spend more than standard tourists. A large sample of medical tourists in Malaysia spent an average of US$8720, of which the single largest component was the cost of medical treatment (US$3742), followed by international airfares (US$1187) and accommodation (US$1038). Food and drink (US$468) and domestic transport (US$159) also took up large sums. Expenditure on evidently tourism-related activities included US$678 for shopping, alongside

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entertainment (US$180) and organized tours (US$489), while there were significant miscellaneous costs (US$779). Almost all medical tourists in Malaysia (108 out of 121) travelled with at least one other person, usually a relative (Doshi, 2008: 78), and their expenditure was not estimated. Had that been included the already substantial expenditure would have been greater. As in Tunisia and Malaysia most medical tourists do not go alone, nor want to do so. Several MTCs offer discounts for friends and relatives. Those travelling to Tunisia took an average of 1.5 friends and relatives with them (Lautier, 2008) and Yemenis took more than one relative with them (Kangas, 2002). Three-quarters of a sample of Bumrungrad patients in 2009 travelled with a companion (Anon., 2010b), a little less than the 83% in the MTA’s more general survey (Anon., 2009). Observations at several hospitals, anecdotal information, alongside the obvious role of relatives in difficult times, suggest that this is normal. A substantial number of additional travellers accompany medical tourists and their expenditure on standard tourism activities is significant. Perhaps predictably tourists from the Gulf are argued to be relatively high spenders, especially from the UAE, where the government funds medical care overseas, and provides hotel allowances, and Arabs have a tradition of purchasing gifts for many family members back home. Indeed in Singapore, where at any time between 100 and 200 UAE citizens are said to be visiting for medical treatment, the income is likely to be considerable since the UAE government pays the full cost alongside return airfares for two companions and a US$4000-a-week allowance to cover the cost of hotel and other expenses, and such ‘high-roller’ patients stay in expensive hotels (Straits Times, 17 April 2006). Occasionally tourists make their own assessments of expenditure on websites for the guidance of others. Writing in May 2010 an Australian woman who had undertaken plastic surgery through Gorgeous Getaways in Kuala Lumpur, observed: I had a tummy tuck & liposuction last July. For the first week out of hospital I spent very little money as I was not very mobile & not

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hungry. I ate cup noodles & salad. I know not very healthy! As most of the hotels GG recommend have kitchens you can do some food shopping before the operation & then you do not need to go out to restaurants. Food is quite cheap in KL compared to Australia & you will find food that you recognise in the supermarkets. KL is fantastic for shopping & taxis during the day are very reliable & cheap. They are nasty at night though as they charge you double because they know it is dark & you will not want to walk to the hotel :-( The market in China Town is a must see. You will be able to buy copy designer handbags, sunglasses, shoes etc. It is a lot of fun! On my trip over last year I spent about [US]$500 over the 2 weeks. I am not a big spender but I did buy some clothes! (Gorgeous Getaways’ discussion board, May 2010)

That ignores hotel and travel costs, and the cost of medical care, but indicates that even cautious tourists, and those from impoverished countries such as Yemen (see p. 119), may spend significant sums simply because they stay quite a long time. Some spend much more. Treatment Abroad (2007) estimated that in 2007 British medical tourists spent an average of £3753 abroad (with dental tourists spending £4189 per head and cosmetic surgery tourists spending £3392) so that overall overseas expenditure amounted to about £375 million. A year later they found that some 11% of dental tourists and 9% of elective surgery respondents spent over £10,000 overseas. A substantial proportion of expenditure is outside the health-care system. Beyond direct tourism expenditure (some of which is invaluable foreign exchange) and job creation, inside and outside the health sector, other benefits include the possibility of return visits, after a taste of the country has been acquired, and the diffusion of information to other potential visitors. Outside the health and tourism sector there may be some trickle down of revenue into areas of the economy, such as agriculture, though tourism sectors in developing countries are particularly prone to the leakage of local expenditure. In some places the impacts of medical tourism are visible. Around Bumrungrad hospital, where many patients are

from the Gulf and elsewhere in the Middle East, a small ‘ethnic ghetto’ – Little Arabia – has emerged where hotels, travel agents, restaurants and stores are oriented to a Muslim clientele (Fig. 7.2). Palestinian restaurants jostle with Pakistani restaurants, halal food is widely advertised, some hotels are almost exclusively occupied by a Gulf clientele of relatives and recuperating patients, and Arabic-speaking travel agencies and stores meet other needs (Chapter 9). While some such economic activities are owned by migrants from those countries, many are owned by Thais or leased by them, generating a considerable local income. Dental tourism has substantially transformed Los Algodones, a Mexican town of just over 4020 people and between 200 and 300 dentists, within walking distance of the US border (Hyo-Mi et al., 2009), and close to retirement townships in America. Wikipedia recorded in June 2010 that: The popularity of both inexpensive prescriptions and medical care catering to Canadian and US senior citizens have prompted a virtual explosion of pharmacies and dental offices which have largely displaced a great deal of the open-air shops and restaurants immediately across the border and have effectively shifted the town’s focus from tourism to medicine.

Similar processes have also happened at places like Piestany (Slovakia) and Sopron (Hungary). Most of the above income and expenditure estimates are gross generalizations based on uncertain numbers, unknown patterns of expenditure, and equally uncertain durations of stay. Yet there is no doubt that medical tourism has become a significant economic niche. It is scarcely surprising that plastic surgeries in Costa Rica are locally known as cirugias de oro (surgeries of gold) though, both there and in Panama, where the ratio of medical tourists to the local population is said to be high, there are no estimates of the economic significance of medical tourism. However, for small countries like Costa Rica and Singapore, where numbers seem substantial, and growth is occurring, the national economic effects may be very significant, while some local effects are even more substantial.

The Economics of Medical Tourism

Fig. 7.2. Bangkok streetscape, Little Arabia, March 2010.

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Cutting Costs Even during the GFC there was surprisingly little indication that medical tourism had declined, other than for some movements from the USA to Latin America. However, perhaps somewhat remarkably, the GFC benefited Central America as many North Americans found it even more difficult to pay for health care at home and increased numbers went overseas. The numbers of international medical tourists at Bumrungrad fell significantly following the GFC as they did elsewhere in Thailand. Similar unrest a year later brought further declines with the largest private hospital operator experiencing a downturn of 20% in the number of overseas visitors, especially from Europe and the Gulf, compared with the previous year, and a second group experiencing a 10% decline (Wiriyapong, 2010). On its web page BIH was forced to warn international patients against travelling to Bangkok. However, in Australia during the financial crisis (in a country where its impacts were well cushioned) the number of ‘dental tourists’ going overseas through one agency actually increased from a couple a week to six, as people were increasingly unable to afford domestic dentistry (Shanahan, 2009). Both within and outside times of crisis economics has been a crucial influence on medical tourism. Economic issues have been influential for both the supply and the demand in medical tourism. Countries have sought to participate based on economic disappointments in other sectors (Chapter 4) and comparative prices

have structured travel and choice of provider. Insurance companies, and even national health-care systems have increasingly gone global, in the search for cheaper (and quicker) treatment, and hierarchies of destinations have emerged based on cost and quality. Yet geography, culture and personal contacts moderate any crude notions of economic determinism, and destinations and durations are influenced by multiple factors. As the General Manager of Singapore’s National Healthcare Group has said: ‘Cost should not be the deciding factor in selection, but more emphasis should be placed on accreditation, clinical outcome indicators, affordable healthcare, and PEST (Political, Economic, Social and Technological) factors’ (quoted in Chan, 2007: 49). If the economic benefits from medical tourism have proved elusive to quantification they are none the less substantial and account for the enthusiasm of many countries to participate and, correspondingly, for growing attempts by some source countries to discourage mobility and retain patients. In some circumstances economic benefits have seemingly even overwhelmed ethical considerations, especially in the poorest countries, anxious to establish profitable ventures, but not easily able to compete in terms of cost and quality. Finally, political and economic factors have influenced and stimulated the privatization of medical care, and the concentration of financial and human resources in this sector, perhaps to the disadvantage of other sectors and some geographical regions. These complex questions are examined in the following chapter.

8 Extremes, Ethics and Inequality

The first task of the doctor is … political: the struggle against disease must begin with a war against bad government. (Foucault, 1963: 33)

Medical tourism has raised complex ethical questions, in terms of the acceptability of particular forms of medical treatment and through broader questions about the impact of medical tourism on local access to health care. That is not surprising; medical practice in any form is open to more ethical considerations than most forms of welfare and service provision. Ethical questions have largely centred on two extremes: (i) the ‘death tourism’ existing in a few highly developed countries where euthanasia is practised and is available to visitors (which, for some, extends to overseas abortions); and (ii) organ transplantation (and surrogate parenthood) that are perceived as highly exploitative of poor residents of poor countries. However, most cosmetic procedures, even seemingly trivial activities such as teeth whitening (where there are issues surrounding the controlled use of strong chemicals), have raised some ethical questions, mainly focused on standards, safety, information disclosure and legal liabilities, alongside familiar issues of reliability and ‘value for money’. Cosmetic surgery has also been criticized for being concerned with modifying appearance rather than health or longevity, while ‘pregnancy

tourism’ or ‘birth tourism’, where women move to give birth to their children in countries where citizenship is particularly coveted (Bookman and Bookman, 2007: 42), is opposed for quite different reasons. The ethics of media depictions of body shapes and invocations to change have also been questioned. Although euthanasia, transplantation, stem cell surgery and surrogate parenthood have raised most questions, and are discussed in some detail below, they are not, however, the core of medical tourism. In the broad ambit of medical tourism, patients are likely to be ‘right’, even if they are young or seek procedures such as gender reassignment or euthanasia. Nor are they necessarily accorded adequate counselling, as medicine meets market demands rather than adheres to standards. Some countries that have taken the lead in medical tourism, such as India, Malaysia and the Philippines, are not known for strong regulation or oversight of health care. Gender reassignment surgery raises complex issues concerning the pathologization of transsexuality (see Aizura, 2009) while variants of cosmetic surgery have quite different connotations across cultures. Going offshore, often long distances, for procedures that are banned or discouraged at home poses certain basic ethical and moral questions, which may also be directed at local practice.

© CAB International 2011. Medical Tourism (J. Connell)

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In a wider context the development of medical tourism raises ethical and practical questions at different scales over the appropriate use of medical resources, whether these are hospitals or skilled health workers, when such resources may be in short supply nationally, and thus whether it may distort national health priorities at the expense of private gains. Such an orientation towards foreigners who can afford to pay, perhaps at the expense of local people who cannot, parallels the rise of exotic spa resorts oriented to a luxury market and requiring local obsequiousness (Chapter 3) and raises similar questions about tourism, ethics and inequality. Otherwise the ethical concerns raised by medical tourism are rather different from those in most other tourism contexts. Although, as Henderson points out, and is evident here, tourism ‘may not always be conventional … when the physical condition of the tourist severely restricts mobility. Anxiety may also preclude the taking of pleasure in common tourist pastimes such as sightseeing’ (2009: 208). While relief may accompany success most procedures discussed in this chapter have limited relationship to tourism.

Transplant Tourism In most developed countries demand for organ transplants is growing much faster than the supply of organs donated through traditional means, hence a small but growing number of the world’s poor are providing body parts, especially kidneys, for sale. This shortage means a lengthy and uncertain wait for critically ill patients or the resort to overseas transplantation, which may mean either trafficking in organs or their being obtained in dubious circumstances from unwitting, unwilling or dead donors. As many as 15% of at least 10,000 American patients die each year while waiting for liver transplants (Rhodes and Schiano, 2010: 4) so that recourse to overseas sources is unsurprising, and similar situations occur in other developed countries. Demand for organs has intensified as populations age and hypertension and obesity become more common. A parallel

process, ‘xenotourism’, involves animal-tohuman transplantation, notably of pig insulin, and raises issues of trans-species viral infection (De Luca, 2006). Transplant commercialism, the trafficking of organs across international borders, accounts for an estimated 5–10% of kidney transplants, despite its contravening international conventions and creating political stigma, while ‘transplant tourism’ involves travelling for overseas transplants. Most overseas transplants take place in relatively poor developing countries (ScheperHughes, 2000, 2005) and are highly controversial because of the potential negative medical impact on the ‘donor’ and, in some countries, their excision from executed prisoners. Durban and Johannesburg, for example, were meeting points for such surgery on ‘transplant tourists’, until the South African government broke up a trafficking ring. It has been described by some as a ‘repugnant market’, outside the range of moral market transactions, though trade bans might also be seen as immoral where dying patients await organs. A similar phrase might also cover aspects of reproductive tourism, where market values challenge social values. Transplantation brings together patients on long waiting lists, the ‘parsimonious payers of their expensive dialysis (states, insurers and providers)’, travel and tourism industries and ‘the impoverished men and women who can sell nothing but their body parts’ in an extreme form of ‘neoliberal globalization’ (Epstein, 2009: 134). This conjuncture raises concerns over the morality of national political economies where individuals are forced to resort to considering transplant commercialism as a valid economic option. In extreme cases vendors have been illegally transported across borders, as in the case of Brazilians taken to South Africa, whose kidneys were then given mainly to Israelis, after they had been given false promises over the money they would earn, the after-care and the aftereffects (Anon., 2006b). Despite some cultural variations, ‘the flow of organs follows the modern routes of capital: from South to North, from Third to First World, from poor to rich, from black to brown and white, and from male to male’ (Scheper-Hughes, 2000: 193).

Extremes, Ethics and Inequality

Significant legal and criminal issues are raised where this allegedly involves the illegal purchase of organs in countries such as India, China, Brazil and South Africa (Shimazano, 2007). Organs for transplantation have been removed without permission from executed Chinese prisoners (the source of about two-thirds of Chinese transplant organs), a situation that left the Chinese judicial system open to corruption by providing perverse incentives to increase the number of executions (Rhodes and Schiano, 2010). Transplant recipients are from developed countries, though even there the high cost of transplant surgery, usually several thousand dollars, has limited the number of beneficiaries. In the mid-2000s estimates suggest that around 400 Americans, mostly from New York and California, received transplants abroad. Out of a sample of 44 patients travelling outside the USA for transplants, all but five travelled to regions of their own ethnicity for treatment; this included 14 who went to China, six to Iran, four to the Philippines, three to India and one each to Pakistan, Turkey, Peru, Mexico, Egypt and Thailand – a classic example of diasporic medical tourism since only one was described as ‘American’ (Gill et al., 2008). Exactly the same was true of a second smaller group of kidney recipients from the USA who followed similar ethnic ties (Canales et al., 2006). Few of the limited benefits have trickled down to impoverished vendors, who are often the victims of manipulation, fraud and physical violence, and whose health and financial status tend to worsen after the transaction, as in India, Moldova, Pakistan and the Philippines (Scheper-Hughes, 2005; Naqvi et al., 2007; Turner, 2007a; Epstein, 2009). Vendors are exploited; the poor have less chance of receiving organs and transplantation success is limited in difficult medical and social circumstances where care in challenging medical contexts is probably substandard (Rhodes and Schiano, 2010; Turner, 2010). In the Philippines most kidney vendors were young men below the poverty line, from impoverished villages or metropolitan squatter settlements, with dependent relatives and a ‘desperate need for cash’ (Mendoza, 2010: 259). Simultaneously patients in developed

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countries die because organs are locally unavailable for transplant, posing global ethical questions that cannot easily be resolved; moreover those who are least able to access transplants in developed countries may be ethnic minority groups in depressed and less affluent regions of the country (Davies, 2006). In a particular form of more general criticisms of medical tourism, through meeting the needs of overseas tourists, transplant tourism has excluded both local patients on waiting lists and the public services that should have treated them. More than a million people in China have been estimated to need organ transplantation, and the country has several transplant centres, but demand significantly exceeds supply so that the principal beneficiaries are wealthy patients (Rhodes and Schiano, 2010). As some available organs are sold to transplant tourists so the proportion available to poor Chinese is limited. A similar situation occurs in Pakistan and India. Transplant tourism is also problematic since failure rates are high, and morbidity can increase, due to poor vendor screening, selection and matching in the supplying country, alongside inadequate record keeping, while patients may also contract transmissible infections. One man who had undergone a renal transplant in India initiated a hepatitis B infection in two London hospitals (Harling et al., 2007). Patients who receive organs from living relatives have better outcomes than those who receive commercial transplants, whether from live donors in India or deceased donors in China (Epstein, 2009: 134; Rhodes and Schiano, 2010: 6). This raises questions over the treatment of returning tourists that are substantially greater than for other forms of medical tourism, because of the extent of their needs and the unethical basis of the operation. Patients who had received transplants in China were perceived less favourably by doctors in their home countries (Biggins et al., 2009). Transplant tourism is also said to have had a negative effect on donation rates in developed countries, further marginalizing people who cannot ‘outsource’ themselves, raising financial burdens on patients and insurance companies and intensifying global competition for patients,

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organs and investments in transplant services, a process that disadvantages everyone (Epstein, 2009: 135). But the main losers are those who sell organs. Criticism has grown, with those countries that hitherto had liberal policies on transplant tourism, especially China, Pakistan and the Philippines, becoming more critical of organ sales. In 2007 Pakistan banned organ sales and the Philippines banned transplants for foreigners. Patients then travelled to Egpyt as former destinations were no longer possible (Yakupoglu et al., 2009). However, legislation (such as that in China where foreigners were excluded from organ transplant programmes in 2009) has sometimes been honoured in the breach, and some activities driven underground. In a country where an illegal trade in babies exists illegal organ trade may not be so extreme. In 2009 the Philippines was still advertising its ‘organ transplant bazaar’ (Turner, 2007a; Mendoza, 2010), but a year later set up a nationwide organ donor register in a bid to stop the poor selling their kidneys, for as little as US$3500, to make ends meet (ABC News, 25 June 2010). Although sales of organs have been banned in India since 1994, a black-market industry emerged and estimates suggest that illegal kidney transplants remain common, often through the duping of poor Indians (Sydney Morning Herald, 2 March and 13 March 2010). Consequently in various contexts patients and hospitals have been warned against dubious practices and MTCs and others have emphasized that such activities are not condoned. In India the IndUShealth company stated in 2010 that ‘Transplants are not performed unless the patient makes arrangements to bring a matching, consenting donor who is known to the recipient and can establish his/her legitimate desire and reason to offer his/her organ to the recipient’ (IndUShealth, 2010). At much the same time, at a national level: The Japanese government recently warned hospitals from assisting with transplant tourism to China … because of China’s lack of transparency and use of prison inmates in obtaining organs. The Japanese Ministry of Health, Labour and Welfare conducted investigations of 247 hospitals in Japan,

finding that doctors in five of the hospitals, including several in Tokyo, were found to have aided patients by providing their medical histories to agencies who could arrange organ transplants overseas for them. The Ministry of Health warned the hospitals not to assist in illegal organ trafficking. (International Medical Travel Journal, 2010)

Regulation may eventually reduce this particular form of globalization and demand more effective national responses (and higher donor rates) in developed countries.

Reproductive Tourism More than most forms of human behaviour, reproduction appears a private and intimate affair, yet it is bound up in national policies (for example towards abortion, provision of contraception, family sizes and one-child families). Partly in response, reproduction has ‘gone global’ through transnational adoption (recently involving prominent film and popular music stars), fertility treatment and reproductive tourism, in what has been described as a ‘global market of commercial fertility’ (Prasad, 2008: 37). Reproductive tourism occurs where people travel to access such reproductive technologies and services as: (i) IVF; (ii) sperm and egg donation; (iii) sex selection and embryonic diagnosis; and (iv) surrogate parenthood (Jones and Keith, 2006; Mulay and Gibson, 2006; Martin, 2009). It also includes the converse: (i) abortion; (ii) contraception; and even (iii) vasectomies. Technological change has enabled a host of decisions over many possibilities, from ‘testtube babies’ to ‘designer children’ (notably by sex), with cloning perhaps waiting in the wings. Fertility centres exist in several countries, from the USA and Israel to small island states such as Cyprus and Barbados. Unlike most other contexts where major ethical principles occur, some standard tourist potential is apparent (see Chapter 9) and it has even been called a ‘procreation vacation’. Israel is a leading fertility tourism destination for IVF, with the highest global ratio of fertility clinics per capita, but the USA and Spain attract many Europeans because of higher success

Extremes, Ethics and Inequality

rates and lenient regulations. Patients travel from countries like Germany and Italy, which are very restrictive over the number of eggs which may be fertilized and of the use of donor eggs, or from Canada, where it is illegal to pay donors for eggs or sperm, or from countries like Costa Rica where it is virtually impossible to obtain eggs (Bookman and Bookman, 2007: 82). Countries such as the UK and Sweden, who only permit nonanonymous sperm donors, have a resultant shortage of donors and long waiting lists (as long as 6 years or more in the UK in 2009), and are more likely to be markets for overseas IVF procedures. Over 250 Swedish sperm recipients annually travel to Denmark for insemination, partly because the insemination of single women is permissible (Ekerhovd et al., 2008). Parents seeking a particular gender for their children tend to go to the USA; parents from Australia, where gender selection is illegal, mainly travel there and face a starting price of at least US$25,000 (Chatfield, 2009). Rather differently therefore from most forms of medical tourism, fertility tourism is centred primarily within developed counties that are the main sources and destinations, involving high costs, and perhaps as many as 20,000 couples a year. ‘Fertility tourism’ involving access to overseas reproductive technology, enables cheaper, more efficient or comprehensive services, and bypasses restrictive regulations, long waiting lists, legal constraints and sometimes high costs. Such ‘global fertility tourists’ have consequently been seen as ‘desperate to break free from not only financial but also legal and ethical constraints’ (Prasad, 2008: 37). As the website of one Spanish clinic states: ‘The present law governing assisted reproduction in Spain allows treatments to be carried out here which are restricted in other countries’ (quoted in Martin, 2009: 251). Countries seeking to establish medical tourism have offered procedures that would not pass scrutiny in many contexts; thus Georgia permits procedures that are banned in Europe: surrogate egg donation and a database of surrogate mothers with photographs, a practice that would breach privacy restrictions in many countries (see pp. 52–3). What is possible in particular

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countries varies considerably and, even within Europe, there are acute differences between states, while attempts at regional regulation have been unsuccessful. Germany imposes strict limitations on access to reproductive technologies, whereas Israel offers strong support, and Ireland has major constraints on abortion. Belgium and Italy have little legislation on assisted reproduction and are popular destinations within Europe. That Spain and Slovenia are both significant destinations for egg procurement indicate that there is no necessary correlation between Catholicism and lack of reproductive support. New reproductive technologies raise a series of ethical questions, first around individual and state responses to liberty, rights and autonomy (Blyth and Farrand, 2005; Voigt and Laing, 2010). Diagnostic tools that can screen for genetic disorders, or simply for sex, raise questions of eugenics, screening for disability and gender inequalities (Martin, 2009: 252). Third-party reproduction, such as surrogacy and sperm, embryo and egg donation, raise additional questions over parental rights and the commodification of bodies and babies, which have not been resolved in national contexts where they are permissible, even without venturing across international borders and into different cultural terrains. Access to IVF, abortion and contraception also raise religious and moral questions over ‘unnatural’ procreation and its termination, with some parallels in stem cell therapy (see below), and over who might have access to technology (such as same-sex couples, older people or individuals without partners). By offering distinctive procedures that are in demand, countries that have not otherwise gained from medical tourism, such as Georgia and Vietnam, have attracted some visitors. Ukraine has also become a minor player, by offering IVF services to gay couples and single parents, while age is no barrier either there or in India, with twins being born to a NRI couple resident in Britain with a combined age of 131 (Prasad, 2008: 37). Surrogacy is primarily an Indian phenomenon. India has been seen as an ideal destination since Indian women rarely smoke and drink, and it more obviously offers ‘First World medical services at Third World

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prices’ (Hodge, 2010: 13). Accessing surrogate mothers in India assures the right of the intended parents to a supply of Asian donors, cheaper services, multiple embryo transfers and sole parental rights, the last especially being impossible in home countries such as the UK or Australia. Conversely the surrogate parent has restricted rights, fewer than available in the source countries, in a high-risk context with perhaps limited economic gain and lost emotional attachments (Martin, 2009: 254). Commercial surrogacy has been legal in India since 2002, as it is in many countries including the USA, but it has come closer there to being ‘a viable industry’ rather than ‘a rare fertility treatment’, so that ‘it could take off for the same reasons outsourcing in other industries has been successful: a wide labour pool working for relatively low rates’ in almost every large city, while prompting concern over ‘baby farms’ and ‘wombs for rent’ at very low cost (Dolnick, 2008: 36), so transforming women into child-producing commodities (Cohen, 2009). Various Indian companies exist, some with evocative names such as ‘Babies and Us’ and ‘I wanna get pregnant’ (Whittaker, 2008). At one small town in India, Anand (Gujarat), coincidentally known as ‘the milk capital of India’, early in 2008 over 50 women, mostly poor villagers, were pregnant with the children of couples from the USA, Taiwan, Japan, Australia, the UK and elsewhere, at least some of whom were diasporic Indians (Dolnick, 2008). Since then surrogacy has expanded rapidly with an estimated 350 providers in India, some three times the number in 2005, enabling about a thousand attempts a year, a third from outside India (Cohen, 2009). Income generated from this in 2009 was estimated at as much as US$445 million (Hodge, 2010). However, in 2010 the Australian government announced that it would not guarantee citizenship to surrogate babies born in India and Australia Surrogacy, an MTC that organizes international surrogacy, stopped working in India because of massive delays and citizenship requirements that had become too onerous (Peatling, 2010). Ethical issues became merged with legal and constitutional questions to challenge the future of Indian surrogacy, at least in the case of Australia.

Surrogate mothers may earn significant sums, rising from about US$2500 in 2004 to over US$10,000, in big cities like New Delhi (Wade, 2009). Surrogate mothers in India earn less than 10% of the overall expenditure on surrogacy, and their incomes are about 10% of those of surrogate mothers in countries like the USA (Hodge, 2010). Studies of surrogacy suggest, however, that the majority of surrogates are satisfied with their surrogacy experience, do not experience emotional attachments to the surrogate child, feel altruistic about surrogacy even years afterwards, while earning incomes that are several times an average annual rural Indian wage. Fears of surrogate mothers keeping babies have been unfounded. During surrogacy women are usually given superior nutrition and medical care and housed in monitored circumstances, in part to escape a stigma of surrogacy. Some women, however, may be forced into surrogacy by their husbands and most volunteer only to escape grinding poverty. Whether this will pose difficulties for some of those children who are visibly of somewhat different ethnicity from their parents remains to be seen. Otherwise debates over surrogacy parallel those over transplant tourism. Despite the Indian focus, growing global complexities have emerged from the intricacies of surrogacy and reproduction: Rudy Rupak, president of Planet Hospital, a California-based medical-tourism company, says that in the first eight months of this year he sent 600 couples or single parents overseas for surrogacy, nearly three times the number in 2008 and up from just 33 in 2007. All of the clients this year went to India except seven who chose Panama. Most were from the U.S.; the rest came from Europe, the Middle East and Asia, mostly Japan, Vietnam, Singapore and Taiwain ... because of growing demand from his clients for eggs from Caucasian women, he’s started to fly donors to India from the former Soviet republic of Georgia. A Planet Hospital package that includes an Indian egg donor costs [US]$32,500, excluding transportation and hotel expenses for the intended parent or parents to travel to India. A package with eggs from a Georgian donor costs an extra [US]$5,000. (Cohen, 2009)

Extremes, Ethics and Inequality

Even more complex globalities are evident. In 2007 a single Russian woman, a management consultant born in Pakistan, first sought to adopt a child in Germany, where she had citizenship. That was unsuccessful and she moved to the UK to take advantage of the country’s more liberal attitude to single women who sought IVF. After 3 years without success she purchased sperm online from a Danish sperm bank retailing in New York, since purchasing in the UK would have involved a 3-year wait and considerable expense, and the sperm was used to fertilize the fresh eggs of an Indian woman in Mumbai. She was thus due to have a child of DanishIndian genetic origin, but knowing little of the two individual donors (Prasad, 2008). Technological change has transformed the mechanics, location and ethics of reproduction. With rare exceptions, such as Malta, throughout the northern hemisphere abortion is legal in certain circumstances, but availability ranges from ‘on demand’ to severely constrained as in the mainly Catholic nations of Ireland, Poland and Mexico. Where abortion is illegal or carries heavy social stigma, pregnant women may travel to countries where they can terminate their pregnancy, a process itself often stigmatized as ‘abortion tourism’. Thus Polish women seeking to escape restrictive abortion laws travel to Ukraine or Belarus to terminate pregnancies, though women with higher incomes travel to nearby EU countries, such as the Czech Republic and Slovakia, or more expensive Germany, Belgium and Austria. However, in 2007 as many as 31,000 Polish women had abortions in the UK, reportedly a 30% jump in number from previous years (Bloom, 2008), but some may have been resident in the UK. Just as in other components of medical tourism, reliable statistics are not surprisingly unavailable, though it has been estimated that in 2007 approximately 200 women per week were travelling to the UK from Ireland and Northern Ireland, and that in 2006 just one Spanish clinic near the Portuguese border saw 4000 Portuguese women come to terminate pregnancies (Bloom, 2008). Several Western European countries have been destinations for women seeking abortions, notably Sweden and Spain, with

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Barcelona described as ‘Europe’s abortion mecca’, where people from much of the continent could evade restrictions on late-term abortions. Class and socio-economic status influence the ability to migrate and gain access to safe abortions. Mexican women travelling to the USA for abortions were typically well educated and wealthy, came from Mexico City and more prosperous states, did not have to cross the border illegally and could avoid clandestine and self-induced procedures. Poor women in Mexico, Ireland and Poland were often in a socio-economic position where they could neither migrate nor gain safe abortions (Bloom, 2008). While such mobility has been strongly criticized in source countries where it breaches widely held moral positions and national legislation, it has also been criticized in destination countries for both the negative connotations of ‘abortion tourism’ for national identity, as occurred in Spain in the late 2000s, and the local costs. In 2010 there was resentment in the UK of an advertising campaign by a pro-abortion group in Poland that mimicked a Mastercard advertisement and offered ‘For everything you pay less than an underground abortion in Poland’. Resentment centred on the view that foreigners used medical tourism, in this and other forms, to take free advantage of the NHS which was estimated to have cost it £200 million a year (Borland, 2010), so giving rise to a degree of moral panic over the ownership and use of national services (Eades, 2010). Similar moral panics have occurred in places as diverse as Thailand, New Zealand and Australia (e.g. Parnell, 2008). In certain circumstances therefore particular variants of medical tourism have been seen as being at some cost to national populations in lost income, or through displacing local people, rather than as a boost to the national economy (see below). In its distinctive form ‘abortion tourism’ has clear parallels with other forms of medical tourism. The rich can afford to travel further for care, while the poor are least likely to travel, or simply cross nearby borders, and may face complications (of various kinds) from not gaining access to adequate, or any, services. Destinations are thus governed by

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cost. Anonymity is also important. However, abortion tourism is largely confined to middleincome and developed countries and is unrelated to diasporic tourism. Contraception is globally more accessible than abortion, and moral objections to it are weaker and less widespread; however, though some techniques and supplies are unavailable in many countries, demand can be considerable. Some MTCs thus advertise access to contraceptive services: Healthbase, in the USA, offers the implantation of intrauterine devices, or their removal, in Mexico, Costa Rica or India. ‘Birth control tourism’ appears to have been described just once, where in the early 2000s the Mayor of Manila issued a total ban on contraceptives and urban residents had to move elsewhere in the Philippines for access (RH Reality Check, 2010). The extent of international travel for access to contraception, or for vasectomies, is unknown, but it plays some part in overall medical tourism.

Stem Cell Therapy Stem cell tourism has similarly become a new phenomenon, with companies marketing injections of stem cells as life-changing treatments and miracle cures for everything from Parkinson’s disease to spinal injuries: diverse ‘last-chance’ solutions. Embryonic stem cells are much valued for their ability to grow into any other kind of tissue, but their use is controversial and the basis of ethical debates because a human embryo must be created to obtain the cells (a situation that resulted in opposition to research, let alone therapy, in some countries, including the USA). A further more pragmatic concern is that of the propensity of embryonic stem cells to form tumours, which although normally benign can be cancerous, while no peer-reviewed publications yet support the validity of any embryonic stem cell treatments. None the less proponents of stem cell therapy have promised improvements in, or even cures for, several neurological or developmental disorders, such as Down’s syndrome, that have yet to be definitively proven, despite apparent individual successes.

Stem cell treatments target patients with a range of heart, nerve and immune disorders but adult stem cell treatment (the more established precursor of embryonic stem cell therapy) involves treatments for cancers and leukaemia. Both forms of stem cell treatment remain somewhat experimental. Embryonic stem cell therapy largely takes place in countries with ‘regulatory gaps’ or very few regulations, such as China and Mexico, and costs at least US$10,000. Korea, Singapore and the Philippines have also been key players. As with organ transplants, regulations have been introduced in several countries that are sources of stem cell therapy but are often ignored. In 2007 the Indian Council of Medical Research adopted guidelines that discouraged stem cell therapy but they were legally unenforceable. In mid-2010 the Costa Rican Ministry of Health closed down the ICM Clinic that had given stem cell therapy to more than 400 non-Costa Rican patients since it opened in 2006, on the grounds that there was no scientific support base for the therapies used there. In 2010 Chinese institutions were forbidden to commercialize stem cell treatments without proper clinical trials hence, just as with transplant tourism, global regulation is increasingly tightening. Particular media stories have continued to describe unusual successes. In an article sub-titled ‘Lax rules attract patients to pricey MD who dispenses “miracles” – or malarkey’, a New Zealand patient received stem cell therapy in Delhi and, after a decade in a wheelchair following a spinal cord injury, gained sensations in his legs and was able to stand up and walk. But: The apparently life-changing therapy he was receiving is untested, unproven, unmonitored and highly controversial. With his trip to Nu Tech MediWorld in the Indian capital, Mr. Thomson became one of thousands of desperate foreigners, including dozens of Canadians, who’ve flocked to Indian stem-cell centres, seeking therapies prohibited in their own countries. With legislation held up indefinitely in its parliament, India has in effect no restriction on what clinics such as Nu Tech can promise. (Nolen, 2010)

Extremes, Ethics and Inequality

Similar stories offer other apparent successes from China, India, the Dominican Republic and elsewhere, but evaluations of such claims have been negative or inconclusive (MacReady, 2009). In India at least, stem cell patients include two groups: (i) one from developing countries such as Pakistan, Sri Lanka and some in the Middle East, where stem cell therapy is absent; and (ii) a group from developed countries where the therapies are possible but not available because of stringent regulations (Patra and Sleeboom-Faulkner, 2009), long waiting lists and high costs. Stem cell procedures, with the exception of bone-marrow transplantation, remain experimental and most providers have been unwilling to subject their clinical results to scientific scrutiny. Some hospitals, such as Bumrungrad, have not incorporated stem cell procedures since they have not gone through peer review (Anon., 2010c). However, stem cell research centres are invariably anxious to recruit patients and continue research, a practice that raises further ethical questions. It is not only patients who travel in search of innovative surgery, but some scientists travel to countries with more permissive regulations on stem cell research: perhaps a form of ‘science tourism’ (Schirber, 2006). In matters of health, desperation seeks out innovation and experimentation, and even unproven possibilities.

Death Tourism The most extreme forms of travel, where the word tourism fits least easily, are those of patients beyond cure who are seeking euthanasia. In recent years this has brought a stream of people to Switzerland, may have taken ‘death tourists’ to the Netherlands and for a time in the 1990s took Australians to the Northern Territory (the only part of the country where euthanasia was briefly permissible) and, similarly, Americans to Oregon. Since 2007 Switzerland has come under considerable international criticism for enabling euthanasia, or what was derogatorily called ‘suicide tourism’, a term that sought to deny anything pleasurable. The contemporary state and its citizens have greatly extended control over death, in

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a biotechnical sense, in debates over eugenics and the criteria of death and in a marginal increase in the willingness to countenance euthanasia. Hastening death remains complicated by complex debates and diverse attitudes to: (i) the sanctity of life; (ii) the measurement of quality of life; and (iii) the role and effectiveness of both palliative care and the state (Norwood, 2007; Seale, 2009). Euthanasia, the administering of a lethal drug or withdrawing existing lifesupport treatments, is legal only in very few places, notably Switzerland, but also the Netherlands, Luxembourg and Belgium. That legality has resulted in ‘death tourism’, mainly to Switzerland, of patients whose diseases appear incurable and who may be terminally ill, from countries where euthanasia is impossible so that they may commit suicide, without themselves or more particularly their friends and relatives committing a crime. A rather separate version has taken people from many countries, but especially the USA, to Tijuana, Mexico, to buy such lethal drugs as Nembutal, that are illegal elsewhere. In Switzerland death tourism has been particularly associated with Dignitas, an organization set up in 1998 by a Swiss lawyer, and which seeks to act as a neutral party without financial or other interest in the deaths of its members. Dignitas provides foreigners with a Swiss doctor who, after seeing the patient once, will supply lethal drugs if the patient’s death wish appears the result of a ‘rational’ decision. By 2008 Dignitas had assisted about 840 people to die, 60% of whom were Germans, and about 100 of whom were from the UK. Many others were Swiss. Death tourism originates and concludes in the most developed countries, raises ethical questions about the morality of euthanasia, the ability of very ill patients to make rational decisions, the rights of others to interpret, enforce or assist in decisions and even queries the meaning of ‘developed’. Within Switzerland it has also been criticized for the image of Switzerland that it may portray. By 2010 Dignitas was charging about US$8500 to organize a suicide, to cover taking over ‘family duties’, including funerals,

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medical costs and official fees, but was being criticized as an economic beneficiary, beyond being a facilitator. Swiss politicians had become increasingly opposed to death tourism, as unethical and harmful to the image of Zurich, and some were demanding that groups such as Dignitas pay huge fines, about US$53,000, for helping anyone to die who had not lived in Zurich for at least a year: Normally people come to Zurich two or three days before they want to die. By saying people must live in Zurich for at least a year, we believe this will cut down the number of suicides dramatically. There needs to be an end to death tourism. We anticipate the fine will be passed on to the person committing suicide by the suicide organisation. Effectively foreigners will be discouraged from coming to Zurich to die. (quoted in the Sun Herald, 24 January 2010)

It was anticipated that a referendum would be held on the proposal in 2010, following intense debate on the morality and rising numbers involved in suicide tourism, and the uncertainty of evaluating patients’ wishes. Though ‘death’ or ‘suicide tourism’ may extinguish pain and suffering for the individual, it has ramifications for families – who may or may not support or condone such activities – and is especially complex in assisted suicide. Moreover it presents wider ethical questions for society, evident in significant political and philosophical debates wherever death tourism has occurred, and especially for the medical profession and palliative care. Quite differently there are cultural and ethical versions of ‘death tourism’ or ‘diaspora tourism’ where individuals return ‘home’ to a familiar cultural context for the last months or years of their lives. Many Mexicans, for example, return to Mexico, not to die or to hasten death, but to live in a familiar and supportive setting where that will occur, especially when they are no longer able to work, and nostalgia for once familiar places and people has renewed significance. Even in death, and perhaps particularly here, therapeutic landscapes are important.

Pilgrimages in Hope? In each of these areas, despite the wider presence of medical tourism in a neo-liberal world of reduced regulation and enhanced freedom of choice, state policies, global markets and technological change are entwined within complex debates over moral and ethical dilemmas in a globalizing world, where cultural differences remain significant. However, relatively few people are involved in most of these unusual categories. Medical tourism functions as a moral safety valve for ‘extreme medical tourists’, yet also takes some patients beyond regulatory systems usually designed to protect them, in circumstances where desperate people with severe conditions are willing and eager to spend substantial sums for a ‘last chance to stretch their lives and to spend money’ (Patra and Sleeboom-Faulkner, 2009: 160) even despite uncertain outcomes in new forms of alternative medicine. It is the right of anyone to travel in search of innovative cures in the hope of finding the holy grail of recovery, even where experimental procedures are yet to be adequately verified. Somewhat similarly sick people travel thousands of kilometres and invest enormous sums in pilgrimages to places such as Lourdes and Fatima, perhaps in the same hope of fantastic last-resort cures. Desperation stretches the boundaries of legality and credibility. Particular cancer therapies, legal in some countries, are illegal in others. An Australian patient, deemed incurable, spent over A$30,000 in search of an illegal cure in Italy, while strongly rejecting any notion that this had any relationship to a holiday (Andrews, 2009). Patient validation of success may be the result of a placebo effect or simply a willingness to be convinced of the positive outcome of an expensive but experimental treatment. Ethical debate is rather less common in developing countries where research continues and the evidence base on outcomes remains small or absent. In these contexts debates over the movement of people and services across international borders have a particular vibrancy and poignancy, where diseases may probably be incurable and patients unusually determined.

Extremes, Ethics and Inequality

Access to such distinctive forms of health care or therapy overseas has to some extent undermined and weakened the regulatory role of the state, like the bulk of medical tourism, despite increased attempts at control. Reproductive tourism, like stem cell tourism, organ transplants and even suicide tourism, ‘reflects a conflict between the individual [and households] and the nationstate’ (Martin, 2009: 257), which the privileged and affluent can escape. Moreover transplant tourism and surrogacy exist because poverty and inequality also exist. In these extreme situations where access to very limited and sometimes experimental provisions is expensive the extent of inequality is greatest. Scheper-Hughes consequently writes of ‘biopiracy’ and questions whether ‘those living under conditions of social insecurity and economic abandonment’ are really the owners of their bodies – a fundamental premise of Western bioethics (2000: 197). This commodification of the body and the resultant ‘bionetworking’, both legal and illegal across international borders, has created a new ‘global geography of human experimentation’ (Petryna, 2002). In extreme form these unusual and challenging variants reflect more subtle debates over the ethics and impacts of medical tourism, so much so that in all these cases, ‘tourism’ is used pejoratively by the broad medical profession precisely to deride something that is very different from any standard concept of tourism, rather being in every sense ‘deadly serious’. To describe such hopeful and desperate journeys as tourism would be to thoroughly trivialize their rationale.

A New Inequality? Health-care systems in developing countries, some of the main destinations of medical tourists, are notoriously uneven, and often becoming more so, in circumstances where both urban bias and the decay of remote and regional facilities have long occurred. Such centralization has been hastened by privatization, stagnant budgets

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for health expenditure and, possibly, by medical tourism. Yet, despite considerable concern, ‘most of the literature is “data free” and based on theory, assumption and conjecture’ (Lautier, 2008: 102), detailed analysis of the national impacts of medical tourism is yet to occur and evaluations of its local social and economic effects are scarcely even fragmentary. There is, however, a gap between the promises, the branded corporate images of medical tourism and its practice, to the sometimes harsh reality of majority health care in particular countries. This is particularly evident in India where the divide between the public sector and the advancing private sector is epitomized in medical tourism and the emergence of corporate medical chains. In 2007 the website of Apollo, the largest national and international medical chain in India, advertised: With over 7000 beds in 38 hospitals, a string of nursing and hospital management colleges, and dual lifelines of pharmacies and diagnostic clinics providing a safety net across Asia, Apollo Hospitals is a healthcare powerhouse you can trust with your life. We unite exceptional clinical success rates and superior technology to match the best in the West with centuries-old traditions of Eastern care and warmth. Because at Apollo Hospitals we believe the world is our extended family – something our 14 million patients from 55 countries can warmly affirm. And by providing patient care beyond compare, we dream of a healthy, happy planet for all. (Apollo Hospitals, 2010)

Apollo Hospitals thus provides something of the new face of medical care – a transnational phenomenon that goes on in a pleasant, modern context, and is linked to tourism in a new structure of horizontal integration between hospitals and hotels. As Tourism India noted in 2006: ‘So the wheel has come full circle. Instead of Western missionary docs coming to India to treat the poor now we have rich First Worlders buying medicare here.’ Even seemingly detached academic accounts have rhapsodized over Apollo, with total deference to their web page:

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Its history of accomplishments, with its unique ability of resource management and able deployment of technology and knowledge in the service of mankind, justifies its recognition in India and abroad … Apollo conducts itself in a conscientious manner in all transactions and deals with people professionally and transparently … Apollo’s patient relationship management programme is almost flawless … Apollo has developed over time unassailable brand equity. (George, 2009: 368–370)

And parallel eulogies exist in the pages of business management texts. Any flaws in public health should be carefully hidden, since they accentuate the problems of marketing medical tourism in India: The sight of the country’s overcrowded public hospitals, open sewers and garbage littered streets would unsettle most visitors’ confidence about public sanitation standards in India. Private health care providers would argue that foreigners can be sheltered from such nastiness. (Swain and Sahu, 2008: 2)

While India’s public-sector health-care and sanitation systems are indeed detached from medical tourism they are all part of a national political economy, and not independent from each other. Similar divisions and dichotomies occur elsewhere if not in such stark terms. Even within hospitals, as in Thailand, differences between the private medical tourism sector and the public sector can be considerable. Phuket International Hospital, for example, has an air-conditioned wing for medical tourists ‘with the sleek furniture and lush floral arrangements of a boutique hotel … flat screened TVs and views of manicured gardens’, but after the writer took a wrong turn she arrived ‘in the public ward, 40 degrees hot and packed with “real” people’ (Nash, 2009: 16–17). The two sectors are not designed or destined to meet and there is little evidence of benefits being transferred from the private to the public sector. Certain inherent negative consequences of medical tourism exist. Thus Bookman and Bookman argue simply that:

More often than not, in developing countries where medical tourism flourishes, basic health care for rural populations and the urban poor is rudimentary. A dual medical system has emerged in which specialization in cardiology, opthalmology and plastic surgery serves the foreign and wealthy domestic patients while the local populations lack basics such as sanitation, clean water and regular deworming. (2007: 7)

It is, however, questionable whether that duality is quite so rigid, whether there are no redeeming features of medical tourism and whether in regimes of privatization such groups would be marginalized and ignored in any case, as they have so often previously been. In an appropriate taxation regime it is possible that medical tourism can lead to improved public health, but no practices support this proposition. In the lone medical tourism guidebook that considers such issues euphoria reigns: in the Philippines ‘the income from medical tourism serves to underwrite health care for the poor’ and ‘virtually the entire medical system of Thailand is underwritten by its medical tourism services. Medical tourism throughout Asia is providing major gains in quantity and quality of healthcare to the local population’ (Gahlinger, 2008: 88, 35). Other sources are much less sanguine. While Indian private-sector hospitals argue that payments for medical care, and hotels and other services, will trickle down and benefit the economy as a whole, there is little real evidence of this, in the absence of effective taxation policies, and unless more revenue is allocated to public health systems the impact will be negligible (Chinai and Goswami, 2007: 165). Moreover, at the same time, national resources are allocated to promoting medical tourism, via the tourism industry, and accrediting hospitals where it occurs, while internal migration of health workers has been stimulated. Although ‘the private sector cannot be blamed for the failings of state-run health bureaucracies in developing countries, which neglected the poor long before medical tourists arrived’ (Anon., 2008a: 12), it contributes to the deterioration of conditions in the public sector, and both deterioration and duality extend far beyond India.

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Migration One direct outcome of medical tourism has been the more rapid growth of a private health-sector labour market in medical tourism destinations, as the economic benefits from employment in that sector became greater, with the consequent movement of health workers into the usually better-paid urban, private sector (Spitzer, 2009: 145), sometimes from rural and regional areas. Such migration has exacerbated existing regional inequalities in access to health care. India particularly, like several other medical tourism destinations, including Thailand, has a shortage of doctors (and sometimes nurses and other health professionals) to meet national needs. India has just four doctors per 10,000 people whereas the USA has 27, and accelerated international migration of health workers has meant that these numerical disparities are steadily increasing (Mudur, 2004; Connell, 2010). The movement of medical tourists away from better-served countries thus indicates that much medical tourism is a perverse flow in terms of overall national capacity. Since some part of medical tourism is a response to long waiting lists, which follow both the rise in demand for care and the challenge of developing priorities in developed countries, this demand and these waiting lists are partly being transferred to relatively poor countries. Where medical tourism has been accompanied by a shift of workers from elsewhere in the health-care system, uneven development is likely to be intensified. In both Thailand and India, for example, the availability of doctors is much less in regional and remote areas (and India, like other parts of south Asia, also experiences the phenomenon of rural ‘ghost doctors’: officially present and earning salaries but never actually there) and rural-urban migration of health workers was intensifying this ‘inverse care law’ even before the growth of medical tourism. Attractive private-sector opportunities, now increased through medical tourism, have been a significant influence on migration (Connell, 2010), intensifying urban bias and national imbalances in health-care provision.

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However, a substantial part of the disease burden in India are chronic infectious diseases such as malaria and tuberculosis, that are given limited attention and have no relationship to medical tourism. States where such diseases flourish, such as Bihar and Uttar Pradesh, are highly disadvantaged. Urban bias in health-care delivery has intensified everywhere. In Malaysia healthcare delivery is increasingly inequitable (Chong et al., 2005; Rasiah et al., 2009) and in Thailand ‘there is a huge drain on the public health sector. To practise medicine in Thailand you must pass a Thai language examination, so the booming private sector can take staff from only one place’ hence, as the Secretary General of the Thai Holistic Health Foundation has pointed out, ‘In the past we had a brain drain; doctors wanted to work outside the country to make more money. Now they don’t have to leave the country, the brain drain is another part of our own society’ (quoted in Levett, 2005: 27). BIH argues that the current national health-care system functions effectively and ‘patients have the opportunity to use public hospitals and see well-qualified physicians at little or no cost. Private hospitals like Bumrungrad have to compete on efficiency and value’ (BIH, 2009: 5), hence do not detract from that system. However, while public-sector patients do have the ‘opportunity’ at low cost, there is a serious shortage of doctors in many parts of Thailand, and migration, an internal brain drain, from the peripheries (Wibulpolprasert and Pengpaibon, 2003; Wibulpolprasert and Pachanee, 2008). With significant sectoral income differentials doctors have moved into private-sector hospitals as part of this ‘internal brain drain’ where, even by 2003: providing health services for foreign patients creates heavy investment in advanced health technology for the private sector at the expense of public health. This enhances the existing tiered health care system, with shifting of human resources for health from the rural public to the urban private services, resulting in increasing inequity ... [where] the resources needed to provide services to one foreigner may be equivalent to those used to provide service to 4–5 Thais. (Wibulpolprasert et al., 2004: 5)

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A Thai doctor observed in 2006: ‘Each time a foreigner sees a Thai doctor at “foreigner prices” he takes away an opportunity for a Thai person to see the same doctor at normal Thai fees. In other words, this program, while presumably bringing foreign capital to our hospitals, is sucking medical care from our own people’ (quoted in E. Cohen, 2008: 250). A growing workload, coupled with a new liability to malpractice litigation, has induced many doctors to transfer from the public to the private sector where they can draw high salaries to compensate for professional risks (UNDP, 2010). However, the actual internal brain drain attributable to medical tourism alone may be small and belated. Similarly some skilled workers are found only in private hospitals: IVF nurses work only in the private sector where wages are higher, hours are more congenial and patient loads rather less. By contrast ‘no one’ now wants to be involved in primary health care (PHC) (Whittaker, 2009) yet medical tourism is not primarily the cause of this. Waiting times in Thailand’s public sector are also lengthy while some of Bumrungrad’s 950 doctors, like others working in health tourism (Wibulpolprasert et al., 2004), have been drawn away from the public sector. Waiting times for Thai cardiac patients increased as doctors moved into the private sector and were expected to increase further as the Thai population aged (Phanayangdoor, 2006). Moreover at many Thai hospitals medical expenses are beyond the financial capacity of much of the resident population (Saniotis, 2007). However, migration from regional areas was occurring before the establishment of medical tourism, and inadequate capacity to pay is a function of the Thai economy, taxation system and structure of healthcare provision. In many countries the loss of doctors from the public sector has resulted in efforts to replace them. Costa Rica, for example, has recruited Cubans, as its own doctors have moved away from general practice to private practice, including medical tourism. Outside Latin America similar forms of replacement have posed cultural and other problems, few of the ‘replacements’ work outside urban areas (Connell, 2010) and replacement has not

occurred in such significant medical tourism destinations as India, Malaysia and Thailand. In several countries where medical tourism has grown, health-care systems have also been characterized by an international brain drain of skilled workers. A higher earning capacity can play a part in reversing the brain drain, a significant issue in such developing countries as India, where many doctors and nurses have migrated overseas, especially from underserved rural areas (Connell, 2010). Increased incomes may also slow migration though retention is only beneficial if the skilled workers are accessible to the population as a whole (Chee, 2007). It has been argued that overseas health workers may be more likely to return home, and with new skills, if they are able to practise in the wellpaid medical tourism sector for part of the time, and the remaining time benefit other patients, and this is broadly the industry position (Laing and Weiler, 2008: 384; Jagyasi, 2010). While the Apollo chain claim to have attracted more than 120 skilled medical professionals to return and work in India (Cortez, 2008), they do not, however, primarily serve local citizens, and especially the needy, and this return migration is about a tenth of the annual flow of skilled doctors from India to the USA alone (Connell, 2010). Bangladesh has begun to develop modern hospitals in partnership with the Apollo Group, hiring mostly US-trained Bangladeshi doctors; some were expected to be attracted back from the USA, but there seemed very little likelihood of them serving poor patients (Rahman and Khan, 2007). In Malaysia the consequences of medical tourism include a greater rate of movement of doctors, nurses and lab technicians out of the public sector, so that ‘the demand-supply deficit in healthcare human capital resources in rural regions and the poor states in Malaysia is expected to be aggravated further’ (Rasiah et al., 2009: 60). Partly because of this shortage, Malaysia sought to encourage the return migration of doctors from overseas to staff the growing medical tourism sector, offering tax incentives and removing the requirement to work for 3 years for the Ministry of Health, to provide more equitable health care (Chong et al., 2005; Chee, 2007), but there was little evidence of such

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return. Unless numbers otherwise increase, by accelerated training, the diversion of health workers (and facilities) to serve overseas patients invariably reduces levels of care for local residents. In Malaysia there are long-established concerns that local people will be unable to access some forms of medical care, and some facilities are currently underused, but primarily because of the migration of health workers rather than diversions to medical tourism (Idris, 2008; Connell, 2010). Potential expansion of medical tourist numbers in Malaysia resulted in hospital officials seeking to assure Malaysians that the influx of Singaporean patients would not drive up prices of medical services and result in ‘multi-tier quality’, declaring, ‘It is, and will remain, a one-tier policy, meaning: one price and one same quality for anybody who wants medical treatment in a Malaysian hospital, whether patients are Malaysians or foreigners’ (quoted in Burgos, 2010). When the Philippines sought to develop medical tourism in the mid-2000s one objective, shared by other states, was to stem emigration and encourage the return migration of overseas health workers, whose migration had eroded the national system. Some local doctors then opposed medical tourism, arguing that it ‘will significantly decrease services available to charity patients, even as it opens up services to paying patients and foreigners or tourists. Such institutionalized privatization of health care will only further marginalize poor Filipino patients’ (quoted in Gahlinger, 2008: 87). Sensitive to criticisms that health tourism was unacceptable, and the Philippines national health system inadequate, officials spoke of founding a special medical charity for the needy, while 11 hospitals taking part in the scheme agreed to donate 10% of their beds to ‘deserving locals’ (Henderson, 2009: 211). Such awareness of need has not always been translated into effective polices for the national poor either there or elsewhere (see below). In Mexico too there is some evidence that growing numbers of health tourists are burdening the national health-care system, and distorting it in ways that favour the privileged (Ramirez de Arellano, 2007; Bergmark et al., 2008). In this case, at least, a large number

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of patients are Mexicans returning from north of the border, hence the services are provided to indigenous Mexicans. Yet many such returnees have Green Cards and permanent residence in the USA whereas poorer Mexican migrants with illegal undocumented status are reluctant to return across the border to gain medical care and risk their place in the USA. A somewhat similar outcome is evident for the provision of stem cell therapy in India which diverted resources from recognized therapies and basic health-care provision, and forced up the price so that even middleclass Indian patients may experience bankruptcy, while for the poor, ‘only the possibility of entering the most risky experimental trials remains’ (Patra and Sleeboom-Faulkner, 2009: 160). Even within the EU, where Dutch insurers have been willing to pay Belgian hospitals above standard rates to remove long delays for cardiac surgery, there are risks that such foreign payment divert resources away from local patients (Glinos et al., 2010: 110). In three quite different contexts local patients are disadvantaged. Expansion of the private sector may therefore be at some cost to the public sector, where patients have limited ability to pay, as skilled health workers move away. The recent boom in medical tourism has occurred in a context where, despite rapid national economic growth, some 40% of India’s population live below the poverty line and have minimal access to basic health care so that infant and maternal mortality rates are high. Public-sector hospitals are often so inadequate that patients turn to the private sector for treatment but may have to sell assets to pay hospital costs (Sengupta, 2008). As one health researcher has pointed out: The poor in India have no access to healthcare because it is either too expensive or not available. We have doctors but they are busy treating the rich in India. Now we have another trend. For years we have been providing doctors to the western world. Now they are coming back and serving foreign patients at home. (Duggal, 2003)

More bluntly, in Yemen, as one man observed, ‘The poor don’t have access to services abroad

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or in Yemen. They die’ (quoted in Kangas, 2002: 56–57). Even in the UK and the USA this has residual truth. Ethical issues have consequently become significant at a national scale (Borman, 2004), both in terms of equity and in the more competitive involvement of the market in medical care. In India, Yemen and elsewhere, medical tourism both limits local access to health care and reduces the autonomy of the local state (Burkett, 2007: 233). By contrast in the much smaller country, and more affluent city-state, of Singapore there is no significant shortage of doctors (though the number of nurses is limited) so that human resources are not obviously drawn away from underserved population groups or areas. As the Director of Health Services with the Singapore Tourist Board has observed: For Singapore, seeing international patients is more than about earning tourism dollars. Singapore is a very small country and our problem is that we can do things that are really high-end but at the end of the day, you need the demand. For example, we have three living-donor liver transplant teams here in Singapore but if we didn’t have foreigners there would not be the cases to sustain that. We’re servicing international patients so we can see our own patients also. (quoted in Nicholas and Hyland, 2009: 22)

In a high-income city-state this means of retaining specialists, to meet the needs of the population as a whole, may currently be exceptional, but it offers similar possibilities for larger states. In Tunisia too there is no evidence that medical tourism has resulted either in an internal brain drain or the reduced availability of health services to the poor, partly because the public sector is well funded, while under-used capacity in the private sector limited the possibility of price discrimination. Medical tourism may also have reduced incentives for medical professionals to migrate abroad (Lautier, 2008). Tunisia and Singapore demonstrate that the impact of medical tourism is very far from homogeneous but varies considerably according to national financial and institutional structures and policy directions, and also according to human-resource endowments. Relatively successful middle-income countries such as

Singapore and Tunisia may thrive whereas India lacks the capacity to develop an equitable health-care system, and medical tourism has contributed to crowding out a much needed public health-care system. Thailand rests in between.

Egalitarian responses Either through recognizing their vulnerability to criticisms of elitism and inadequate response to local needs, or out of some degree of altruism, or both, some leading hospitals and chains involved in medical tourism have developed programmes to serve the local poor. Apollo Hospitals set up the Save A Child’s Heart Foundation in 2003 to provide care for children in lower socio-economic groups. Since then it has organized an estimated 900 surgeries/interventions with a claimed success rate of 97% and has ‘touched the lives’ of over 50,000 children with heart diseases across India through the work of ‘the most accomplished and distinguished cardiologists and cardiothoracic surgeons from Apollo hospitals who tirelessly work on transforming the lives of afflicted children by performing complex surgeries on them’. It was argued that half the children operated on through the Foundation would have died without this medical intervention (Apollo Hospitals, 2010). The Wockhardt chain claim to screen 12,000 blind patients a year through a mobile eye clinic ‘in slums, rural areas and poor locations’, repair as many as around 100 cleft palates a month, and conduct deworming camps (Wockhardt Foundation, 2010). Other activities are discussed on their website but there is little information about whether the procedures are actually undertaken. Particularly controversial have been promises and programmes of serving poor patients in the same facilities as medical tourists and rich patients, and the extent to which this is merely a cosmetic exercise. The Apollo Group was said to have provided free hospital beds for poor Indians who were unable to pay, and also to have introduced a trust fund to aid the needy, and pioneered telemedicine in rural and remote India, but there has been

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no independent monitoring of any of these activities. In the mid-2000s an ABC television programme seeking to find evidence of provision for the poor merely found a ward full of empty beds (ABC, 2005). Where such ‘free beds’ are occupied they have become part of systems of nepotism and favouritism: ‘it is well known that the free patients on their list are relatives of hospital staff, bureaucrats and ministers’ (Duggal, 2003). In some respects the ‘free-bed programme’ epitomizes the divisions in the national health-care system as a dual structure. While Apollo argue that ‘India is now ready to heal the world’ to a substantial extent ‘the majority of its own people remain at the back of the queue’ (ABC, 2005). However, Cuba too has also been criticized for devoting disproportionate numbers of beds and medicines to foreigners (Bookman and Bookman, 2007: 77) but there is no real evidence of this. Bumrungrad (‘care for the community’) argue that their name is realistic since they provided 103 no-cost heart surgeries ‘for needy Thai children’ in 2009, bringing the total of such operations to 365 in a 5-year period. A mobile medical team from Bumrungrad joins with staff from Bangkok Insurance Co. Ltd to provide free treatment once a year to some 10,000 villagers in Mukdahan and Sakon Nakorn provinces in north-east Thailand. A handicraft-training project in Nong Kong village, Mukdahan province, was also initiated to provide supplementary income to underprivileged people, and they have supported a housing programme in northern Thailand. The MTC TourNCare mention on their website that free plastic surgery is available at Pasam Hospital (Kodaikanal, Tamil Nadu, India) and that: If you know anyone who has met with a fire accident or people who are born with problems/disabilities such as jointed ear, nose and mouth, please note they can avail free plastic surgery at Pasam Hospital, KODAIKANAL (TN) from March 23rd to 4th April 2010 by German Doctors. (TourNCare, 2010)

Who learn of such offers or take them up and in what circumstances, is unknown. The

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needy are unlikely to access websites. Though a few Latin American hospitals seem to support philanthropic ventures it is only the very largest hospitals in Thailand and India that make any mention of foundations or work with the poor. While several such hospitals have provided health care to relatively poor groups, mainly in nearby urban areas, their programmes have never been evaluated and they are unlikely to have made significant contributions to national health care. Where medical tourism may have contributed is through the development of skills and techniques, including in areas such as telemedicine, but that too is immeasurable. Medical tourism is most likely to have a role in national health care, not by its direct contribution through charitable programmes or because hospitals focused on medical tourism have rather higher proportions of local patients, but through a taxation regime that can ensure effective trickle down in support of an appropriate national health-care delivery system.

Trickle down? The strongest argument for medical tourism in destination countries is that it creates a considerable flow of foreign exchange, that directly benefits the health, tourism and related sectors, and thus the national economy, and which can stimulate economic growth and development. Indisputably it has contributed to the tourism sector (Chapter 9) and, as in Tunisia, to ‘backward sectors’ such as pharmaceuticals, construction, transport and communication (Lautier, 2008). However, to sustain an effective medical tourism industry, investment must be made into ancillary activities, not least costly education and training programmes, but also transport, electricity, water and sewerage, which may intensify urban bias by drawing resources from rural and regional activities. The outcome has been that in the health-care sector new jobs have been created, some of which are indirectly related to health. The MTC Gorgeous Getaways alone employs 11 people in Malaysia from office managers to four drivers – all

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outside the health system. Other MTCs have created similar jobs. New employment inside and outside the health system was an important reason for countries to seek involvement in medical tourism. In Latvia the economic downturn following the GFC meant a substantial decline in local demand for cosmetic surgery and the migration of many surgeons and doctors to the UK, Germany and Norway, which in turn had led to layoffs of nurses and ancillary staff, so that marketing medical tourism was seen as essential for retaining local employment (Adams, 2010). Such linkages between sectors and the extent of employment creation are undocumented. With appropriate taxation policies, the income generated by medical tourism could subsidize public health and improve overall access to health care. This is an attractive proposition that assumes that the ‘maturity’ of medical tourism will bring policies that will ensure trickle down. Profits and taxable incomes are welcome, and can be redistributed to develop public health care, but this depends on strong economic and public health policy, whereas such redistributive policies are elusive in most emerging middleincome countries. Since even the hospitals that are most focused on medical tourism have a majority of national patients, many of whom are the wealthy elite, they are somewhat sheltered from domestic criticism and taxation. There is no real evidence of any trickle down to support arguments that ‘even if specific hospitals in developing countries are open only to foreigners and local elites, the health-care systems of these countries will be enriched by the influx of revenue, enabling them to offer local populations increased access to medical care’ (Herrick, 2007: 23). Overseas patients may be charged rather more than local patients, as they are in Tunisia. The Barbados Fertility Centre has a sliding scale, with the lowest fees for Barbadians, higher fees for patients from the 15-member regional Caribbean community (CARICOM) states and the highest fees for ‘overseas couples’. In Israel, though most of the revenue from medical tourism, as elsewhere, goes to the largest hospitals, this can be substantial since ‘local hospitals have a hard time finding

funds and breaking even’ and foreigners are charged 50% more than Israelis (Haaretz, 20 June 2010). Medical tourism may benefit public health by improving facilities, increasing the number of skilled health workers and enabling better access. It may just as easily drive up prices, as it has done in Thailand, and reduce access for the relatively poor. Moreover, as in Mexico, bilingual nurses may be trained specifically for the medical tourism market (Chapter 4), diverting resources from national needs. Income generated from medical tourism accrues either to the hospitals (and their staff), or to standard (usually urban) components of the tourism industry. Trickle-down effects through taxation, and any benefits to the rural sector, are at best trivial and probably counteracted by lost rural services. Likewise any new skills acquired by doctors and other health workers engaged in medical tourism, are only likely to benefit private national patients and have no bearing on the needs of rural areas (where PHC remains important). Conversely governments have tended to give financial support to medical tourism to stimulate its growth. In India special tax concessions were given to medical tourism providers. National support for medical tourism (through more active promotion, tax concessions on technology purchase, supportive employment tax regimes, etc.) may weaken support for and reduce resources allocated to public health and PHC. In Malaysia powerful interest groups have driven the expansion of the private sector in tandem with medical tourism, with the government subsequently stimulating the growth of medical tourism in the drive for new market access (Rasiah et al., 2009). The same loose combination of privatization, large conglomerates and government nurture – with a steady rise in private-sector expenditure on health services – has occurred throughout Asia, and elsewhere, with similar outcomes, including the slow immiseration of the public sector. Governments have not usually been held accountable for their obligations to provide services to the poor. Although the private sector, including medical tourism, cannot be blamed for the failings of public-sector health care its growth has made it more difficult for that sector,

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especially in India where the private sector provides nearly three-quarters of all healthcare services. As skilled workers, whether health workers or managers, move from the public to the private sector the task of meeting the needs of the poor, especially in remote areas, becomes more difficult. None the less medical tourism remains in its infancy in most countries and in most places its direct impacts are too slight (and largely unrecorded) to have had a significant bearing on such issues as national equity and inequality. It is just one part of the shift towards privatization of medical care and its considerable impacts.

Source countries Medical tourism serves those with the ability to pay, even where patients are underinsured. At source medical tourism is inequitable. After all, it emerged from the inability (but also unwillingness) of some patients to pay for medical treatment in their home countries for whatever reason. As in the UK: ‘Fertility tourism has always happened and will continue to happen. The real tragedy is that those with money can always go overseas, but the people who haven’t two brass farthings to rub together are always the people who lose out’ (Graham, 2006: 9). While fertility tourism is particularly expensive and exclusive, in Yemen and elsewhere the relatively poor are unable to take advantage of any form of medical tourism, but have no effective local health services. When new EU legislation enabled the ready movement of patients from the UK to Europe, more than 50 Labour Members of Parliament protested that only the wealthy would be able to benefit from the changes since costs had to be paid up front, while one argued: This directive could undermine the fundamental principles of the NHS, impose unnecessary burdens of cost and bureaucracy, overrule clinical priorities and worsen health inequalities. Treatment would be no longer free at the point of delivery and only the wealthy can use these new so-called rights. (quoted in Charter, 2008: 16)

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The slow response rate in the UK suggests that such fears were, however, premature or unfounded. Cross-border competition and volatility of patient flows may even affect capacity planning and resource management and potentially further disadvantage the poorest. Capital flows from source countries have sometimes been considerable (Chapter 7), though this may be greatest in developed countries. The USA was estimated to be losing over US$67 million in 2010 from transferred domestic health-care expenditure (Sobo, 2009: 327). Were foreign exchange losses of countries such as the USA to contribute to greater equity and more effective health care in destination countries they would be invaluable. While financial losses to countries such as Yemen are smaller in monetary terms they are more significant for national development. Such losses account for attempts to trap and reverse the flows. Countries such as Nigeria and Indonesia, which have lost substantial revenue to medical tourism, have made attempts to strengthen local facilities, partly in response. Indonesia has sought to divert a quarter of its stated 200,000 medical tourists to Siloam Hospital in Jakarta, managed by an Australian team and the first national hospital to receive JCI accreditation (Reisman, 2010: 102). In Tunisia, expansion of domestic capacity in the early 2000s meant that Tunisians no longer left for cardiovascular surgery and cardiology, which had accounted for 61% of treatment abroad in 1998 (Lautier, 2008: 106), and flows reversed. Government-funded medical travel for oncology fell by 92% in Oman between 2004 and 2005 after a national oncology centre opened, and a similar reduction in cardiology costs occurred in Abu Dhabi following localization (Ehrbeck et al., 2008: 8). In much less-developed Papua New Guinea the government has proposed a Pacific Medical Centre, linked to Stanford University in the USA, and intended to obviate problems described by the Minister of Health: ‘many people in the country die while seeking funds to be able to travel overseas and get specialist medical help or even while sorting out visa-related issues’. The national newspaper noted: ‘No longer will we have to see people dying as their family

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members and friends run raffles, pass around the collection plate, organize dances and parties, in the often futile attempts to finance the cost of sending the sick one and chaperone to Australia or Asia for treatment’ (Papua New Guinea Post Courier, 22 February 2010). At much the same time Hygeia Nigeria Limited announced a financial partnership with the International Finance Corporation (a member of the World Bank Group) and the Netherlands Development Finance Company and Satya Capital, a private equity firm, to develop superior facilities in Lagos (Mordi, 2010). Where more affluent states, such as the UAE and Libya, finance the medical tourism of citizens, such movements towards greater self-reliance may not be imminent, yet even Dubai has established DHCC to slow the flow and garner a Gulf market. Three years since it started DHCC had had little impact, catering almost entirely for local people and resident expatriates, but was seeking ‘to build trust through emphasis on quality standards that meet and exceed international benchmarks’ (International Medical Travel Journal, 2010). For both economic and health reasons medical tourism has resulted in some new directions in national health care in several countries. Medical tourism may also contribute to reduced local capability. In the short term the loss of significant numbers of national patients in particular categories, such as cosmetic surgery, could endanger the viability of such programmes and the institutions that provide them (Horowitz and Rosensweig, 2008). In Ireland, where elective surgery is either performed in local private hospitals or overseas, there has been concern that an inadequate number of public patients would result in the production of surgeons with limited experience and unfamiliar with elective procedures at the end of their training (Healy, 2009: 127). More generally, were the numbers of medical tourists from any particular country or place to become considerable, there is some possibility of a reduction in the viability of local programmes and facilities. Such circumstances would potentially boost medical tourism. In the long term, overseas competition through medical tourism might lead to

greater competition and reduced prices in such areas as cosmetic surgery (though it might then discourage health workers entering areas where prices were low and competition considerable). In rare instances prices have fallen. Serbian doctors working in Rome responded to the growing movement of the Serbian diaspora from Italy to Serbia for medical treatment by re-evaluating their pricing strategy and offering medical treatment at the same prices patients would pay in Belgrade (Bookman and Bookman, 2007: 97). That may not necessarily be an option for others. An even more innovative response emerged in Miami, which became a centre for illegal and unlicensed plastic surgery undertaken by doctors from other countries (Bookman and Bookman, 2007: 51). However, where patients are moving away from long waiting lists, and so reducing them, the incentive to ameliorate such problems declines. Developing effective policies to manage human resources in a flexible global context is extraordinarily difficult. Few countries have not considered the possibility of medical tourism, as the construction of DHCC indicates, possibly as many as have considered restructuring health-care systems to serve national populations. Few have rejected it out of hand, and many have sought to stem the flow of their own citizens, market high quality skills and facilities and gain revenue and employment. Malta considered developing medical tourism partly to reduce the migration of local health workers to better paid jobs in medical tourism destinations elsewhere, ‘to the detriment of the average Maltese citizen’, so that ‘we need to consider whether it is time to start producing more doctors and nurses instead of chefs and receptionists as part of our tourism strategy’ (Farrugia, 2006). In 2010 proponents of medical tourism in Canada, including the Health Minister of British Columbia, hoped to divert northwards the millions of dollars spent by Americans on overseas health care. The assumption was made that Americans would pay for procedures that made use of excess capacity in hospitals, with the profit providing health care for British Columbians, so ‘rather than

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competing with local residents now on waiting lists, surgical tourists would enable health regions to provide more services, thus reducing waiting times’. Arguments were made that health tourism would bring in muchneeded revenue, help retain Canadiantrained doctors and reduce waiting times for all. However, alongside uncertainties about costs, there were doubts about being able to compete with lower-cost Asian destinations, and questions of equity. If we had a real cost advantage, I wonder why private clinics that are now advertising to Canadians would not already be actively soliciting that business. The optics of offering through our public health care system services to Americans that Canadians are not able to get are simply appalling. The idea that someone from Seattle can pay for surgery in Vancouver while a Vancouver resident has to wait – or go to Seattle – is so appalling, in fact, that a conspiracy theorist might speculate this whole plan is being considered to deliberately undermine the credibility of our public system to pave the way for its demise. (McInnes, 2010)

In New Zealand too, where about 1000 foreign visitors a year (mainly from the USA) choose to have medical treatments because it is cheaper than their own country, the Accident Compensation Corporation was asked by the government in 2009 to ensure that New Zealanders were not subsidizing private hospitals oriented to overseas visitors, but that costs of medical treatment were met by the industry and not by other New Zealanders (eTurboNews, 2010). More broadly the arrival of many health tourists from overseas, especially where perceived to be ‘undeserving’, such as pregnant women arriving in the UK shortly before giving birth, or clandestine border crossers in Australia, and the pressure they place on public health-care systems, have created moral panics (see above). Advocates of an effective public sector have been the strongest opponents of medical tourism, but significantly in developed countries, rather than in the developing countries where it is most needed. Medical tourism has wide-ranging ethical and political dimensions.

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Equity, Capitalism and Commodification While most popular accounts of medical tourism focus on relatively benign cosmetic procedures with high success rates, there is an ‘underbelly’ of more complex procedures, such as transplants, where success rates are lower and the ethics more dubious, and of experimental techniques, such as stem cell therapy, where notions of tourism are stretched beyond credibility. Here, and especially in the ‘global fertility bazaar’ (Prasad, 2008), where regulation is lax, countries such as Georgia may be able to attract business by downplaying ethics in favour of commerce. Although such processes and procedures raise ethical and moral concerns, the numbers involved are slight relative to most other arenas of medical tourism that are not so tarnished. In the wider context, where medical tourism plays a small part in distorting national health care, it has been described by some as a form of ‘medical colonialism’ (TRAM, 2006). While privatization has raised standards of care and contributed to the improvement of medical facilities in many countries, notably India and Thailand, the most prestigious hospitals are scarcely accessible to most nationals, and technological and fiscal benefits have failed to trickle down structurally or geographically to where they are most needed. Medical tourism has emphasized and strengthened such trends and made them more acute and more visible, especially in areas such as reproductive tourism, stem cell surgery (and also international adoption) where costs are very high and only mobile elites can benefit. Yet even in the richest countries the poor have restricted access to medical care. Privatization has preceded and continued irrespective of the rise of medical tourism. National development policies, or their absence, alongside the global pull on health workers, rather than medical tourism, have increased inequalities, weakened public health and preventative care and worsened access in regional areas. Medical tourism reinforces privatization alongside a technological and medicalized

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view of the health system where medical services can be bought ‘off the shelf’ from the lowest cost provider, rather than well-being created by remedying the social, political and economic determinants of health: an analogy with the relationship between cosmetic surgery and diet and exercise. The incursions of capitalism and commodification into hitherto personal and intimate experiences, from birth through to death, that are suggestive of a materialist, egoistical and self-absorbed society, are symptomatic of much of medical tourism, which has both stimulated and responded to such trends. It reduces pressures on governments, as the more affluent and powerful move in and move on. The private medicine that is epitomized in the principle centres of medical tourism offers examples of places and providers that are not only sites of treatment but key elements in emerging and highly competitive neo-liberal landscapes of discretionary consumption (Kearns et al., 2003), where advertising and marketing play a critical role, and links with international companies, from Starbucks to Flight Centre, are as significant as those with pharmaceutical companies (Chapter 10). Medical tourism consequently ‘represents the full integration of medicine with global capitalism’ and, where service is purely a function of the ability to pay, redeeming features are elusive in a system that tolerates ‘striking inequalities in income and health’ (Turner, 2007a: 113, 128). In this perspective medical tourism is both symbol and manifestation of the failures of privatization and national healthcare systems. There is little evidence that: (i) it has attracted beneficial foreign investment, except perhaps in parts of the tourist industry; (ii) competition has benefited the health sector as a whole; and (iii) greater numbers of skilled health workers have been produced, or corporate social responsibility

increased, even on the part of the more successful hospitals. Most criticisms of medical tourism are actually criticisms of capitalism and privatization, albeit both epitomized in medical tourism, and implicitly of the failings of health systems, especially in developing countries, to provide more effective and equitable health care. Part of that criticism stems from repugnance at situations where foreigners availing themselves of cosmetic surgery must be ‘sheltered’ from adjacent poverty and pestilence, where citizens are marginalized. In overwhelmingly capitalist societies medical tourism is somewhat different from other sectors in its direct relationship to life and death. Ethical and moral questions abound. Yet, inside and outside the ‘neoliberal landscapes’ of corporate well-being, patients have been obvious beneficiaries, some moving away from difficult local circumstances (such as many of those from Yemen), waiting lists and spiralling costs, and gaining healthy new lives (even perhaps at the expense of some national citizens). However, inadequately measured or simply ignored, medical tourism has also contributed to employment and income generation. As in almost every tourism context, large companies (the MTCs, the travel industry, and also the health providers) are the main beneficiaries, the tourists get more or less what they anticipate and have paid for, and the local population (including such direct providers as surrogate mothers and liver donors) are least likely to experience trickledown effects. In this emerging nexus of complex privatizations, links with components of the tourism industry provide institutional evidence that medical procedures overseas are not merely of clinical interest, but that they are in fact a new niche in the tourism industry, a notion taken further in the following chapter.

9 But is it Tourism?

People from an overdeveloped world often wanted an adventurous, relaxing or rejuvenating holiday with their bargainbasement surgery, and stayed in luxury hotels eating seafood, while people from poor countries such as Thailand were spending up to a year’s wages on their procedures and stayed in clinics where they had their surgeries, eating two-minute noodles they had to bring themselves. (Jones, 2009)

Given the gravity of sometimes complicated and serious medical procedures is medical tourism really tourism? Do invasive medical procedures have anything to do with holidays? Are not holidays supposed to be about pleasure not pain? At the very least medical tourism seems very different from most conceptions of tourism. To go on holiday for something that might be painful and require days of recuperation is not the most obvious association for tourism and recreation. Tourism is supposed to be about relaxation and pleasure, but also an increase in well-being and even health, and only bank accounts are supposed to suffer. Even for heritage and cultural tourism, with notions of tourism as a learning experience, learning was expected to be relaxing, undemanding and pleasurable. Tourists need not necessarily be hedonists, totally absorbed in pleasure, but they anticipate enjoyable days and nights. Yet medical tourism is

largely detached from more hedonistic forms of tourism and even from the relaxed and minimal intervention of spa tourism, but it is still one more distinctive form, or more correctly several forms, of niche tourism. Invariably and not at all surprisingly advertisements for medical tourism stress the links between surgery and tourism, especially during recuperation. Adverts, especially those of MTCs, invoke obvious themes such as the need to stay and enjoy yourself before going home, taking time to recover slowly and restfully, experiencing the country, its people and cuisine, and so on. While such possibilities may reduce the tensions involved in operations in distant, sometimes unknown and uncertain places, they obviously aim to encourage ‘standard’ tourism. The extent to which recuperating patients may be able to benefit from ‘normal’ elements of tourism may be queried. Is this therefore merely longdistance migration for surgery, marketed as an attractive tourist experience, or is there actual tourism? Indeed describing a medical procedure as part of a tourist experience might seem to be cosmetic advertising, for circumstances where insecurity and helplessness may accompany pain and discomfort. Since the mid-1990s medical tourism has become a complex international industry, where people often travel long distances to overseas countries to obtain medical, dental

© CAB International 2011. Medical Tourism (J. Connell)

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and surgical care, while simultaneously being holidaymakers in a more conventional sense. Many medical tourists travel much further than they would usually go for holidays, even going overseas for the first time. Some may travel alone but, more often than not (especially if overseas travel is unfamiliar), they travel with friends and family who may assist in recuperation and who fit more easily into a more conventional tourist mode. A frequently asked question on interactive websites is that of what arrangements might be made for accompanying family members. Diasporic returnees are equally likely to travel with their families. Enormous variations characterize medical tourism and how different versions link to a more ‘orthodox’ tourism also varies. While the previous chapter described certain procedures that seem to have minimal relationship to any sense of tourism, they are atypical. In circumstances where travellers have sold much-needed goods, or taken out loans, as in the case of Yemenis, and travelled to culturally different regions for essential medical procedures, it is also implausible that the notion of holiday was relevant. Yet both these quite different situations have an impact on the tourist infrastructure, whether transport or hotels, and such patients also travel with others. This chapter examines how medical tourism constitutes a particular form of niche tourism.

The Rise of Niche Tourism Since the earliest days tourism has encompassed a diversity of activities, involving active and passive experiences and preferences for different destinations. While the 20th century seemed dominated by mass tourism, and this century by its Asian derivatives, especially in rapidly expanding coastal resorts, such resorts varied considerably as did the activities of tourists, from passive sunbathing and reading to more active swimming or terrestrial activities such as golf, while visitors took variable interests in local culture and gastronomy. Long before then tourism had spawned multiple specialist

groups, such as hikers and mountaineers, whose vacations were dominated by such activities, with perhaps no more than evenings devoted to eating, drinking, experiencing concerts and other forms of entertainment, and expenditure on both specialisms and ‘standard’ tourist activities. Many such niches have evolved, expanded and become differentiated further. Despite disputes over terminology, niche tourism (and its precursor ‘special-interest tourism’) is usually seen in contrast to mass tourism, as a form of tourism that may be more sustainable and sophisticated, has its own segmented marketing mechanisms (‘niche marketing’) and where tourists engage in only a fraction of the activities possible at a particular destination (Robinson and Novelli, 2005). Health tourism, linking and combining some sports, diet, nutrition and spas, is such a niche (Hall, 1992; Novelli, 2006), though, like most niches, its boundaries are imprecise, since alcohol and food consumption may also reduce stress and enhance pleasure. Medical tourism is partly an extension of this: a parallel niche but with its own internal diversity. Niches largely emerged from the mid- to late 20th century in developed countries as official vacation times lengthened, households had more disposable income available for leisure pursuits, second holidays were possible, and personal transport enabled avoiding the ‘masses’ as car ownership became more common. Holidays could be fragmented and divided with time for both ‘standard’ family holidays, perhaps still dominated by typical coastal vacations, and specialist activities. Birdwatching, for example, quickly grew as the outcome of greater affluence, leisure time and mobility and renewed interest in nature, resulting in new magazines, specialist tourism companies and websites and a boost to the economy of remote areas where unusual species were found (Connell, 2009). Some such niches, particularly those involving adventure sports, such as skiing, rock climbing, canyoning, base jumping and hang gliding, could be seen both by their adherents and others as dirty, dangerous, difficult and occasionally even life threatening. They were a long way

But is it Tourism?

from sunbathing on the beach. Some niches were largely passive and reflective, others more active; some brought relaxation, others enabled rejuvenation. Many offered nostalgia. Most niches, such as birdwatching, contained both relatively passive participants and highly active members, where costs and time posed few constraints. Many included obsessives, perhaps none more than the Japanese tourist who travelled without a break to see the Mull of Kintyre in Scotland, simply because it was the setting for his favourite song (Gibson and Connell, 2005: 87–88). Such obsessive travellers might have been introspective and single minded but they were no lesser tourists. Perhaps the most obvious characteristic of niche tourism is that the niche is more important than the tourism. Given the proliferation and diversity within niche tourism it is at the very least plausible that medical tourism is one more very significant new niche, even if in parts of the industry, as in Thailand and in one of the five guidebooks, there is a preference for the terms ‘medical procedures’ and ‘medical travel’ which provide a degree of gravity, and sound trustworthy rather than frivolous. This variant of niche tourism may thus be seen as a form of ‘serious leisure’, much like rock climbing or birding, involving the systematic pursuit of a particular activity to the extent that it virtually becomes a dynamic form of identity creation, measured, among other ways, by substantial investments of time, money, energy and emotion (Stebbins, 1999). Medical tourism certainly identifies a group of serious travellers. Medical tourism also has affinities with another niche tourism sector, MICE tourism, or that part of it where groups meet for a particular purpose, centred on a particular theme, such as a hobby (including such sports events as marathons), a profession or an educational topic. Such tourism is usually specialized with its own trade shows, planning structures and a relatively demanding clientele. Several countries involved in medical tourism, including India, Malaysia and Singapore, are simultaneously seeking to expand MICE tourism. India stresses on its tourism website Incredible India that:

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India is in a continual process of upgrading its MICE (Meetings, Incentives, Conferences and Exhibitions) facilities. There are multiple plans on the anvil for more world-class convention centers, airports that contest with the best in the world and efforts to team the famous Indian hospitality with customisation as per a visitor’s requirement. You could also offer the credit to the world class incentive programs, her ability to heal spiritually, her unmatched offering as a health destination or continually improved infrastructure facilities that over 3 million foreign tourists thronged there this year. (Incredible India, 2010)

Medical tourism is also a form of VFR (visiting friends and relatives) tourism, since a significant proportion of medical tourists are returning to their home countries for medical attention in a familiar cultural context, and use this as an opportunity to catch up with or stay with relatives. Alternatively while visiting friends and relations they catch up on medical care. While Lee et al. argue that ‘brief return trips to a home country principally for health-care purposes cannot be regarded as tourism per se’ since ‘deeper reasons’ account for this ‘utilitarian travel’ (2010: 108) there is no real reason for it to be discounted as a particular form of VFR tourism even if relatives and friends may be the backdrop rather than the central focus. Many medical tourists in Malaysia were drawn there by their relatives and their main activity during recuperation was socializing with them (Doshi, 2008: 81). Nor is there any reason why such travel should be simply utilitarian, rather than taking on additional elements. For many medical tourism is thus a form of ‘diaspora tourism’ where individuals and groups return to their home countries, and to their kin, for a range of reasons, of which health care is one. Several countries, including Korea, Taiwan and India, have deliberately sought to market medical tourism to overseas communities. Diasporic travellers tend to be located somewhere between the supposedly ideal types of migrants, tourists and pilgrims, and incorporate elements of each (Cohen, 1992; Coles and Timothy, 2004). They are usually perceived as seeking cultural connections, rediscovering ‘roots’ and enhancing and revitalizing memories, alongside discharging

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economic obligations or investing, but other practical pursuits such as obtaining health care are often inherent. Although many medical tourists are not particularly wealthy, like some MICE tourists, and simply cross nearby borders and stay with kin, and even have no great desire to be thought of as ‘tourists’ in many senses of the word, they are still niche tourists.

Governments and Guidebooks Development policies in many countries support and encourage medical tourism, as a valuable means of economic growth and diversification. In some countries it is linked to promotion of business and commerce but, just as frequently, it is directly linked to tourism, and seen as one component of a tourism development strategy, or even, as in India (above), part of a strategy that links different strands of tourism together. As medical tourism has become successful its promotion has intensified, as have its links to other components of the travel industry (see below). In countries where tourism promotion was unheard of as recently as the 1980s it has grown and intensified, marking the shift from agriculture and industry to the service sector, but its diversity has blossomed, well exemplified in India’s ‘Incredible India’ theme. Not only therefore is medical tourism promoted but, like other niches in the tourism industry, it has drawn government investment and subsidy. Whole nations, as well as and alongside individual providers, are thus competing for custom. Government promotion was initially most evident in Cuba, the lone country where it is primarily a public-sector activity, as ‘one of the main objectives of the Cuban government has been to convert the country into a world medical power’ (Benavides quoted in Bookman and Bookman, 2007: 71). Similarly Chile sought to ‘add surgical operations and cutting edge medical treatments to its traditional exports of copper, wine and salmon’ (Benavides quoted in Bookman and Bookman, 2007: 71). Thailand first actively promoted medical tourism through its

‘Amazing Thailand’ campaign in the late 1990s, and the 2010 version of this website has an interactive Thailand Medical Tourism portal with wide-ranging advice and information about medical tourism, while in the same year the Tourism Authority of Thailand conducted a Medical Health and Wellness Road Show in Oman. By contrast the 2010 version of Incredible India provides clear links to a 37-page booklet on ‘The Global Healthcare Destination’ with separate coverage of Ayurveda, hi-tech healing and spas. ‘Malaysia Truly Asia’ has invocations to experience medical tourism and clear links to providers and ‘Your Singapore’ has links to alternative Chinese medicine and spas but not to medical tourism. Conversely Malaysia’s official medical tourism website had pictures of orchids and the official tourism logo. When the Philippines sought to enter the market in 2005 it announced that the Departments of Tourism and Health were combining to introduce medical tourism. In Turkey the Culture and Tourism Ministry promotes hospitals alongside museums and hotels and exhibits at international tourism fairs and expos (Reisman, 2010: 134) as do many other tourism organizations. With exceptions, where medical tourism has become significant it has also become important enough to be more evidently part of the tourism industry, at least in the eyes of government, and has been as actively promoted as other facets of the tourism industry. Despite government support, like most other forms of niche tourism medical tourism largely escapes coverage in standard guidebooks, travel magazines, newspaper and magazine tourism supplements, etc., although health tourism, especially spas, has become prominent, and effectively a separate niche. A handful of stories have appeared in the travel pages of Australian and British newspapers such as ‘Cosmetic cuts on the run’ (Weaver, 2008b), which discussed how shopping and other forms of tourism could be combined with cosmetic surgery in Malaysia, and ‘Incisor trading’ (Haslam, 2007), on dental tourism in Hungary. Guidebooks as a whole now say less about any health virtues of travel than they did a century ago, when cruises were seen as

But is it Tourism?

health-giving experiences, health resorts were recommended and coastal and mountain areas claimed to offer valuable recuperative properties. In the UK at least, ‘bracing air’ was still offered in the 1960s. Nothing is usually said about medical tourism in standard guidebooks, though prominent hospitals are listed (as in the Lonely Planet guide to Thailand). However, the Lonely Planet guide to Bangkok covers spas, massage and yoga and, under the heading ‘Medical Services’, notes that ‘Bangkok has become a major destination for medical tourism’, briefly discusses Bumrungrad and the presence of McDonald’s (‘would you like a thick shake with that bypass?’) and advises on which hospitals should be able to help ‘whether your stay is to recover from a nasty “Thai tattoo” (burned inner right calf after a motorcycle mishap), for corrective surgery you couldn’t afford or wait for at home, or for something more cosmetic – new nose, lips, breasts, Adam’s apple removal’. It also notes that ‘many farang [foreigners] are combining their holiday with a spot of cheap root canal or some “personal outlook” care’ (Burke and Bush, 2008: 262). It neither endorses medical tourism nor features it prominently. This is exactly the situation with many other niches: MICE is entirely absent, ornithology may receive a page or so if birds are exotic and not too remote and rock climbing and similar outdoor activities are rarely evident. It may be that niche tourism may partly be distinguished by its absence from standard guidebooks. Medical tourism guidebooks differ from standard guidebooks in focusing not on people who have already chosen to go away, and have chosen a destination, but on those who are only considering the possibility (Chapter 6). Like other guidebooks they are wildly enthusiastic about the topic. Conventional guidebooks assume that decisions and destination have been organized, whereas medical tourism guides uniformly devote significant space to convincing readers that travelling for medical procedures is a good idea, trying to normalize it through case studies and reviewing multiple destinations. Guidebooks are aimed at those with some money and the ability to choose, rather than

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border crossers or diasporic tourists who are already familiar with the destinations. This helps to distort the image of medical tourism. All but Woodman’s (2008) book, which refers to medical travel, have ‘tourism’ or ‘tourist’ on the cover and in the text, but all regard tourism itself as a secondary concern. None the less through governments and guidebooks medical tourism has acquired a more formal touristic presence.

Into Tourism For some destinations, including Germany, the Czech Republic, Hungary and Mauritius, medical tourism possibilities are advertised in in-flight magazines and standard government tourist publications, on the assumption that tourists might avail themselves of smallscale procedures such as dentistry, during otherwise standard tourist visits. Thai International’s Sawaddee magazine and Malaysia Airlines’ Going Places invariably feature some advertisements, as does Jetstar, an Australian budget airline that flies to Asia. Here at least tourism itself is the actual starting point. In such cases patients have either chosen holiday destinations with the secondary goal of medical treatment, or have scarcely thought about it, but may suddenly decide upon it (just as others decide on tattoos) for familiar low-risk procedures such as dentistry. Medical tourism is not easily marketed, because of its diversity and because medical procedures take centre stage. Low-key procedures are more obviously part of tourism advertising, and dentistry offers greater possibilities for tourism, because of its minimal recuperation time. As one British patient in Piestany (Slovakia), who had made several visits for extensive treatment, recorded: This meant 4 trips back and forth, each one was a city break in it’s self [sic] and was not expensive due to Ryan Air’s discounts. All in all I can say my experience with this clinic was fantastic, the only down side is that although Piestany is a beautiful town there is not a great deal of entertainment past the Spa, but hey I am a single chap and my needs maybe different to yours. I did a tandem skydive on one of my trips, three root canals

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in the morning and out of a plane at 15k feet strapped to some bloke in the afternoon that should give you an idea of the tip top pain relief I received! (Treatment Abroad, 2010)

His own familiarity with the procedures and with the place opened up a range of possibilities. In Thailand it is argued that the reputation of the country as a tourist destination has boosted medical tourism to the extent that for the Bangkok Dental Spa, which treated about 1000 overseas patients in its first year, ‘Ninety percent of patients already know Thailand and love it as a holiday destination’ (Levett, 2005: 27). Standard tourism development has contributed to the growth of medical tourism through engendering familiarity and providing the basic infrastructure. But relatively little medical tourism has developed from existing tourism, and has contributed to it, so that ‘playgrounds’ are much rarer than ‘backyards’. Medical tourists are more likely to be concerned with medical factors in their choice of destination (Heung et al., 2010) and more likely to engage in ‘standard’ tourism activities when: (i) particular procedures are familiar; (ii) recuperation times are short (or nonexistent); and (iii) obvious tourism facilities exist. For example: Californian resident Eva Dang decided to take the 24 hour flight over the Pacific Ocean for a dental appointment. ‘[Singapore] is just as good as America. Doctors are very professional and caring and very attentive.’ And cheaper too. What is more she can get to relax by the pool in a tropical climate, grab some food at the hawker stalls and catch the sights at the same time. (CNN, 2005)

Beyond obvious tourism infrastructure, such as hotels, the specific features of certain destinations offer possibilities. The climate itself may be an attraction. One British woman in her 60s, who had chosen Malta for a hip replacement, observed that ‘I thought I might as well go somewhere nice and warm to recuperate’ so ruling out France and elsewhere in continental Europe (quoted in Charter, 2008: 17). However, tropical climates may also be

deterrents for some and the guidebooks advise on precautions. Shopping, dining and going to shows, usually comfortable and undemanding activities, often in air-conditioning, are widely seen as elements of tourism that can be linked to medical tourism. Diethelm Travel Asia, located on Bumrungrad’s second floor, books tickets for local shows as much as organizing other forms of travel and tourism. Most Bangkok hospitals offer and organize night markets and nightclub shows (if not in the more risqué Patpong). Eating, sightseeing, poolside reading, shopping (and window shopping) and taking in a show are neither particularly challenging nor necessarily expensive and most such activities form some part of medical tourism experiences (Chapter 7). Some 85% of international Bumrungrad patients stated that they and/or their companions had done some tourist activities such as sightseeing, shopping, eating out or ‘enjoying the local culture’ (Anon., 2010b) while a more general survey found that percentage to be as high as 95% (Anon., 2009). That may be a minimalist definition of tourism but it incorporates most medical tourists. If patients are well enough to travel to distant destinations they are usually well enough to engage in that much tourism. An Australian couple, who had made four visits to Malaysia for cosmetic surgery were said to return as much as anything for ‘shopping and trying traditional Malaysian food’ while another Australian noted ‘I felt a bit groggy after surgery but as soon as I got back to the hotel – the day after surgery – I was out shopping’ (quoted in Weaver, 2008b). Indeed where cosmetic surgery has produced significant structural changes, shopping for new clothes may be more necessary than entertainment. As in other forms of niche tourism there are specialized and standard components. Marketing naturally stresses the pleasures of the destinations. Goa Tourism’s brochure Find All in November 2006 featured health tourism, and so reached those who had already arrived in Goa, pointing out: Welcome to tropical sun and escape from the gloomy European winter. It is only now that the idea of offering health care services has been taken up. Combining holidays with

But is it Tourism?

health treatment is becoming more and more popular among tourists coming to Goa. The advanced treatment here costs a fraction of that in the developed world. So it makes perfect sense to combine holidays with treatment.

The brochure went on to suggest that tourists avail themselves of anything and everything from Ayurveda, homeopathy and reiki to dental and hearing clinics, cosmetic surgery (tummy tucks, facelifts and hair transplants) and beauty parlours, most of which required no major decisions, referrals or, indeed, a great deal of money. This kind of link between health care and tourism is evident in the website for the Nirmalyam Ayurvedic Retreat and Hotels Company in Kerala, which also stresses the possibilities of catamarans and house boats: The tourists are attracted by Yoga, Ayurveda and Vedic Astrology, the great sciences which grace Indian culture. One of the resorts which supports these sciences is the famous Nirmalyam Ayurvedic Retreat, where many tourists come and stay for Ayurvedic treatment and enjoyment of scenic beauties in God’s own country, Guravayur, Kerala. Within a couple of kilometres from Guruvayur, the famous temple city, is the world’s largest elephant sanctuary of 58 elephants, which is visited by many a tourist. The Nirmalyam Ayurvedic Retreat functions as an Ayurveda centre as well as a three star hotel with state of the art 60 rooms with economical rates. (Nirmalyam Ayurvedic Retreat and Hotels Company, 2010)

While this is primarily health rather than medical tourism, tourists who have not experienced invasive procedures are more likely to appreciate the delights of elephants and catamarans. South African medical tourism companies developed packages that combined enjoyment of World Cup football matches, with medical procedures and tourism. The Johannesburg-based Medi-Sculpt clinic, launched a ‘Liquid Face Lift and Safari package’ that included Botox and dermal fillers and spa treatments and a visit to a lion sanctuary where patients ‘can feed giraffes and play with lion cubs’ (Slamdien, 2010): a rather

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low-key and undemanding safari! Fertility tourism lends itself to some degree of tourism. The website of the Barbados Fertility Centre, subtitled ‘A Holiday with a Purpose’, states: In between your appointments you have constant access to our team of experts by cellular phone but with the freedom of being on holiday. You can enjoy the soothing sound of the lapping Caribbean Sea, go for a long romantic walk along the white sandy beaches and then enjoy the tantalizing tastes of the Caribbean’s cuisine. (quoted in Martin, 2009: 251; Voigt and Laing, 2010: 261–262)

Incorporating some notion of love and romance into parenthood, in what might otherwise be a somewhat clinical process, has merit. Yet, here and in other contexts where some degree of anxiety might be anticipated, the extent to which patients actually behave as tourists or whether this is mere cosmetic advertising is uncertain. More dramatically one Mumbai (India) hospital has used the slogan ‘open your new eyes on the beach at Juha’, some 30 km to the north, although patients may prefer to do this first in the hospital before exploring the beach. Most potential medical tourists expect some degree of tourism, however limited this may be, even despite limited knowledge of their destinations. A Canadian who had only been to Florida outside Canada, when questioned about foreign travel, said: he has no misgivings about going to a faraway destination to have both his eyes operated: ‘Thailand will have to be better. I’ve seen what happens here for more than 10 years now.’ Pare doesn’t have any firm ideas yet about how his life will change after the surgery, but in all likelihood he will treat his post-glaucoma eyes to the colours of the floating vegetable market on the Chao Phraya River and the sun playing on the majestic Buddhist temple, Wat Arun. ‘I’m going to ask my boss for an extra week off after (the medical treatment). I want to see Bangkok a little bit.’ (Anon., 2006a)

Indonesian visitors to Malaysia prefer to be treated in the large coastal cities of Penang and Malacca, both of which have a significant

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tourism industry, rather than in metropolitan Kuala Lumpur. However, even those who are treated in Kuala Lumpur are involved in tourism activities after their treatment: at least half of a sample of medical tourists were engaged in shopping, organized touring or other recreational activities, including visiting relatives (Doshi, 2008: A-24). Tourism in the aftermath of medical attention may necessarily be unexciting but most anticipate and take part in it.

Hotels, Hospitals and the Travel Industry The glittering testimony to well-being that is the Bumrungrad foyer resembles a hotel as much as a hospital. Concierges wait outside. Limousine service from the airport is available. Gentle music wafts through the foyer with its ‘soaring lobby ceilings’ and no nurses or doctors are present there. Five-star rooms have personal video cassette recorders, where

technology is about leisure rather than medicine, alongside private marble bathrooms and good views. Italian and Japanese restaurants, Au Bon Pain, McDonald’s and Starbucks, are all part of the first floor of the hospital (Fig. 9.1). The tiny food court, flower shop and newsagents hint at a small shopping mall. An enthusiastic American health tourist was moved to comment: ‘the hospital looks quite modern and even the faint hospital smell is masked by an overriding odor of capitalism’ (Leenhouts, 2009: 23). A travel agency and a visa centre on the second floor organize travel, visas and concert visits for patients and their relatives. The hospitals at the core of medical tourism have transformed themselves from the dowdy, functional and clinical public hospitals that preceded them. Hospitals in Costa Rica have IMAX cinemas and helicopter landing pads. Samitivej offers wireless Internet access to all international patients. Bangkok Hospital provides cable television with various language channels, microwave ovens and guest sofa-beds. Its Phuket branch

Fig. 9.1. Bumrungrad International Hospital (BIH), first floor.

But is it Tourism?

includes a private garden, cable television, a computerized patient bed and Internet and book service, for premier patients in rooms where the resemblance to traditional hospitals is slight (Fig. 9.2). Samitivej emphasizes that its ‘plaza has almost 20 tenants ranging from daily convenience stores such as 7-eleven, bank and even Starbucks. In addition, there is a range of retail and food and beverage outlets’ (Samitivej Hospital, 2010). Singapore is expected to open the first ‘medical hotel’ in Asia in 2010, a luxury building connected to a new hospital, with conference centre, indoor and outdoor gardens and a dialysis machine and other medical equipment for patients who do not want to stay in the hospital itself (Butler, 2009a). Singapore hospitals are already giving dining menus and elegant toiletry packs on ‘check-in’. Bumrungrad participates in a ‘Great Chefs’ programme where top hotel chefs design 12 special menus, each featured for 1 month of the year. The Barbados Fertility Centre relocated its entire facility to provide sea views.

Fig. 9.2. Hospital room in Bangkok Hospital, Phuket.

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In the late 20th century hospitals went from being functional, technological places to more open human landscapes and living spaces (Sternberg, 2009). Corporate hospitals took on elements of elite hotels, IT offices and shopping malls, with an architecture that projected ‘the corporate hospital as anything but a hospital’ (Lefebvre, 2008: 102). The newest projects such as the Indian hotel chain Welcomgroup’s Fortune Park Lake City hotel claims to be a hotel within a hospital, being on the grounds of the Jupiter Lifeline Hospital in Mumbai, and part owned by the hospital: a prototype ‘hospitel’ due to be completed in 2010 (Express Hospitality, 2010). In form and function the key hospitals in the medical tourism industry have come close to luxury hotels, in a transition where consumption and consumerism have been added to cure and care. Rather like such hotels, they too have become ‘non-places’: placeless and largely indistinguishable (Augé, 1995), and thus more like the basic elements, the hotel chains, of the international tourism industry.

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While hospitals like Bumrungrad have approximated hotels in their elegant design and luxury facilities, and a hint that the image of opulence may extend to care, those facilities are only for patients (and occasionally family members), and they are not yet also hotels. A few hospitals, like Bumrungrad and the Apollo in Delhi, do have nearby suites for friends and relatives. Many medical tourism procedures, especially of a ‘drop-in’ nature, require no hospitalization. Check-ups, mini-facelifts and Lasik eye patients need no extensive medical care and recuperation, though they may wish to spend a short time near the hospital. If such short-term patients have travelled long distances they are however, likely to need accommodation. By contrast even complex procedures may not demand lengthy recuperation and, where economics is important, patients may be reluctant to stay any longer than is absolutely necessary, or stay with relatives. Thus Mexicans may return very quickly to the USA after treatment. One surgeon in Morelia, 1000 km south of the US border, noted: ‘I often have patients that come on Friday from Los Angeles, have their operations on Saturday, and the following day they return to Los Angeles’ (quoted in Bergmark et al., 2008). Dental patients near borders may stay less than a day. The limited demands of dentistry on patients have enabled them to participate in standard tourism (and skydiving) to a greater extent than most medical tourists where some degree of rest and recuperation are required and where the particular procedure may rule out certain activities (as cosmetic surgery usually rules out safaris). Yet dentistry enables such flexibility that for some the procedure is everything. On the same site as the skydiver other British patients were simply there for the procedure: I met other patients who were only there for the day and came regularly – arrived in the morning and flew back that night and back at work the next day. They found they had better service, quicker appointments and even with the flight it worked out cheaper than the UK for the same treatment. (Treatment Abroad, 2010)

In this context any intended tourism is wholly absent, and nor have the patients even stayed for the 24 hours that still defines tourism. But these are the exceptions that dispute the rule. Almost every other medical tourist is part, if sometimes a small part, of the tourism industry. Most medical tourists travel with companions (though short-term dental patients are somewhat different) and stay for significant periods of time. The number of companions is almost double the number of actual patients, and they are more likely to behave as ‘standard’ tourists in terms of activities and expenditure (Chapter 7). Hotels in the vicinity of hospitals benefit from medical tourism as much as the hospitals themselves, and some have directly oriented themselves to the medical tourism market. Many have acquired affiliations with MTCs and are recommended by them, with links on websites. At two Bangkok hotels, close to Bumrungrad, up to 40% of their guests were either patients or their relatives (Reisman, 2010: 104). The JW Marriott Hotel, which employs 720 workers, and is a 10 minute walk from Bumrungrad Hospital, ‘has been welcoming frequent visitors from Hong Kong and Singapore, incorporating check-ups and procedures into their shopping weekends’. The hotel deliberately targets patients who choose not to stay in the hospitals, has ramps and wheelchair-accessible rooms and ‘some staff trained to dispense basic first aid and alert nearby Bumrungrad Hospital or Bangkok Christian Hospital … for more serious matters’ (Ritruangdej, 2009: 34). In other words the hotel, like others, has carefully integrated itself into the wider medical tourism system. A degree of convergence has occurred: hospitals have become less daunting and functional and nearby hotels more oriented to the needs of medical tourism. Some hospital chains have become functionally integrated into the tourist industry. Bumrungrad owns 74 serviced apartments and 54 hospitality suites for patients and families, with a swimming pool and fitness facilities. The Raffles Medical Group in Singapore arranges airport transfers, books relatives into hotels and helps arrange local tours. Indian hospitals have similarly become integrated into a wider network, and hotels in

But is it Tourism?

Malaysia have become horizontally integrated with hospitals. In an advertising supplement in Brunei’s national daily newspaper Malaysian hospitals stressed the links with tourism: Vista Vision Specialist was selected as the Best LASIK Centre in the 2006 Malaysia Spa and Wellness Awards hosted by Tourism Malaysia. Vista is located at The Curve, Malaysia’s first lifestyle pedestrianised shopping mall. A four-star boutique hotel is easily accessible and a one minute walk. You and your companions can also enjoy other services such as karaoke, spas, beauty salons, gyms, and even banks and movies at the Cineleisure Damansara. The centres’ strategic vision provides you with a one-stop shopping wonder. To date Vista has performed over 10,000 Lasik procedures in Malaysia of which 20 per cent were foreigners from the US, Europe, Japan, Australia, Singapore, Brunei and many more. (Borneo Bulletin, 12 March 2007)

Costa Rica has specialized in ‘recovery retreats’, hotel or ranch-style accommodation exclusively for recovering patients and close to their hospitals, with the amenities of standard hotels but also staffed by nurses and interns, where patients can recover in a context of mutual support. Linkages sometimes intensified in difficult circumstances. In the wake of the December 2004 tsunami, Thai hospitals in Phuket, like nearby hotels, offered special packages (focused on cosmetic surgery) to revitalize the (medical) tourist industry there. The Phuket Health and Travel website notes: In addition to scheduling your medical treatment, we also arrange your travel and accommodation, as well as any car hire, cruises, tours or other vacation services. You will fly on a scheduled flight to Bangkok, then join a connecting flight to Phuket … After your medical procedure we will then arrange for your transfer to the hotel or resort selected by you, for your relaxation and recuperation. (Phuket Health and Travel, 2010)

In Australia several private hospitals market ‘hotel baby programs’ where they transfer new mothers to five-star hotels to recover from childbirth (Voigt and Laing, 2010).

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Tourism is not merely a separate part of medical tourism. Hospitals have also become linked to airlines. As the Bangkok Hospital Phuket’s website advertised early in 2010, also indicating its regional emphasis: An exclusive deal for AirAsia passengers flying from Jakarta, Medan, Ho Chi Minh City, Hong Kong, and Singapore to Phuket. This campaign is available from 1st of March until 31st of May, 2010. By presenting your AirAsia Boarding Pass and Passport at the Bangkok Hospital in Phuket, passengers can enjoy a comprehensive offer worth THB 2,000 for FREE. (Phuket Hospital, 2010)

Bumrungrad has an agreement with Flight Centre in North America for it to be the preferred travel provider for patients travelling from there. The press release that accompanied the announcement claimed that an annual ‘60,000 patients came from the U.S. and that working through a global travel agency would keep the cost of travel affordable, preserving the price advantages of medical tourism’ (AllBusiness, 2010). In October 2009 Turkish Airlines announced that they were working with the major national medical tourism providers to provide discounted fares from the USA and various European countries for travellers who had made medical tourism bookings in Turkey. In 2010 the Hungarian airline Malev was offering dental packages in Budapest in a host of West European cities (Fig. 9.3). In Hong Kong Dragon Air (a subsidiary of Cathay Pacific) and the Union Hospital worked together to bring in middle-class Chinese mainlanders, with a combination of frequent-flyer points, sightseeing and medical check-ups. Malaysian Airlines offered similar stopover packages in Kuala Lumpur (Reisman, 2010: 130). Thai International have also offered packages and similar arrangements probably exist elsewhere. Over time larger hospitals, where international visitors are particularly important, have integrated themselves into wider elements of the travel industry, to encourage greater numbers and profitability by providing a more wide-ranging service. Such hospitals have become more like MTCs, part of

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Fig. 9.3. Malev Airlines dental packages, 2010.

integrated systems where, if not owning components of the travel industry, they are at least closely integrated into it, with preferential arrangements with particular hotels, airlines and other companies. In some contexts that integration has gone much further with hospitals becoming part of much larger conglomerates (Chapter 10). At the very least, most providers recommend nearby hotels on their websites, and draw revenue from this, as medical care and the hospitality industry become intertwined.

‘It’s a Fine Line between Pleasure and Pain’ If tourism is about travel and the experience of other cultures (however minimal that might be) then all medical tourism is tourism. Usually it is also rather more than that, if only because medical tourists can only return home when they are well enough to be travellers and perhaps therefore tourists. Actual tourism in its conventional sense, including enjoying local sights, sounds and tastes, may involve friends and relatives rather more than the patients themselves, but most patients sample some standard tourist experiences. Most prefer to travel with companions, making the experience less challenging and more pleasurable and drawing it closer to tourism. Yet for some procedures that may be impossible and travel that emanates from the absence of health insurance may not be the obvious place that tourism starts from.

Ironically, despite its name, patients of the Surgeon and Safari company in South Africa may actually be discouraged from going on safari after plastic surgery to ensure proper recovery. More gentle tourism is the preferred option. As its founder has said: Generally safaris take a back seat during the recuperation process, because the clients must concentrate their energies on healing. However we keep our patients occupied with day trips to Sandton City [a shopping mall], cultural villages, Soweto, the Apartheid Museum and other unique experiences. (quoted in Witepski, 2005)

In Thailand ‘a tuk-tuk ride is not recommended for anyone with a weak physical condition or a recovering patient’ since tuktuks, three-wheeled motorized taxis, have minimal shock absorption, are close to the ground, cramped, open to pollution and lack air conditioning (Mabra, 2009). Local driving techniques may also be idiosyncratic and problematic. Much of this is simply stating the obvious: not all tourism is an appropriate sequel to operations. As one testimonial in Thailand noted: Went with this company for dental treatments. Sent my inquiry in, got a quick response with quote. Was helpful with travel arrangements and other things about Thailand since it was my first trip in Asia. Was picked up free at Airport and brought to my hotel. They then picked me up next morning for consultation. Dentist was very helpful and spoke excellent English. Throughout my next two weeks I had gotten veneers on my upper teeth and two implants in the bottom. The only thing I was upset with was I could not go scuba

But is it Tourism?

diving. But I enjoyed my time in Phuket very much and I am very satisfied with my results and the money that I have saved. I recommend to everyone! You will love Phuket!!!!! (Treatment Abroad, 2010)

The more serious the procedure the greater proportion of time is likely to be spent on that, with active tourism improbable after complex and delicate procedures. Others may prefer to recuperate at length, even get used to their ‘new selves’, through tourism, and later see specialists for a final time. Private time with ‘new bodies’ may be more appropriate than their display in resorts. Gender reassignment patients may attend classes in applying cosmetics, visit hairdressers and take part in Thai massage and cooking classes that enhance their new femininity (Aizura, 2009). Almost all visitors spend some time eating and shopping, even if no further than hotel stores, and justify this (should they feel it necessary) in terms of the money saved through overseas medical care. Some may even need new clothes for their new sizes (or even sexes). In any case few can avoid, or wish to avoid, spending some money. Ultimately ‘tourism’ is more than just a cosmetic noun for an activity that may seem to have little to do with conventional notions of tourism. The whole infrastructure of the tourist industry (travel agents, airlines, hotels, restaurants, taxis, etc.) benefits considerably from this new niche. Indeed, since for a significant proportion of patients there may be a lengthy period of recuperation, the rewards to the tourist industry, and especially the hotel sector, are greater than for standard tourism. Medical tourists who are visiting relatives may stay even longer. Where hospitals

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and hotels are clustered together, as in central Bangkok, tourist ‘ghettoes’ have developed drawing in more tourist facilities. This partly explains why some hospitals have sought to diversify into tourism, and why growing numbers of MTCs have played integrative roles. So it is tourism: a rather unusual but increasingly valuable niche in the ever more competitive travel industry. While many painful activities, such as transplant surgery, have no relationship to the pleasure and even frivolity usually associated with tourism, and ‘suicide tourism’ can be excluded, despite its termination of pain and suffering, most components of medical tourism have parallels in other forms of tourism, and obvious impacts on the tourism industry. Ironically, the more dramatic surgical procedures that may seem to define medical tourism, are the ones that are least amenable to linkages with tourism (as warnings about safaris and tuk-tuks emphasize), while such low-level procedures as dentistry exclude almost nothing. Some would find many other kinds of niche tourism uncomfortable, unpleasant and even dangerous – potholing or rock climbing, for example – but they too are all part of the rich tourism family. Equally medical tourism has much in common with VFR, diaspora and MICE tourism, the last where tourists often travel independent of other family members, and spend most of their time engaged in activities that others would find dull, or bereft of pleasure and relaxation. All such activities minimally benefit the infrastructure of tourism. If medical tourism may sometimes seem devoid of hedonistic pleasures – which may also be true of other tourism niches – the long-term outcomes may be exceptionally pleasurable.

10 Global Health

Nigerians are among the most prolific health-related travellers and, given the standard of medical care available in the country, few can blame those who can afford to do so for seeking quality care abroad, even if it costs them small fortunes. (Mordi, 2010: 54) I have just sold my home and I am moving in 3 days … so I would like a facelift to go with my new home! (Gorgeous Getaways’ discussion board, May 2010)

Medical tourism is the last phase in the long history of people travelling in search of better health, long ago evident on the shores of the Mediterranean. Movement to distant places and therapeutic landscapes has existed for over 2000 years in multiple forms. Over time travellers sought more complex and holistic solutions, spiritual and psychological wellbeing became important, and new medical possibilities emerged. As transport costs fell and incomes increased, interests shifted to the East, and diversified to more obvious alternative therapies. Medical tourism has continued to emphasize Asia but alternative therapies, outside spas and ashrams, have given way to more prosaic mobility for biomedical procedures at reduced cost. This has been the global flourish of a continuously expanding diversity of therapeutic places, from the biomedicine of thousands of formal 172

health-care facilities, big and small, through landscapes and places of ‘natural’, ‘traditional’ and spiritual remedies, to the medical tourist destinations of Asia, Latin America and their smaller, younger rivals. While ‘wellness or health tourism’ has more pleasurable and positive connotations than ‘medical tourism’ (or ‘illness tourism’), with its more painful and invasive procedures, they are not inseparable. As ‘clusters’ have developed, where clinics, hospitals, medical institutions, spas and related industries work together (e.g. Novelli, 2006), health care has slowly become more inclusive, and part of a growing global integration through linked facilities, modern technology and holistic care. Tourism too is increasingly structurally integrated into health care and plays some part in binding health and wellness together conceptually and physically. The boundaries between biomedical and alternative therapies have become blurred though never indistinguishable, even as ‘expertise trumps authenticity’ and spirituality founders. The rise of medical tourism in little more than a decade has demonstrated that a form of service provision, the provision of health care, so labour intensive, personal and cultural that it was assumed to be highly localized, can be globalized. This is all the more remarkable since sickness normally induces

© CAB International 2011. Medical Tourism (J. Connell)

Global Health

conservatism rather than expansiveness to a world of opportunities. Just as industries, call centres and the IT industry have moved from developed countries to developing countries, in search of cheaper labour and reduced regulation, the outsourcing of medical care, in medical tourism, has demonstrated that seemingly location-specific economic activity is also not immune to mobility. The ‘export’ of workers for medical examinations and of old people into nursing homes, has taken this to contemporary extremes. Development of medical tourism has followed a growing emphasis on technology and private enterprise, and the attitude that health care can be bought ‘off the shelf’. Medical technology has constantly evolved, raising new ethical issues as the body has increasingly become a playground for ‘experimentation and insight’ (Schultz, 2004: 110). This has posed complex bioethical questions, especially for new and experimental procedures where a variety of differentiated and geographically distinct practices are subordinated to the ‘logic of the market’ (Parry, 2008) in contexts where regulation is weak but where a political economy of hope prevails. Higher incomes, especially in Asia, enhance the probability of accessing new technologies and procedures. Greater expectations, rising affluence, media depictions of what is appropriate and normal have fuelled searches, made feasible by the Internet, MTCs and brand marketing, for alternatives to slow and narrow public choices and perspectives. The emerging middle classes have followed the earlier diasporic travels of the relatively poor and the Western predilections of rich elites. Medical tourism has largely reversed an earlier pattern of wealthy patients from around the world travelling to richworld centres, such as London, and resulted in patients – niche tourists – travelling away from affluent global cities to India, Thailand, Mexico and elsewhere. In a very short time medical tourism has changed direction, incorporated bidirectional flows and become increasingly complex. Globalization has intensified, expanded and diversified such movements in the ever shifting interplay of centre and periphery, as the ‘new’ medical care has shifted from core towards periphery. Yet, as

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the significance of local flows suggests, whether from Indonesia to Malaysia, Bangladesh to India or from the Andes to Chile, contemporary medical tourism may not be greatly different from older hierarchical movements to London. Trade in health services is growing, becoming more competitive, and creating new dimensions of globalization. Yet doubt surrounds the impact and significance of medical tourism in terms of the particular players in origins and destinations (whether countries, hospitals or clinics), in patient numbers and procedures and, weakest of all, in its impact on the travel industry, on local communities, and on the medical tourists themselves. Part of all uncertainty about the future of medical tourism stems from the absence of adequate data. Numbers are inaccurate and largely exaggerated and there are too few studies to assess who most patients are, why they have chosen particular destinations, which are the more successful destinations, and whether growth is actually occurring. Almost nothing has been written about diasporic medical tourists or those from poor countries other than Yemen. Such huge lacunae remain to be filled, and predictions based on superficial understandings of trends are likely to be erroneous. While some of this is unavoidable in a new arena where confidentiality plays an obvious role, the lack of data on even the most basic numbers, and the unwillingness of hospitals to release seemingly uncontroversial data, prevents clear conclusions over temporal, structural and geographical change. It also raises issues about the ethics of the new health-care providers and why such confidentiality reigns, even in a competitive arena. For a better understanding of medical tourism more adequate data are essential.

A New Niche Doubts about what exactly medical tourism is and where its boundaries lie are unable to be easily resolved, but that is true of other niches within the tourism industry. Death tourism provides an extreme and, for many, an abhorrent example, and issues of euthanasia, transplantation and surrogate parenthood,

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in ‘repugnant markets’, have raised many ethical questions, let alone how they relate to tourism. A massive difference separates the substantial economic expenditure that makes transplant tourism possible (however limited that might be, and where the frailty of patients makes any pretence at a practice of tourism improbable) and reclining on a beach after teeth whitening. Likewise massive variations exist between desperate Yemenis requiring urgent medical attention, Mexicans returning home for belated dentistry, affluent British tourists in search of cosmetic surgery and Japanese seeking gender reassignment in Bangkok. Albeit somewhat uneasily and ambiguously they are all part of a new and amorphous niche tourism industry. BIH is often held up as the leader in the field, but its brand image of elitism and longdistance patients disguises a wider reality where regional cross-border movements are dominant. Local movements are usually more important and medical tourists often travel only short distances. Equally important diasporic tourism may be both short and long distance. BIH may be closest to a polar type of medical tourism but even there regional patients dominate. Once the province of the elite, medical tourism has become more democratized, and much more about crossborder and regional mobility than the transcontinental mobility much favoured in media accounts. Elite Europeans may continue to dominate the media and promotional brochures, but there is greater mobility from the Gulf, and many medical tourists are very far from elite. Cosmetic surgery may be memorable, sex changes dramatic and stem cell surgery uncertain, but much medical tourism is quite banal: little more than low-level drop-in procedures, such as dentistry and routine health screening. The more dramatic and more publicized forms of medical tourism are exceptional rather than the norm. The most substantial barrier to the growth of medical tourism is that of marketing quite intimate procedures in distant, sometimes unknown and perhaps impersonal locations. Acquiring the knowledge and confidence that overseas treatment does not have hidden costs and is unikely to be flawed, while linguistic, cultural, culinary

(and even climatic) challenges can be overcome, is difficult. Even in developed countries such as the USA resistance to overseas travel, let alone travel for unfamiliar medical procedures, persists. Where countries are closer and better known, as in Europe, overcoming fear and the tyranny of distance has proved easier. Mobility is more probable for procedures like dentistry that are familiar and not culturally contingent. Migration, international tourism and the media have done much to allay such concerns but, without main-street travel agencies, medical tourism has been a somewhat do-it-yourself activity, based on word of mouth, like other forms of niche tourism. The growth of MTCs (and links with hotels) have drawn it closer to the mainstream, where ‘standard’ travel agencies have tentatively become involved. In much earlier times travel to places such as Harley Street constituted nascent medical tourism, but in an era where international tourism was yet to become important, and niches unrecognized. This raises philosophical and practical issues about what tourism is, ranging from concepts of enjoyment and pleasure (though these are surely present in the adrenalin thrills of extreme sports), and detachment from the everyday (whether exile or escapism), to the role of travel in boosting the tourism industry (which all travel does) and whether invasive medical procedures of any kind are simply too serious to be trivialized as tourism. Surgery demands proper recuperation rather than tourism, and insurance companies are unlikely to appreciate ‘tourism’ as part of an insurance package. However, at the very least, the notion of ‘tourism’ makes medical tourism seem pleasant and enjoyable and less serious and fearful, just as ‘cosmetic surgery’ seems more pleasant and benign than corrective surgery. Almost everywhere patients have some time for conventional tourism. That may not be strenuous or energetic, but shopping, sunbathing and dining are relaxing, recuperative and enduring forms. Tourism may not be the primary reason for travel, but it is anticipated, widely advertised and enjoyed by most patients. This has been accentuated as hospitals themselves have developed close ties and even overlapping ownership with the

Global Health

tourism industry. As competition intensifies, tourism is built into attractive packages, frequent-flyer miles can be gained from operations and hospitals become quasi-hotels: ‘hospitels’. The countries that have gained most from medical tourism are those with reasonable access to markets, and particularly where it can be more effectively linked into a broader health tourism that links invasive procedures to rejuvenation, healthy living and the potential for recuperation in a resort. A partial legacy of past health tourism, and the reputation of the national tourism industry, has proved helpful. While that might seem to offer opportunities for established tourism destinations, only those where high quality health-care services currently exist have been successful, a situation that has posed problems for India. While some have seen growth being based on links with authentic indigenous health procedures and herbal remedies (e.g. Chambers and McIntosh, 2008), this has rarely been feasible and, with minor exceptions in India and Singapore, has neither been tried or succeeded. However, the continued existence of traditional medical procedures (and spas) provides a colourful and exotic backdrop to medical tourism. Despite some convergence, medical tourism has largely been distinct from health tourism, and has emerged and evolved as a distinct niche.

Whose Niche? Medical tourism is the outcome of uneven social and economic development, alongside the convergence of biotechnological development in medicine, middle-class modernity and mobility and the evolution of the airline industry. That is evident with cosmetic surgery accompanying the global celebrity and media age and new vulnerabilities in the global economy (Elliott, 2009). Medical tourism has been a triumph for the private sector, involving a series of players at various levels including the state, public and private health-care providers, regulatory bodies, MTCs and individual patients/tourists but where the market has held the upper hand.

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Governments have, however, increasingly played a role in marketing, supported tourism campaigns that include medical tourism, invested in joint operations and incorporated medical tourism into national development plans, while simultaneously financing public health care. Both health and medical tourism are highly competitive activities. That has created conflict between practitioners in richworld countries and their competitors overseas, and between MTCs and providers, and raised ethical concerns over acceptable and exploitative forms of medical treatment. In the absence of local support, and where patients often find it difficult enough to evaluate and select even a local neighbourhood health-care provider, the growth of medical tourism is quite remarkable. It has offered greater choice to patients (increasingly referred to as ‘health consumers’) in all countries, but alongside a cult of individualism, and where the poor cannot make extensive or expensive ‘choices’. The private sector has distorted some health-care systems by shifting resources from the poor. The best metropolitan hospitals, where medical tourism is a part of their activities, have drawn skilled resources from regional areas and smaller hospitals as part of a continued process combining privatization, urban bias and the weakening and withdrawal of national planning. Inherent inequality has excluded the poor and geographically distant. Medical tourism has played a small part in widening health-care divides in most destination countries as trickle down fails to occur. No hospitals exclusively cater for rich tourists, and invariably more than half the patients are local (albeit relatively well off). While private hospitals in developing counties could not survive only on cash-paying medical tourists (Bookman and Bookman, 2007; Herrick, 2007: 23) they prosper by treating affluent local people. Competition is rife. In Thailand, for example, as BIH’s annual report makes clear: ‘the private healthcare industry is a fragmented market and only a few hospitals are operating close to their full capacity [hence] the competition for patients remains intense’ (Bumrungrad Hospital Limited, 2010: 60),

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and at a time when queues in public hospitals are lengthy and parts of the country poorly served. Medical tourism emphasizes uneven development and the ‘inverse care law’. In the source countries of medical tourists their absence may stimulate some restructuring, competition and cost-cutting, though there is little evidence of this. As the opening quotation to this chapter argues, Nigerians cannot be blamed for seeking superior medical care overseas; the tragedy is that they (and many others) cannot receive effective care at home. The main beneficiaries of medical tourism are the providers (the private hospitals and their staff), the patients and the related tourist industry, while the losers are those who cannot afford the prices of private hospitals and who have reduced access to public health services, whether in source or destination countries.

The Epitome of Globalization? Globalization manifestly offers new opportunities and greater mobility, new flows in a compressed world, yet at the same time it enhances structural inequalities, that tend to empower those who are relatively well off at the expense of the less privileged, so that globalization is far from a uniform process. The globalization of the market for medical treatment parallels what has become a global market for skilled health-care workers (Connell, 2010), the steady privatization of health care and the emergence of global insurance and pharmaceutical companies. This has been matched by the individualization of patients who have an unprecedented freedom to choose as long as they also have a capacity to pay. Patients are both outsourcing and globalizing themselves. Medical tourism epitomizes contemporary globalization in its technological base (from biotechnology to the Internet), its capitalist structure and legal systems, and its increasingly pervasive spread to embrace markets and destinations (many countries acting as both) alongside the withdrawal of the regulatory state and reduced social obligations. Labour and capital markets have become more closely integrated alongside the shift towards a network society.

Long-distance travel for health care has grown at the same time that national healthcare systems, lifestyles and diseases have globally converged, with tropical infectious diseases giving way to lifestyle NCDs such as cancer, obesity and cardiovascular problems, with treatment regimes being comparable. World Trade Organization trade agreements, with standardized EU regulations on crossborder trade in the context of the General Agreement on Trade in Services (GATS), have provided a new more flexible institutional context for cross-border mobility, though progress has been slow. Cross-border movements within Europe, while more feasible institutionally, are expensive and usually only realistic where waiting times are very long (Botten et al., 2004). They have proved most effective where language differences are easily overcome, but even in Western Europe political, cultural and economic factors continue to constrain globalization. Medical tourism is likely to grow as: (i) medical care continues to be funded by overseas investment; (ii) technology improves in developing countries; (iii) word of mouth extends; (iv) marketing intensifies; and (v) significant cost differentials remain. While medical tourism has largely been an individual phenomenon, like other components of tourism, it has acquired some institutional characteristics as governments have become involved. Greater collusion within state systems has developed, patients are encouraged to cross borders (at least in the EU), networks and clusters of health-care facilities span those borders (for example between Luxembourg, Belgium and France), insurance policies provide for and even encourage medical care overseas and some companies ‘export’ workers for health checks. Singapore’s decision in 2010 to enable citizens to use their Medisave funds (accumulated by citizens putting up to 9% of their income into personal accounts) outside Singapore, and for hospitalization and day surgeries in 12 selected hospitals in Malaysia, is likely to substantially boost tourism to Malaysia, since patients could potentially halve their medical bills (Burgos, 2010). In just a few years MTCs have emerged from nowhere to develop global linkages and alliances with hospitals and

Global Health

transport companies. Institutional changes are crucial to the future of medical tourism. As people profess to attach more importance to good health, evident in ‘exercise industries’ and obsessions with the body beautiful (and having it now), they also live longer, develop a more sedentary lifestyle and expect a higher level of service and care, so placing more demands on health services. Those demands and needs are less easily able to be satisfied in rich-world countries where health workforces are static or declining, and services more expensive and effectively rationed. The outcome is greater demand for overseas health care. With the growing global incidence of NCDs, alongside a more sophisticated range of medicines and procedures and shortages of health workers, health costs everywhere can only increase so encouraging further movement offshore in search of cheaper solutions. Increasingly medical tourism is part of a wider globalization of health care involving: (i) the accelerated movement of skilled health workers (inducing some deficits which, in turn, have led to the mobility of patients); (ii) trade in pharmaceutical products; (iii) transnational diagnostic laboratory companies (like Quest Diagnostics); (iv) global NGOs such as Médecins sans Frontières; (v) a rise in international aid programmes mainly targeted at specific diseases (notably the Global Fund); (vi) the emergence of international hospital groups, such as Apollo (as healthcentred transnational corporations); and (vii) the international transfer of radiology X-rays and scans and other ‘back-office’ work, such as medical transcriptions, case mix evaluation and the processing of insurance claims, alongside telemedicine (albeit still limited in an international context). Bumrungrad claims to be a ‘paper-free hospital’, with all medical and other patient records computerized, and able to be instantly transmitted anywhere. Imposition of global standards, whether through JCI accreditation or the registration of cosmetic surgeons, intensifies global linkages. The flattening world of biotechnology has extended to: (i) supply chains of pharmaceutical goods and sperm (directed by Internet orders); (ii) the globalization of surgery via robotics and telemedicine; (iii) web-

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surfing for providers; (iv) expanded global franchises (of hospitals, hotels and MTCs) within large medical conglomerates, such as Kaiser; and (v) call centres in developing countries answering queries from American patients supported by the growing ubiquity of the English language. In fertility tourism, eggs and women are going in multiple directions (pp. 142–3). Teleconferencing and video link-ups have brought patients and providers closer together, and the new electronic social media have enabled collaborations between patients themselves. Patients are more likely to demand that their travel is the outcome of some collaboration and consultation between doctors at home and overseas, so that they are not venturing far into the unknown. Beyond what can be an elite world of privilege, global topography presents a variegated mosaic of economic, social, cultural and political terrains that are anything but flat. Although the world may be increasingly interconnected, with global health scares about infectious diseases such as severe acute respiratory syndrome (SARS) and avian flu, health care is far from ‘flat’ in any meaningful sense, with access to basic care limited by cultural and economic factors, conservatism, intellectual property laws, basic education and, above all, incomes, even within particular countries. Class, poverty, inertia and uncertainty challenge crossing borders so that, despite the primacy of economics (that permits access to certain advanced or expensive treatments), Midwesterners in the USA may be more constrained, or choose to be constrained, than impoverished Yemenis. And, for all that the Internet and websites dominate the marketing of medical tourism, old-fashioned word of mouth remains invaluable, and creates small-scale ‘chain mobility’ ties between particular places. Globalization has distinct limits.

New Geographies Since the 1990s medical tourism has become particularly successful in a handful of middleincome Asian, and also Latin American countries – but notably the Asian ‘big four’ – where the conditions have been right, including the

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rise of a middle class, domestic investment, an emerging skill base and technological change. The current phase of medical tourism has been driven by the forces of transnationalism, both the return of skilled health workers from developed countries to their home countries and the subsequent return of successful migrants, anxious to return home as much for treatment in a familiar cultural setting (but not usually with ‘traditional’ techniques) as for cheaper access to health care. Over time, however, a shift away from dependence on cultural and diasporic ties, as others have entered the market, has given medical tourism a greater economic focus. Shifting demand and shifting provision, notably the growth of cosmetic surgery, have restructured the geography of health care. Diasporic tourism is growing apace, best documented in Mexico but perhaps especially of NRIs. Presently experimental procedures may be validated and transform markets. Were waiting lists to increase further an extension of the policy of sending patients overseas, but presently over short distances, might benefit those countries now seeking medical tourists. Manipulating post-colonial ties, larger Indian companies have negotiated with the NHS about outsourcing the treatment of British patients to India (as a cheaper destination than any in Europe). Currently, at least in the UK, waiting lists are shortening (Hamid, 2010), hence expectations of growth may be unfulfilled. As employers and insurance providers become further involved – which also means the need for accreditation of standards – so global collaboration will increase. Again institutional contexts are critical to the future of medical tourism, even in a context of deregulation and privatization. The number of countries seeking to develop medical tourism continues to grow despite the challenges of breaking into a highly competitive market, where costs matter and word of mouth is vital. Simultaneously MTCs scour the world for new and attractive destinations. Asian success has prompted growing regional and global interest and competition, yet certain countries and regions retain a comparative advantage. Just as spa and health tourism had distinct Asian

advantages (Laing and Weiler, 2008) so medical tourism has drawn on these and taken them further. Asian countries will continue to compete and have a strategic advantage in their proven success, access to large regional markets (especially as China moves further towards becoming a ‘middle-class’ country) and technological development. More than a decade on from the Asian economic crisis, regional consumer markets are growing, and being part of a stable, dynamic industrial and financial region, with Singapore the centre of an expanding pharmaceutical (and IT) industry and with stem cell research centred in the region, has been important. Quite differently, access to Asian traditional medicine may remain advantageous. Having a tourist economy, and the familiarity and infrastructure that goes with that, is invaluable, and partly explains Thailand’s success, compared with Singapore, Taiwan and Korea. Whether the growth of medical tourism will continue to be centred in Asia, and whether it will be controlled by Asian economic interests, remains to be seen. Rich countries can rarely compete and restore the exclusive old order across the panorama of medical care. Since they can only effectively compete on innovation and quality there will always be scope for undercutting them. However, the UK, Germany and the USA have fared well in the competition for elite patients, partly through innovation in areas like fertility. In the minds of many Harley Street will never lose its eminence, and London and other European cities remain major if somewhat forgotten health tourism destinations, at the pinnacle of a hierarchy of resort. Japan (and, worlds away, Iceland and Saudi Arabia) are unlikely to significantly divert flows. Whether in Harley Street, Bangkok or Berlin, the Gulf remains the principal source. For old and new centres of medical tourism, the West is primarily seen as market rather than destination; while China may become a source of tourists the real target is elsewhere. In Israel, the head of the Israeli branch of the MTA has said quite simply: ‘we want to reach markets such as the USA, England and Canada’ (quoted in Haaretz, 10 June 2010). Fortis, in India, welcomed a growth in

Global Health

numbers in 2009 but, as their CEO stated: ‘More than the number, what we are trying to emphasize on is patient arrivals from the developed world – this creates the value’ (quoted in the Economic Times, 27 June 2010). This is the home of the affluent: the most sought-after patients. In theory technology and geography should enable South and Central America to surpass Asia, especially for the North American market. However, there is still inadequate hospital capacity in the Americas and standards are weaker – Singapore has 13 JCIaccredited hospitals, Costa Rica and Mexico have none – hence general quality concerns are yet to be alleviated. All Asian hospitals have websites in English but few in South America (one in Brazil) have English websites, which both points to the dominance of diasporic tourism there and suggests the potential for expansion. Diasporic tourism should benefit such places as Puerto Rico. Likewise Eastern Europe may attract larger numbers, within the expanded EU, either through dentistry or through cross-border movements with national support. Prosperous and peaceful Middle-Eastern states should also experience growth in the regional market. Transport costs are unlikely to fall significantly in the future, as peak oil and carbon reduction pose problems, so that remote places such as Mauritius will be disadvantaged, and newcomers deterred. Regional markets are likely to grow with greater prosperity, and cross-border mobility extend its significance, as it has done in Asia, Central America, Europe and the Middle East. Optimism and hope spring eternal. Wherever new economic opportunities emerge there will be those seeking to exploit and profit from them. Munich International Airport, a private company, hosts a clinic with two operating theatres (Bookman and Bookman, 2007: 91). While most medical tourism has emerged within countries with a relatively sophisticated health-care system (or, at least, where parts are highly developed) it is possible that medical tourism could become more tourism led, as it is in countries like Hungary and Mauritius, where patients drop in for short procedures. Optimism

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extends even to East Africa, notably Kenya, famous for its travel packages; the CEO of African Medical Investments has said: ‘There are huge untapped prospects. East Africa is a tourist hub with world famous untapped sites. World standard healthcare and promotion would ignite a medical tourism drive into the region’ (quoted in Easen, 2009: 81). That may well be true, and the Mombasa Hospital offers kidney transplants, but developing ‘world standard’ care (and marketing this), without affecting local health-care systems, would be an almost impossible challenge. Removing perceptions of Africa as an unsafe, dirty place of famine, malaria and human immunodeficiency virus (HIV)/AIDS would not be easy, and nowhere else in the world has such a shortage of skilled health workers. Similar optimism in Jamaica (Chapter 4) proved unfounded, due to absent skills and regional competition, despite an established tourist economy. Estimates of future numbers are invariably over-optimistic, such as Singapore’s expressed wish to triple medical tourism numbers in a 3-year period, in a high-cost destination in the wake of a global recession, where existing infrastructure is under considerable pressure and there is some resentment at levels of immigration. Perhaps most optimistic of all was the Manager of Marketing for Bombay Hospital who predicted in 2006 that ‘medical tourism would do for India’s economic growth in the 2000s ten to twenty times what information technology did for it in the 1990s’ (Bookman and Bookman, 2007: 3). If only. Steady growth in many countries, but especially those already established, is certainly possible. For latecomers the opportunities for entry are slight, without shifting ethical parameters, and, as in Georgia, this affects only the margins of medical tourism.

The Quest for Global Patients? A large part of medical tourism consists of regional movements and cross-border travel and is often of diasporic tourists, for some of whom procedures are quite straightforward. The smaller numbers of patients who have

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travelled greater distances from developed countries are more sought after since their treatments are more costly, they are more affluent and they are likely to stay longer and become standard tourists. Hospitals have thus sought to go ‘up-market’ in the search for more wealthy patients, a process that has encompassed both the globalization of hospital chains and the geographical extension of such chains towards the market. Globalization of hospital chains is not new. American hospital chains embarked on global expansion in the 1970s, in the Gulf, Europe (where they competed effectively with an unprepared British NHS, and attracted their staff) and especially ‘in those areas with new or expanding wealth or that have become crossroads of international tourism and commerce (e.g. Singapore or Malaysia)’ and Latin America, where they met elite needs, prompting concerns over the loss of revenue to the USA (Berliner and Regan, 1987). Most such destinations were eventually to become the centres of medical tourism. Three decades later chains were emerging from the south, and reversing the process. Affiliations to hospitals in developing countries were initially important, and links were formalized in other ways. A Malaysian hospital announced in 2009 its scheduled signing of a memorandum of understanding with Australia’s Macquarie Neurosurgery to enable renowned surgeon, Dr Michael Morgan, to work exclusively with it to provide high-end neurosurgical procedures. More recently hospitals chains like Apollo became transnational with links between hospitals in the north and in the south, as investment became more important. From seeking markets in distant continents, preferably in Europe and North America, through both accreditation and affiliation with respected hospitals there, medical tourism providers moved on to becoming part of transnational companies (some with interests far beyond health care) and by establishing branches in or close to the markets. Expanding the global reach of medical tourism, especially from Asia, where chains and conglomerates are most visible, is both institutional and structural. Some of the new conglomerates took in more than even the health

and travel industries. Various hospital chains have sought to conclude insurance deals with Western and international insurance companies and other companies, as Bumrungrad has done with Blue Cross of South Carolina to provide a ‘Global Care Option’ (Anon., 2010c), that would guarantee a steady stream of patients. Insurance companies themselves have become global. Aspirations towards a more strategic and thus a more global presence, in being closer to potential patients, are widely evident. Most geographically strategic investments are regional. Taiwanese intentions of building a world-class Chinese language hospital at Subic Bay in the Philippines, to attract a mainland Chinese market, and the ownership by the Formosa Plastics Group of a major hotel in Xiamen, China (Reisman, 2010: 14), and other Taiwanese investments in Guangzhou (pp. 75–6) illustrate the contemporary globalization of medical care, as hospital chains seek to move closer or in to national target markets. Groups such as Apollo, Fortis and Parkway dominate the medical tourism industry in India and Singapore; they and BIH have clinics and other facilities in various parts of South-east and east Asia. The largest international private medical chain in India, Apollo, has partnerships in hospitals in Sri Lanka and Bangladesh, has planned hospitals in Nigeria and Mauritius and seeks further expansion in Africa and the Middle East. Parkway, based in Singapore, owns and operates private hospitals, clinics and laboratories in seven Asian states, and is also involved in trade and property investment (Chapter 5). Regional expansion has been a stepping stone to a more global presence. Parkway and Fortis not only epitomize the growth of hospital chains and globalization in their own right, but their structures have become intertwined, after the 2010 merger when they became much the largest hospital network in Asia. Fortis thus positioned itself to become the regional leader in medical tourism, with a strong presence in India (where it has 46 hospitals) for the most price-sensitive patients, a new base in Singapore for higher-end customers aiming for more luxury and a continental base for global expansion. After acquiring the major

Global Health

shareholding in Parkway, in May 2010, Fortis’ Chairman explained: Parkway is a reputed brand and its size is three times that of Fortis. The next phase of our growth will be well beyond Asia. Our ambition is to strengthen our brand at a global level. First step in this strategy was to penetrate the Indian market, which we have done through Fortis Healthcare and Fortis Hospitals. The next step is to establish a footprint in Asia that will be done through our acquisition of Parkway. Parkway’s strong presence in Malaysia with the Pantai Group gives us great confidence. This gives us a strong platform to leverage our partnership to position ourselves for the next phase of growth outside Asia. This acquisition will significantly expand our footprint across the region and place us strategically and geographically for geographical and clinical leadership in Asia, a big step close to our vision of establishing a global healthcare delivery network. (International Medical Travel Journal, 1 April 2010)

Within months of Fortis acquiring Parkway the investments arms of both the Singapore and the Malaysian government, minority shareowners, were seeking ways to take over ownership. Much smaller companies have also moved towards a global presence. In 2010 the Indian company Narayana Hrudayalaya signed a joint venture with the Cayman Islands government to build a Health City (a 2000-bed hospital) with Indian specialists, a ‘large facility for assisted living for elderly Americans’ and a ‘world-class medical university’ to train doctors and nurses from the Americas. However, as the company’s Chairman stated: The main purpose of building a hospital in this region is based on the impact of health reforms in USA. We believe that the waiting list for operations will force the insurance companies to send their patients to Cayman Island [sic] which is a first world country less than one hour from Miami. We believe that these patients will find it very inconvenient to travel to India because of the distance. (Express Health Care Management, 2010)

In this drive for market access, global expansion and corporate control the role and content of health care itself was never prominent.

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Emerging, expanding and evolving chains, conglomerates, medical cities (below) and institutional linkages have involved increasingly complex transnational relationships gradually embracing hotels, hospitals, travel agents (including the rapidly expanding MTCs, with their websites and guidebooks) and tourist-related services such as airlines. The larger hospitals themselves are engaged in more than health care, let alone medical tourism, exemplifying the complex structures of privatization. Medical tourism has contributed to the privatization and profitability of health care and the incorporation of hospitals in transnational business circuits. Rather differently localized conglomerates have been more loosely created in emerging ‘health-care cities’ that bring various activities together. The prototype, DHCC, begun in 2007 in collaboration with Harvard Medical International, sought to provide a range of medical and wellness facilities on one site, along with small businesses and retail establishments, including banks and restaurants. By early 2010 it had two hospitals, 90 clinics and branches of globally famous medical institutions such as the Mayo Clinic and Moorfields Eye Hospital, but the GFC had delayed construction of hotels, apartments and other facilities. Some 220,000 patients were treated in 2009; while 10% were not UAE nationals most were probably local or regional expatriates. Monterrey has proclaimed itself a health-care city but integration of facilities is limited. At a much smaller scale, Villa Medica, a subsidiary of a residential development company, Nusasiri, built a ‘boutique resort and hospital’ in Phuket (Thailand), offering alternative and conventional medicine, surgery, spa therapy and rehabilitation. Phuket was chosen, according to the company’s Vice President ‘because foreigners recognize Phuket is now the medical hub of this region’ (quoted in Jitpleecheep, 2010). The company previously constructed the Bangkok Mediplex Centre (in alliance with the Singapore-based Pacific Healthcare), providing a variety of health-related businesses, from beauty clinics and organic supermarkets, to Korean surgery and ophthalmology, connected to a prestigious serviced apartment complex (Cabrera, 2009c). A

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construction company has thus expanded into health care, incorporated a holistic range of treatments, sought new overseas markets and drawn overseas surgeons towards the Thai market. Much less grand and ambitious than DHCC these are effectively small ‘one-stop shops’ for health and medical care. While conglomerates in Asia have spread towards developed countries, health-care providers in those countries have themselves expanded outwards in more familiar circumstances. Early in 2010, for example, the Harley Street Fertility Centre merged with the London Fertility Centre to concentrate its British operations with the founder of the Centre moving to Mauritius to expand development there, rather than in the UK (p. 40). Ensuring a stake in distant market demands some degree of mobility, flexibility, competiveness and globalization. Just as Bumrungrad has invested in a private hospital in Abu Dhabi, to move closer to the market, so some US dentists, recognizing the challenge of Mexican competition, have set up branches of their own businesses there to take advantage of lower costs. The Dallasbased International Hospital Corporation has built and operated hospitals in Mexico that meet American standards. Harvard Medical International has given affiliations, and therefore imprimatur, to emerging hospitals in their own search for profitability. This ‘multinationalization’ of health businesses is likely to continue, and reflects similar but more long-established practices in the tourism industry, and in the manufacturing sector, as companies seek to escape what amounts to local protectionism and tariff barriers. Medical tourism has not just been one component of the globalization of the health-care industry it has actively influenced it. Privatization has ensured that hospitals have become increasingly like businesses, even to the extent that they have been described as ‘focused factories’ where tasks and procedures have been streamlined for maximum efficiency so that they operate much like ‘a Toyota automotive plant’ (Herrick, 2007: 12). The implication of an impersonal robotics is at some variance with the expressed emphasis on care. Given that focus, at the very least in advertising, any

notion of a production line is harsh, though there is irony in Bumrungrad’s use of car metaphors for comparative prices. The Rajan Dhall Hospital in New Delhi, however, is said to use a business model that combines the personalized service of a hotel with the industrial processes of car manufacture, both industries in which its senior executives had previous experience, one of whom described the hospital as ‘a hotel providing clinical medical excellence’ and ‘we run [it] like a business. It is no different from when I ran a hotel’ (quoted in Stokes, 2007: 37). Executives, like the CEO of IndUSHealth (Chapter 6), move between sectors and industries, and, evident in magazines like Medical Tourism Magazine, excel in the language of business and management efficiency, regularly quoting business gurus such as Peter Drucker, in a world of clients and consumers rather than patients. The executive summary of Bumrungrad’s Annual Report 2009 stated that it was ‘aggressively looking for additional healthcare opportunities in the region’ while its CEO noted that it ‘continues to find ways to leverage its brand and intellectual property to open future business opportunities’ (Bumrungrad Hospital Limited, 2010: 56; my italics). Beyond the words there is a corporate style. Rajan Dhall has a waiting room that is ‘more airport business lounge than public health clinic’ (Stokes, 2007: 40). Bumrungrad has a Healthy Living Club that, in an exact analogy with frequent flyers, offers club rooms, discounts and privileges to regular visitors. Bangkok Hospital has a similar Perfect Diamond card. Hospitals are listed on stock exchanges. Some have open days. Many publish glossy brochures, magazines and newsletters. In these evolving private spaces and places ‘The patients are refashioned as consumers and the healthcare system is becoming part of the consumer’s world’ (Kearns and Barnett, 1997: 173) not least in the physical form of ‘hospitals as hotels’. Indeed some have seen the emerging relationships between hotels, hospitals and nearby places of consumption as a shift towards ‘health theme parks’ (Lefebvre, 2008). The rise of health care as consumption, long apparent in wellness and spilling over into the cosmetic

Global Health

components of medical tourism, has brought a more homogeneous world, where branding is as crucial as technology, comfort and care. Globalization and advanced capitalism have gone hand in hand, extending the range of the private sector, consolidating chains and conglomerates in form and function, and begun to re-orient the geographies of health care that constitute medical tourism back towards the developed world and its more wealthy patients.

A Final Cut Tourism is notoriously sensitive not merely to economic shifts, such as through currency fluctuations, but above all to crime and political unrest. Medical tourism is even more sensitive. The aftermath of the GFC in the USA was a decline and deferral of plastic surgery (Saint-Louis, 2010), but a boost for Central America as North Americans found it more difficult to pay for health care at home and increased numbers went overseas (though others could afford neither). In Thailand, more distant from sources, the GFC resulted in a downturn in numbers. When it experienced political problems early in 2009 (with the international airport blockaded for a week) overall tourist numbers fell, as did the number of medical tourists, as they were to do again a year later (Chapter 7).Visitors went to other places where they felt safer or stayed at home. In a vastly different political sense, insurance policies and practices change. The repercussions of the changes to the US health system in 2010, set in place by President Obama, notably the provision of insurance to those millions without it, will have a considerable influence on the medical landscape with medical tourism experiencing some decline. Though the future is inevitably uncertain, incomes and health care will remain uneven across international borders and hierarchies of resort take advantage of these. Medical tourism will always be geographically uneven, not just in the relatively small number of countries who are the primary beneficiaries, but because, with exceptions, the new medical tourism is a metropolitan and middle-class phenomenon

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that has taken advantage of the best hospitals and practitioners in particular countries and, alongside privatization and deregulation, has skewed, however slightly, national structures of health care. Despite the complex but overlapping typology of medical tourists it remains largely regional, cross-border and diasporic, but with the potential to become more global. With rare exceptions, such as Thailand, it is concentrated in ‘backyards’ not ‘playgrounds’. Market mechanisms have become increasingly important. National structural changes may challenge such trends but in an expanding phase of neo-liberalism that seems unlikely. Outbreaks of strange diseases in tropical countries, such as SARS and avian flu, may dampen the enthusiasm of all tourists. Medical tourism will also be uneven because of the intense competition for patients, while every part of the tourism industry is subject to shifts in fashion, finance and flight paths. Supply may run ahead of demand in times of economic downturn, accounting for the entry of countries such as Iceland and Latvia, while the anticipated middle-class Chinese market may easily be reversed depending on structural changes in Chinese health care that might extend medical tourism from the Russian Far East. Cruiseship medical tourism may take patients out of countries but not into new jurisdictions. Conservative Americans may acquire passports. Speculation also attends structural changes in source countries that might reduce waiting lists, introduce cost-cutting technology or even reduce the demand for cosmetic surgery. The substantial restructure of the American health-care system in 2010, with its probable influence on medical tourism, demonstrates how easily significant changes can happen. The nature of future medical tourism is also uncertain. The cosmetic surgery industry is more likely to prosper than decline, especially where body image is important for employment, and obesity is rampant. Status anxiety, and the body as self-expression, have no small roles to play (as the second opening quotation of this chapter indicates). And, for some, cosmetic surgery has become tantamount to lifestyle. A further post on the same Gorgeous Getaways discussion board a couple of days later read:

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Counting down the days now. Back to KL [Kuala Lumpur] for some more surgery. Partner coming along for some too. Getting arm and back lift, tummy tuck. Partner lipo neck and tummy area. Looking forward to seeing all the GG people again as I had a great time last time I was over.

Increasing numbers of people are willing and able to pay more (sometimes much more) to be well and look better, but also to avoid waiting lists, high costs, arrogance and cultural dissonance at home, by becoming medical tourists. Many see this as an entitlement. Others are effectively forced to travel, because of urgent needs. Increasing links between traditional and modern systems may develop as holistic therapies become more popular (and the most ‘modern’ hospitals like Bumrungrad now have wellness centres) than purely medical interventions. Good health demands a holistic approach, which in terms of medical tourism involves greater integration of spas and surgery, but perhaps also some withdrawal from materialism, individualism and consumerism, though that seems unlikely. Medical tourism is probably slowly growing out of infancy. In an unequal world it meets many genuine needs, and offers greater patient autonomy. However, whether that growth is healthy in terms of rising materialism, the continued obsession with body shape, self-indulgence and the distortion of

health care in various countries raises questions. The growing privatization of health care, its drift away from traditional notions of ‘family doctors’ and neighbourhood care, and consequently growing international competition for markets, has meant that health care is increasingly global rather than local and is to be traded, evident in GATS, rather than a right. In health care, as in other spheres, greater familiarity, availability, access and quality are all part of globalization. The Internet and global media have led to a democratization of health information. Convenience and speed are central to modernity, as they are to medical tourism, which has grown from the conjuncture of all of these. It has become a particular niche in the tourist industry, even if, in many contexts, gravity and distaste for apparent frivolity may discourage use of the term. Whether it is tourism, medical travel and procedures abroad or ‘transnational medical care’, it would seem to have a healthy future. Ironically, that ‘healthy’ future will continue as long as providing medical care takes priority over creating and sustaining good health, and as long as preventative health care and PHC are marginalized, and demands for the instant body beautiful take priority. The future will be a more competitive, corporate and uneven one, where healthy medical tourism mirrors the inadequacies of national health-care systems.

Appendix I Destinations and Delivery

Country Antigua and Barbuda Argentina Australia Austria Bangladesh Barbados Belgium Bolivia Brazil Bulgaria Canada China Colombia Costa Rica Croatia Cuba Cyprus Czech Republic Dominican Republic Ecuador Egypt El Salvador Estonia Finland France Germany Greece Guatemala

Destination country where MTCs offer treatmenta 0 10 3 10 1 1 34 1 14 5 4 2 4 14 31 1 54 17 2 1 9 3 2 1 25 20 17 2

Country where MTCs are based 1 5 10 9 0 1 26 1 8 5 9 1 2 6 24 1 44 12 1 0 5 1 2 1 15 18 15 2 (continued )

© CAB International 2011. Medical Tourism (J. Connell)

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Continued

Country Hungary India Indonesia Ireland Israel Italy Jordan Korea (South) Kyrgyzstan Latvia Lebanon Lithuania Macedonia Malaysia Malta Mauritius Mexico Mongolia Morocco Nepal Netherlands New Zealand Norway Oman Pakistan Panama Peru Philippines Poland Portugal Romania Russia Serbia Seychelles Singapore Slovakia Slovenia South Africa Spain Sweden Switzerland Syria Taiwan Thailand Tunisia Turkey UAE UK Ukraine

Destination country where MTCs offer treatmenta 69 116 1 3 5 6 3 11 0 7 1 6 3 16 16 2 16 0 1 2 6 1 3 0 2 4 3 12 37 3 13 6 6 1 13 6 2 23 79 0 8 2 5 37 6 50 4 3 3

Country where MTCs are based 49 89 0 5 4 5 1 5 1 4 0 5 0 8 8 3 8 1 0 1 5 5 2 1 1 3 2 7 27 2 10 3 4 0 7 5 2 19 66 2 7 1 4 15 5 38 1 74 2

Appendix I Destinations and Delivery

Country USA Venezuela Vietnam Not specified Regions Asia Africa Europe Indian Ocean Latin America West Indies Worldwide services Total

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Destination country where MTCs offer treatmenta

Country where MTCs are based

14 2 3 9

33 1 3 41

Region where MTCs offer treatment 3 1 3 1 2 1 8 957

Region where MTC is based – – – – – – – 820

a For example for Argentina this means that ten MTCs somewhere in the world offer the possibility of treatment in Argentina and there are five MTCs based in Argentina (source: Treatment Abroad, 2010).

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Index

Page numbers in bold type refer to figures and tables. abortion 1, 5, 48, 118, 137, 140–144 Abu Dhabi 69, 117, 155, 182 accreditation 2, 3, 11, 51, 52, 63, 65, 70, 71, 85–7, 130, 156, 177, 178, 180 global acceptance of standards 177, 178 Joint Commission International (JCI) 51, 52, 63, 65, 71, 86, 86–87, 105–7 marketing role 85–87, 98–99, 106 acupuncture 6, 10, 14, 25, 26, 90, 113 advertising see marketing aesthetics x, 7, 8, 31–2, 37–8, 129 affluence xi, 9, 24, 42, 50, 53, 56, 118–9, 125, 160–1, 173 luxury health and spa tourism 31–33 Afghanistan 24, 55, 115, 119 ageing 2, 29, 35, 36, 37, 42, 77, 120, 138 baby-boomers, demands and expectations 35, 42, 120 transnational retirement 1, 48, 73, 76 agriculture 8, 10, 16, 134, 162 aid 4, 5 air transport 2, 5, 46, 68, 71, 97 business links (airlines and hospitals) 68, 169, 170 Albania 52 Angola 67, 117 anonymity 47–48, 124, 144 Antigua 49, 93, 185 Apollo Hospitals 69, 70–71, 85, 87, 115, 128, 131, 150, 152–153, 168, 177, 180 international expansion 71, 180 marketing 107–108, 147–148

Argentina 49, 50, 57, 91, 92, 96, 99, 185 aromatherapy 14 Asian financial crisis (late 1990s) 61, 62, 63–4, 65, 66, 71, 73 astrology 10, 69, 165 Au Bon Pain 69 130, 166 Australia 4, 5, 11, 12, 14, 24, 25, 27, 28, 32, 36, 37, 39, 43, 44, 45, 48, 56, 58, 63, 67, 68, 81, 82, 84–5, 86, 87, 89, 91, 93–100, 103, 113, 114, 115, 118, 123, 125, 127, 128, 133, 134, 136, 141–2, 145, 146, 155, 156, 157, 162, 163, 164, 169, 180, 185 Austria 51, 57, 58, 143, 185 authenticity 3, 16, 22, 30, 33, 35, 40, 172, 175 Ayurvedic medicine 25, 27, 33, 35, 40, 45, 69–70, 162, 165 Azerbaijan 52

baby boomers 35, 120 Baden-Baden (Germany) 13 Bahamas 28 Bahrain 67, 115 Bali 30, 31, 33 Bangkok Hospital 68, 107, 111, 130, 164, 167, 169, 182 Bangladesh 56, 67, 68, 70–2, 114, 115, 118, 119, 150, 173, 180, 185 Barbados 56, 67, 68, 70–72, 114, 115, 118, 119, 150, 173, 180, 185 bariatric surgery 50, 117 Bath (UK) 13, 14, 19 203

204

Index

bathing 12–13, 19–20, 32 Beach Boys 110 Beatles 25 beauty x, 7, 8, 31–2, 37–8, 129 beauty treatments 31–32, 165, 169, 181 Belarus 51, 143 Belgium 10, 13, 185 Berlin 3, 178 Bermuda 45 Bhutan 28, 70, 115 blogs 91, 105, 109–110, 129, 177 Blue Cross/ Blue Shield 131, 180 body image 7, 37–8, 41, 183–184 Bolivia 50, 185 Borneo 28 Botox injections 14, 36, 75, 165 Botswana 117 brain drain 149, 150, 152 Brazil xi, 49, 50, 57, 86, 91, 96, 103, 125, 138, 139, 179, 185 breast surgery 7, 36, 48, 82, 85, 90, 95, 100, 122, 123–124 Brighton (UK) 19–20 Brunei 71, 72, 73, 126, 165 Brych, Milan 5 Bulgaria 185 Bumrungrad International Hospital, Thailand (BIH) 7, 48, 62, 63–9, 66, 76, 89, 92, 96, 104, 109–10, 115, 117, 120, 129, 130, 133, 136, 149, 153, 163–7, 168–9, 175, 177, 180–2, 184 marketing strategies 65, 105, 106, 108–109, 115, 116, 164, 166, 166 translation facilities 64, 65 bureaucracy 70, 120, 121, 148, 153, 155 Burma (Myanmar) 5, 67–8, 71–3, 77, 114, 131 bushwalking see hiking Buxton (UK) 14, 15 Byron Bay (Australia) 25

Cambodia 64, 67–8, 72, 76, 115, 118 Campbell, Naomi xi Canada 3, 4, 21, 39, 43, 45, 54, 68, 70, 86, 92, 98, 114, 115, 117, 128, 129, 141, 156, 165, 178, 185 equity issues 156–157 waiting lists, non-urgent surgery 43 cancer 5, 9, 20, 26, 36, 40, 44, 48, 58, 73, 76, 77, 92, 118–9, 120, 123, 129, 144, 146, 147, 155 capitalism 69, 95, 157–158, 166, 176, 181–183 cardiac surgery see heart surgery Caribbean 20, 35, 39, 49, 54, 55, 93, 103, 154, 165 Carson, Rachel 24 Casteneda, Carlos 25 Cayman Islands 181 celebrity culture xi, 26, 35, 36, 37, 48, 75, 175 children 39, 40, 48, 58, 122, 140–2, 152, 153

Chile 50, 162, 173 China 8, 9, 17, 56, 67–9, 71–2, 75, 76–8, 114, 115, 134, 139–40, 144, 145, 148, 178, 180, 185 cosmetic surgery demand 8, 38 middle class 62, 75–76, 78 traditional medicine 53 transplant organ sources 139, 140 Chiva Som (Thailand) 33–5 Chopra, Deepak 29 class 3, 8, 14, 19, 20, 34, 42, 53–4, 58–9, 62–4, 76, 78, 143, 157, 169, 173, 175, 178, 183 Cleopatra 12 cloning 140 coastal resorts 14, 19–21, 24, 71, 160 Colombia 45, 49, 50, 83, 85, 122, 126, 185 colonialism 18–19 compensation 15, 82, 84, 98, 157 complications 81–4, 122, 139 see also legal liability confidentiality see anonymity contraception 1, 140, 141, 144 Cook Islands 5 Coronation Street xi corruption 20, 139, 153 cosmetic surgery x, 1, 2, 5, 6-7, 8, 9, 10, 23, 35–8, 39–41, 42–4, 47–8, 50, 51, 56, 59, 61, 63, 68, 69, 81–4, 74–5, 93, 100, 101, 106–7, 115, 117, 122–3, 134, 137, 164, 183 see also dentistry Costa Rica 3, 50, 57, 83, 85–6, 95–6, 102–4, 115, 117, 122, 123, 129, 130, 131, 133, 134, 141, 144, 150, 166, 169, 179, 185 costs see prices counterculture 24, 25–26, 30, 32 crime 50–51, 102 Croatia 57, 91, 185 cross-border medical tourism 5, 10, 43, 45, 51, 56, 58–9, 64, 67, 77–8, 113–7, 118, 174, 178, 180, 181, 183 cruise-ships 12, 21, 162, 183 Cuba xi, 3, 49, 52, 57, 85, 86, 104, 107, 114, 120, 132, 150, 153, 162, 185 health-care quality and accreditation 86, 107 marketing image 85 sources of medical tourists 49 culture in medical tourism 2, 4, 17, 23–4, 30, 45, 58–60, 68, 73, 74, 79, 87, 92, 100, 107, 111, 114–5, 111, 125–6, 130, 146, 161, 176, 178 see also diasporic medical tourism, ethnicity, language Cyprus 40, 52, 55, 57, 89, 93, 120, 140, 185 Czech Republic 13, 15, 32, 51, 57, 96, 143, 163, 185

data see statistics ‘death tourism’ (euthanasia) 48, 145–146 Denmark 10, 26, 48, 141 infertility tourism 48, 141

Index

dentistry 48, 51, 84, 85, 106–7, 113, 117, 118, 123, 134 cosmetic 7, 8, 11, 43, 68, 80, 81 tourism x, 2, 5, 6, 9, 88, 97, 123, 128, 134, 163–164, 168, 169, 170 detoxification xi, 1, 27, 34 DHCC (Dubai Healthcare City) 55, 156, 181–182 diasporic medical tourism 1, 4, 10, 26, 49, 50, 45, 54–5, 58, 59, 70, 71, 89, 114, 125–6, 146, 161–2, 178, 179 Mexico 44, 45, 50–51, 58 diets x, 6, 7, 9, 10, 27, 28, 34, 35, 37, 38, 42, 158, 160 Dignitas 145–146 diseases 13, 15–16, 18–20 non-communicable (‘diseases of affluence’) 9, 129, 176, 183 see also cancer, obesity, tuberculosis doctors 6, 11, 19, 27, 38–40, 43–6, 52, 55, 58, 63, 77, 83, 85, 88, 92, 98, 103, 105–8, 114, 120–1, 125–9, 140, 181 migration 51, 63, 69, 70, 149–151, 154, 156 Dominican Republic 49, 91, 104, 145, 185 ‘drop-in’ procedures 4–7, 51, 52, 62, 80, 118, 168, 174 Drugs 24–5, 145 Dubai (UAE) 55, 69, 86, 104, 115, 156, 181–2 Dusit Medical Group 64, 68

ecology 24, 25–6, 111 economic impacts 62, 132–4, 136, 142, 147–8, 153–6 ecotourism 28, 50 Ecuador 49, 50, 104, 185 education 33, 114, 153, 161, 177 Egypt 13, 39, 40, 44, 55, 57, 79, 92, 112, 114, 119, 139, 185 El Salvador 96, 131, 185 elitism 3, 12, 16, 18, 19, 24, 33, 34, 38–40, 42, 48, 54, 56, 59, 76, 81, 113, 117–9, 130, 132, 152, 154, 157, 173–4, 177–8 emotion 17, 26, 29, 60, 142, 161 employment see work entitlement x, 2, 10, 37, 172, 183 environment 10, 16, 21, 22, 24–5, 29 see also therapeutic place Epidaurus (ancient Greece) 12, 13, 16 Equatorial Guinea 54 equity 21, 133, 138–9, 149–53, 155–8 see also uneven development Estonia 185 ethics 34–5, 48, 92, 98, 137–138, 146–7, 157, 179 death tourism (euthanasia) 145–146 organ transplants 138–140 reproductive (fertility) tourism 140–144 stem cell therapy 144–145 Ethiopia 46, 67, 70–1, 115, 117 ethnicity 8–9, 36–7, 45–6, 63, 115, 116, 142–3

205

eugenics 141, 145 European Union (EU) 3, 10, 43, 46, 56, 114, 115, 119, 130, 143, 151, 155, 179–80 euthanasia (death/suicide tourism) 1, 7, 48, 145–146 exercise x, 9, 12, 20–2, 27, 29, 34, 35, 38, 98, 158, 177 expatriates 4, 54, 59, 62–4, 67–71, 89, 113–4, 156, 181 expenditure 45, 100, 102, 132–5 see also shopping eye surgery 3, 8, 35, 36, 37, 43, 49, 73, 75–6, 117, 119, 152, 165 see also Lasik eye surgery

facelifts see cosmetic surgery family see relatives and friends Fatima (Portugal) 12, 17, 40, 146 Federated States of Micronesia (FSM) 55, 76 feng shui 10, 29 fertility treatment (IVF) 39, 48, 53, 54, 56, 83, 90–1, 104, 117, 126, 140–4, 154, 155, 157, 165–7, 177–8 Harley Street 40, 182 Fiji 32, 55, 56 Finland 15, 120, 185 Flight Centre 158, 169 food 28, 118, 134 Fortis Healthcare 71, 72, 107, 115, 178–81 France 10, 12, 13, 14, 17, 19, 34, 36, 44, 54, 57, 68, 114, 126, 130, 164, 176, 185

gender reassignment (sex change) 36, 47, 48, 53, 61, 137, 106, 171, 174 selection of children 140–1 General Agreement on Trade in Services (GATS) 176, 184 Georgia 52–3, 60, 141, 142, 157, 179 Germany 10, 13, 14, 21, 32, 34, 51, 54–8, 67–8, 81, 114–5, 119, 141, 143, 163, 178, 185 Ghana 67 Gilbert, Elizabeth 30 global financial crisis (GFC) 11, 36, 51–52, 66, 136, 183 globalization 11, 40, 49, 60, 92, 138, 172–173, 176–177, 178, 182–184 see also transnationalism Gorgeous Getaways 37–8, 100, 153 business growth 93, 96, 97–99 discussion board 124, 127–128, 133–134 marketing and advertising 87–88, 99, 100, 101, 109, 128 government policies 11, 14, 39, 44–45, 49–56, 60, 69, 73, 133, 154, 155–156, 162 Greece 12, 13, 16, 40, 55, 57, 185 Guam 55, 76

206

Index

Guatemala 185 guidebooks 6, 13, 24, 87, 88–9, 101–4, 162–3 Gulf states 38, 44–5, 55, 59, 63, 66, 67, 68, 70, 86, 115, 130–4, 156, 174, 178, 180

hair restoration x, 44, 47–48, 53, 66, 91, 106 Harley Street, London (UK) 3, 38–40, 41, 174, 178, 182 Harrogate (UK) 14 Harvard Medical International 71, 87, 181, 182 health (wellness) tourism xi, 5–6, 7, 12, 21, 26–35 healthcare provision, national 3, 143, 150–7 healthcare cities 55, 87, 156, 181–2 health insurance 1, 2, 10, 42–5, 48, 49, 50, 54, 58–9, 60, 73, 83–4, 98, 114, 118–23, 130–1, 136, 153, 174, 176, 177, 180 heart surgery 45, 54, 55, 72, 83, 86, 98, 120, 153 comparative costs 122, 122, 123 conscious coronary artery bypass (COPCAB) 45, 107 herbal medicine 10, 27, 29 hiking 1, 7, 160 hill stations 14, 18–19 hip replacements x, xii, 7, 10, 43, 45, 70, 76, 131 cost comparisons 72, 122, 123 hippie trail 24, 25 Hippocrates 12, 13 holistic therapies 2, 5–6, 9–10, 23–6, 30–5, 40–41 homeopathy 26, 165 Hong Kong 32, 53, 56, 67, 69, 86, 91, 95, 115, 168–9 hospitals 64–68, 67, 107, 129–130, 166–168, 167, 166–168, 167, 170 transnational chains 68–69, 70–73, 177, 180–2 see also individual hospitals hot springs 13, 14, 16, 34 hotels 4, 13, 31–3, 78, 92, 124, 133–4, 171, 182 hospital linkages 55, 166–170, 175, 182 Hungary 13, 43, 51, 57, 89, 91, 93, 96, 114, 118, 128, 134, 162–3, 179, 186

Iceland 13, 16, 51–2, 178, 183 identity 2, 41, 161 India x, 2, 3, 8–9, 14, 16, 17, 18, 25, 27–8, 30, 36, 40, 43, 53, 56, 57–9, 61, 63, 64, 68–71, 72, 73, 74, 76, 77, 78, 81, 83–6, 87, 91, 93, 95–6, 97, 98, 99, 103, 104, 106, 107, 109, 114, 115, 119, 121–3, 125, 126, 128, 129–33, 137, 139–44, 145, 147–55, 157, 161–2, 165, 167–8, 173, 175, 178, 179, 180, 181, 186 health worker shortages 149 public and private sector inequality 147–148, 152–153, 155 Indonesia 35, 62, 71, 72, 73, 77, 91, 114, 115, 118, 126, 132, 155, 165, 173, 186 insurance see health insurance

International Medical Travel Association 104 International Medical Travel Journal 105 International Standards Organization (ISO) 86 Internet 43, 46–47, 79, 89, 127–129, 177, 184 inverse care law 149, 175–176 in vitro fertilization (IVF) 39, 48, 49, 54, 69, 83, 85, 123, 126, 140–3 Iran (Persia) 12, 55, 104, 139 Iraq 54, 119 Ireland 5, 17, 27, 43, 48, 86, 90, 115, 131, 141, 143, 156, 186 islands 4, 19, 32–3, 44, 55 Israel 17, 54, 57–8, 60, 115, 126, 132, 138, 140, 141, 154, 178, 186 Italy 12, 13, 30, 35, 39, 51, 54, 68, 86, 141, 146, 156, 186

Jamaica 49, 179 Japan 9, 13, 14–16, 35, 37, 48, 55, 63–4, 66, 67, 68, 70, 73, 74, 76, 77, 91, 93, 105, 107, 111, 112, 114, 115, 126, 130, 131, 140, 142, 161, 166, 169, 174, 178 Jerusalem 17 Joad, Cyril 21 Joint Commission International (JCI) 65, 86–7, 95, 106–7, 113, 177, 179 Jordan 44, 54, 55, 58, 84, 104, 114, 119, 132, 186

Karlovy Var, Karlsbad (Czech Republic) 13 Kashmir 17, 18 Kazakhstan 52 Kenya 28, 48, 54, 179 Kerouac, Jack 24 kinship see family Kiribati 114 knee reconstructions 10, 43, 83, 120–23 Korea, South 9, 68, 74–5, 76, 86, 89, 91, 96, 102, 107, 114, 125–6, 133, 144, 161, 178, 181, 186 Kuwait 40, 67, 70, 115 Kyrgyzstan 15, 186

language 10, 49, 54, 56, 58, 59, 64, 73, 74, 91, 105, 110, 111, 115, 119, 120, 126, 179 bilingual staff 50, 51, 126 interpreters 39, 64, 65, 77, 107 Laos 68, 77 laparoscopy 122 Lasik eye surgery 35, 43, 44, 91, 168, 169 Latvia 51, 57, 114, 154, 183, 186 Lebanon 55, 79, 186 legal liability 83–84, 121 Libya 40, 44, 54–5, 71, 114, 126, 156 liposuction 35, 36, 37, 83, 118, 122 Lithuania 85, 186

Index

Lonely Planet 163 Lourdes (France) 12, 17, 40, 146 Luxembourg 10, 56, 145, 176

Macau 56 McDonald’s 130, 163, 166 Macedonia 186 magazines, in-flight 43, 80, 106, 163 makeovers see cosmetic surgery Malaysia 2, 3, 11, 34, 35, 37, 39, 48, 53, 57, 58, 60, 61, 62, 64, 68, 70, 71, 72, 73, 73, 74, 76, 77, 82, 83, 85, 86, 89, 91, 92, 95, 96, 99, 100, 102, 104, 109, 114–5, 117, 118, 122, 124, 126, 128, 132, 133, 137, 149, 150–1, 153, 154, 161, 162, 163, 164, 165, 169, 173, 176, 180, 181, 184, 186 Maldives 70, 141, 145 Malta 52, 57, 58, 59, 71, 79, 114, 143, 156, 164, 186 Maradona, Diego xi marketing 61–63, 77–78, 79–81, 85–87, 88–92, 101–104, 105–8, 110–111, 159–60, 162–166, 178, 182 see also medical tourism companies, patient testimonials massage 7, 10, 12, 14, 27, 33, 98, 113, 171 Mauritius 40, 43, 47, 70, 106, 115, 163, 179, 180, 182, 186 Mecca (Saudi Arabia) 17, 55 media xi, 2, 7, 9, 30, 37, 43, 47, 49, 80, 81, 87–88, 89, 106, 127, 133 Medical Tourism Association 11, 104–5, 178 medical tourism, definition 4, 6 medical tourism companies (MTCs) 7, 46, 47, 49, 57, 92–101, 102, 104, 121–4, 131–132, 185–7 Medical Tourism Magazine 91, 105 meditation 1, 10, 25, 27, 28, 30 Mexico 2, 4, 24, 25, 28, 44, 45, 48, 50–51, 56, 57, 58–9, 83, 85–6, 88, 91, 93, 94, 96, 97, 103–4, 114, 118, 120, 123, 125–6, 129, 131, 134, 139, 143–6, 151, 154, 168, 173, 174, 178, 179, 182, 186 diaspora, return for healthcare 44, 45, 50–51, 58, 125 MICE (meetings, incentives, conferences and exhibitions) tourism 4, 161, 162, 163, 171 Middle East see Gulf migration, health workers 45–46, 114, 150–2 Mitchell, Joni 24 Moldova 51, 118, 139 ‘mommy makeover’ 83 Mongolia 46, 67, 72, 75, 186 Montenegro 92, 114 Monterrey (Mexico) 56, 93, 94, 181 Moore, Michael 49 Morocco 27, 186 music therapy 25

207

National Health Service, UK (NHS) 10, 38, 82, 143, 178, 180 naturism 1, 21 naturopathy 25, 39 Nepal 17, 22, 24, 67, 70, 71, 115, 186 Netherlands 10, 43, 114, 115, 145, 156, 186 New Caledonia 14 New Zealand 4, 13, 20, 28, 44, 48, 56, 57, 58, 67, 93, 100, 114, 115, 125, 143, 144, 157, 186 niche (special interest) tourism 1, 4, 7, 28, 31, 79, 160–162, 163, 170–1, 173–5, 184 Nigeria 39, 40, 54, 67, 114, 115, 117, 118–9, 155, 156, 172, 176, 180 non-communicable diseases (NCDs) see diseases non-government organizations (NGOs) 5, 177 Norway 10, 43, 52, 154, 186

Obama, Barack 8, 183 obesity 9, 38, 48, 50, 129, 176, 183 Oman 55, 67–8, 71, 114, 115, 127, 131, 155, 162, 186 organ transplantation see transplants

Pakistan 40, 70, 72, 76–7, 78, 85, 115, 125, 134, 139–40, 143, 145, 186 Palau 55 Palestine 54 Panama 50, 97, 105, 134, 142, 186 Papua New Guinea 5, 155, 156 Parkway Group (Singapore) 72, 180–181 patient testimonials 82–83, 88, 89, 108–110, 111, 126–30 Patients Beyond Borders (Woodman), guidebook 6, 91, 102 Peru 50, 139, 186 pharmaceutical tourism 4, 50 philanthropy 153 Philippines 2, 6, 76, 86, 91, 95, 96, 110, 114, 126, 127, 137, 139, 140, 144, 148, 151, 162, 180, 186 Phuket Hospital (Thailand) 64–8, 97, 106, 148, 166, 169, 171, 181 pilgrimage 16–18, 24–6, 55, 146–7 Planet Hospital 44, 92, 94–96, 131, 142 plastic surgery see cosmetic surgery Poland 15–16, 51, 57, 91, 114, 143, 186 political stability 76, 85, 183 Portugal 3, 5, 12, 17, 54, 67, 118, 143, 186 prices 61, 90, 91, 120–5, 122, 123, 154 primary health care (PHC) 150, 154, 184 privatization x, 42, 59, 64, 78, 92, 147–148, 151, 154–155, 175–176, 178, 182–183, 184 psychiatry 48, 119 public sector xi, 10, 11, 43, 47, 62, 69, 139 see also privatization Puerto Rico 47, 179

208

Index

Qatar 55, 67, 68, 115 qualifications 95–96, 105–8, 127

Raffles Medical Group 168 recreation 19, 21, 22, 166 recuperation 20–21, 22, 97–8, 169, 170–171 referrals 44, 59, 69 relatives and friends 2, 4, 62, 128 accompanying medical tourists 4, 127–128, 133, 168, 170 financial support for medical travel 125–126, 155–156 religion 12, 14, 16–18, 25, 55, 68, 87, 141, 126, 134 reproductive tourism 5, 48, 53, 140–44 see also fertility treatment resorts 12, 13, 19–20, 24, 27, 32–5, 138 retirement 1–2, 48, 44, 48, 50, 63, 73, 76, 134 rhinoplasty 36, 44 Roman Empire 12, 13, 19 Romania 57, 91, 92, 114, 186 Rotorua (New Zealand) 13 Russia 42, 52, 56, 58, 72, 74, 76–7, 119, 126, 143, 183, 186

Samitivej Hospital (Bangkok) 64, 68, 106, 166, 167 SARS 177, 183 Saudi Arabia 17, 39, 45, 55, 70, 72, 86, 114, 115, 119, 126, 178 Scarborough (UK) 14, 19 science 17, 22, 23, 25, 29 see also technology seaside resorts see coastal resorts Senegal 54 Serbia 92, 156, 186 Seychelles 67, 70, 115, 186 sex change (gender reassignment) 47, 48, 137, 171, 174 shopping 39, 98, 100, 103, 111, 128, 133–4, 164, 167–9, 174 Siamese twins 72 Singapore 11, 53, 57, 59, 60–1, 63, 64–5, 67, 68, 69, 71–3, 74, 75, 77, 83, 85, 86, 87, 89, 91–2, 95, 96, 97, 102, 104, 107, 114–5, 117, 118, 120, 122, 123, 126, 127, 129, 130, 131, 132, 133, 134, 136, 142, 144, 151, 152, 161, 162, 164, 167–9, 175, 176, 178, 179–82, 186 skin treatment 8–9, 16, 35, 36, 97 Slovakia 51, 57, 80, 134, 143, 163, 186 Slovenia 58, 141, 186 Slumdog Millionaire 85 social capital 30, 33, 36, 37–8, 41, 75 South Africa 64, 56, 57, 58, 86, 91, 93, 96, 96, 99, 104, 117, 122, 124, 126, 132, 138, 139, 165, 170, 186

Spain 2, 17–18, 19, 43, 48, 50, 54, 57, 93, 115, 130, 140–3, 186 spas 1, 12–16, 22, 32–35, 34, 51, 52, 138, 160, 162, 165, 178, 184 spirituality 10, 12, 16–18, 21–22, 23, 26–30, 40, 42, 172 sport 12, 20–21, 160, 174 springs 13, 14, 16, 22 Sri Lanka 67, 70, 71, 72, 115, 145, 180 Starbucks 129, 130, 166 statistics xi, 7, 42–3, 61–2, 74, 82, 83, 112, 113, 173, 179 stem cell therapy 1, 5, 48, 53, 76, 137, 144–145, 151, 157 Sudan 67, 114 suicide see euthanasia sunbathing 20, 21 Surgeon and Safari 92, 93, 117, 124, 170 SurgeryPlanet 57, 90 surrogacy 53, 69, 126, 137, 140–144, 147, 158, 173 Sweden 10, 52, 114, 115, 141, 143, 186 Switzerland 6, 18, 32–3, 54, 56, 57, 58, 90, 114, 115, 145–6, 186 Dignitas 145–146 Syria 54, 104, 186

Taiwan 9, 13, 53, 56, 57, 61, 67, 68, 74–76, 78, 86, 95, 102, 114, 115, 125, 142, 161, 178, 180, 186 Tanzania 71 tattooing 3–4, 36, 44 technology 2, 36, 42, 45–6, 51, 69, 72, 105–8, 120–2, 141–3, 152, 177 telemedicine 152, 177 television xi, 7, 9, 30, 88, 127 testimonials see patient testimonials Thailand x, 2, 5, 7, 8, 9, 11, 13, 28, 33, 34, 35, 40, 43, 47–8, 47, 53, 57, 61–9, 63, 65, 66, 70, 71–2, 74, 75, 77, 80, 82, 85, 86, 89, 90, 91, 93, 94–7, 99, 102, 104, 105, 106, 107, 109, 114, 115, 118, 121, 122, 123, 126, 127, 129, 130, 131, 132, 134, 135, 136, 139, 143, 148, 149–50, 152, 153, 154, 157, 159, 161, 162, 163, 164, 165, 166, 167, 169, 170, 171, 173, 175, 178, 181, 182, 183, 186 regional health worker shortages 149–150 spa resorts 33–34, 35 `Thai tattoo’ 163 therapeutic places 12, 16–22, 29, 30 see also hospitals trade 6, 176 trade unions 14, 131 transnationalism 1, 6, 48, 78, 140, 143, 177–8, 182, 184 transnational hospital chains 70, 68–9, 71–2, 73, 76, 87, 131, 180–1, 182

Index

transplants 1, 7, 54, 69, 72, 106, 139–40, 171, 179 organ trafficking 138–139, 140 success rates 83, 128–9, 157 transport 2, 3, 5, 20, 46, 66, 71, 169, 170, travel agents/agencies 55, 79, 134, 166, 174, 181 Treatment Abroad, website 57, 90, 91, 93, 104–5, 134 trickle-down 134, 148, 153–155 tuberculosis 18, 20, 21, 149 Tunisia 45, 54, 57, 58, 89, 110, 114, 122, 126, 132–3, 152, 153, 154, 155, 186 medical tourist expenditure 132–133 Turkey 13, 52, 55, 57, 86, 91, 96, 102, 104, 131, 139, 162, 169, 186 Turkmenistan 52

Ukraine 51, 58, 76, 72, 114, 118, 41, 143, 186 uneven development x, 4, 35, 133, 147–8, 149, 153, 175–6, 183–4 United Arab Emirates (UAE) 40, 44, 45, 55, 67, 68, 71, 72, 69, 86, 96, 104, 114, 115, 131, 133, 156, 181–2, 186 United Kingdom 9, 10, 13, 14, 16, 20, 21, 27, 28, 34, 39, 40, 43, 44, 45, 48, 541, 52, 53, 54, 55, 56, 57, 58, 59, 63, 67, 68, 70, 82, 86, 88, 90, 91, 93, 95, 101, 107, 110, 113, 114, 115, 117, 119, 122, 124, 125, 126, 130, 141, 142, 143, 145, 152, 155, 162, 163, 168, 174, 178, 180, 182, 186 United States of America 3, 7, 8, 9, 10, 11, 13, 14, 19, 21, 24, 32, 36, 39, 43, 44, 45, 49–50, 52, 54, 56, 60, 64, 66, 67, 68, 70, 75, 76, 84, 86, 87, 88, 89, 90–1, 92, 93, 95, 06, 97, 98, 101, 103, 110, 113, 114, 115, 117, 118, 119, 120, 121–2, 1213, 124, 125, 126, 129, 130, 131, 136, 139, 140, 141, 142, 143, 144, 145, 149, 150, 151, 152, 155, 157, 168, 169, 172, 174, 177, 178, 180, 181, 183, 187 health insurance cover 44, 183 urban bias 147, 149, 153, 175

209

Uzbekistan 52

Vanuatu 39, 44 Vatican City 17 Vejthani Hospital (Thailand) 105, 107 Venezuela 49, 187 VFR (visiting friends and relatives) tourism 161, 171 Vietnam 14, 62, 64, 67, 68, 72, 73, 76, 118, 126, 131, 141, 142, 187 visas 39, 46, 69, 70, 76, 77, 110, 155, 166

waiting lists 3, 4, 10, 42, 43–4, 58, 98, 118, 138, 141, 158, 176, 178, 181, 183, 184 waiting times 7, 10, 43, 48, 65, 98, 113, 119, 150, 157 water 12–16, 15, 19–20 websites 88–92, 105–109 whiteness 8, 9, 115, 116 Wikipedia 7, 57, 134 Winfrey, Oprah 30, 88 Wockhardt Hospitals 45, 69, 71, 87, 97, 107, 152 Women on Waves 5 World Bank 156 World Health Organization (WHO) 10, 107

xenotourism 138

Yanhee Hospital (Bangkok) 82, 107–8, 110, 112, 115 Yemen 5, 44, 45, 59, 67, 71, 84, 114, 118, 119, 125–126, 133–4, 151–2, 155, 158, 160, 174, 177 yoga 4, 7, 10, 23, 25, 26–28, 30, 31, 35, 163, 165

Zambia 117