Medical Tourism

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Medical Tourism

John Connell
University of Sydney
Australia
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A catalogue record for this book is available from the British Library, London, UK.
Library of Congress Cataloging-in-Publication Data
Connell, John, 1946-
Medical 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 vi

List of Abbreviations 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. Medical tourism? xii

Fig. 1.1. Thai billboard, Bangkok 2010. 8
Fig. 2.1. Buxton Spa advertisement from the 1920s. 15
Fig. 3.1. Bali Sacred Journey, 2008. 31
Fig. 3.2. Banjaran Hotsprings Retreat, Malaysia 2009. 34
Fig. 4.1. Technology in medical tourism? 46
Fig. 4.2. Pratunam Polyclinic advertisement. 47
Fig. 4.3. Advertisement for drop-in clinic, Bangkok. 52
Fig. 4.4. A geography of medical tourism. 57
Fig. 5.1. Cosmetic surgery in Thailand? 63
Fig. 5.2. Translation centre, Bumrungrad International Hospital (BIH). 65
Fig. 5.3. Bumrungrad International Hospital (BIH), Bangkok. 66
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. 67
Fig. 5.5. Malaysia Healthcare advertisement, 2009. 74
Fig. 6.1. Dental tourism advertisement (a) and Sukhumvit street sign, Bangkok (b). 80
Fig. 6.2. Monterrey, Mexico. 94
Fig. 6.3. Gorgeous Getaways flier, 2010. 100
Fig. 7.1. Bumrungrad International Hospital brochure (Source: Bumrungrad
International Hospital, Bangkok). 116
Fig. 7.2. Bangkok streetscape, Little Arabia, March 2010. 135
Fig. 9.1. Bumrungrad International Hospital (BIH), first floor. 166
Fig. 9.2. Hospital room in Bangkok Hospital, Phuket. 167
Fig. 9.3. Malev Airlines dental packages, 2010. 170

vi
 List of Figures and Tables vii

Tables

Table 7.1. Comparative prices (US$) of procedures, March 2010. 122

Table 7.2. Comparative prices (US$) of procedures, May 2010. 123
Table 7.3. Comparative prices (US$) of procedures, April 2010. 123
 List of Abbreviations

ABC Australian Broadcasting Commission

AIDS acquired immunodeficiency syndrome
BIH Bumrungrad International Hospital
BMG Bavaria Medical Group
CABG coronary artery bypass surgery
CEO chief executive officer
COPCAB conscious off-pump coronary artery bypass
CV curriculum vitae
DHCC Dubai Healthcare City
EU European Union
GATS General Agreement on Trade in Services
GDP gross domestic product
GFC global financial crisis
GG Gorgeous Getaways
HIV human immunodeficiency virus
IMTA International Medical Travel Association
ISAPS International Society of Aesthetic Plastic Surgery
ISO International Standards Organization
IT information technology
IVF in vitro fertilization
JCI Joint Commission International
KL Kuala Lumpur
MICE Meetings, Incentives, Conferences and Exhibitions
MTA Medical Tourism Association
MTC medical tourism company
NCDs non-communicable diseases
NGO non-governmental organization
NHC National Heart Centre Singapore
NHS National Health Service
NRI non-resident Indian
PHC primary health care
SARS severe acute respiratory syndrome

viii
 List of Abbreviations ix

UAE United Arab Emirates

UK United Kingdom
USA United States of America
VFR visiting friends and relatives
WHO World Health Organization
 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 empha-
sizes a number of contemporary themes including the privatization of health care in post-
industrial 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 encour-
aged 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 inade-
quacy. Yet, fortuitously, my own lone foray into medical tourism was an hour of dental treat-
ment 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 obses-
sion. 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 West-
ern 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 med-
ical 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 opti-
mistic press releases, and their repetition as wisdom, and sometimes impressionistic and sen-
sationalized 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 care-
ful analysis of particular circumstances. Much of the literature is promotional rather than ana-
lytical, 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 ade-
quate overview of an emerging component of the tourist industry and a distinct and contro-
versial 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, ben-
efiting 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 travel-
ling 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
© CAB International 2011. Medical Tourism (J. Connell)
hiking/bushwalking to meditation and
detoxification. In some respects medical tour-
ism 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, tooth-
ache tourism and detox tourism. There are
many others. When and where the term ‘med-
ical tourism’ itself originated is unknown.
It has become important for many rea-
sons: (i) disappointments with medical treat-
ments 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 transplanta-
tion (‘transplant tourism’) and stem cell ther-
apy, even contraception and ultimately ‘death
tourism’, have raised ethical issues. Diasporic
medical tourism has taken patients back to
their homelands, while ‘transnational retire-
ment’ migration, as global populations age,
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 eco-
nomics 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 communi-
cation, transport and tourism. Medical tour-
ism is thus underpinned by diverse political,
economic, social and cultural influences.
Medical tourism has also emerged from a
greater willingness to accept alternative prac-
tices and procedures, and experience differ-
ent cultures and places, even though most
medical tourism is centred on ‘formal’ bio-
medical procedures. It has, however, followed
various social and economic changes encou-
raging 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 philo-
sophical orientations towards health and
life, rather than those of the ‘medical estab-
lishment’. 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 individua-
lism. Ironically therefore greater support for
complementary and alternative medicine has
grown alongside the rise of cosmetic sur-
gery, 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 dis-
eases, 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 coun-
tries, 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 tech-
nically challenging, such as dentistry and
orthodontics, have become extremely expen-
sive. 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 inc-
rease, 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 provid-
ers. 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 red-
uced 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 cultu-
rally familiar care, seems the very antithesis of
societal norms. Such norms and values, iner-
tia 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 emer-
gence 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 primar-
ily a 21st century phenomenon.
While medical tourism is generally per-
ceived 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 destina-
tion 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 sur-
gery (Glinos et al., 2010). As in Europe cross-
border movements occur between Canada
and the USA, and in Asia, Africa and the Mid-
dle 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 trans-
portation 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 health-
care systems as they are from rich countries
with generally adequate systems. In the poor-
est 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 cit-
ies 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 increas-
ingly 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 rich-
world 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 anx-
iously and enthusiastically poised to enter the
market.
What’s in a Name?
Is ‘medical tourism’ the best term? Tourism
suggests pleasure and relaxation – not neces-
sarily characteristics associated with medi-
cine. 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’ proce-
dures or ‘tourism’. Outside that umbrella,
tattooing, rarely regarded as a medical proce-
dure, is certainly more painful and invasive
than many forms of treatment usually sub-
sumed 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 ‘pharmaceuti-
cal 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 simi-
larly growing Meetings, Incentives, Confer-
ences 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 sig-
nificant part of a new form of ‘diaspora tour-
ism’ where patients return to their home
countries, kin and extended families to expe-
rience 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 restau-
rants), medical tourism is a valuable niche in
the international tourist industry.
Who are medical tourists? Cohen has
suggested a fourfold classification: (i) ‘medi-
cated tourist’ (who receives treatment for
accidents or health problems that occur dur-
ing 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 vis-
its mainly for medical treatment, but makes
incidental use of holiday opportunities, usu-
ally during the convalescence period); and
(iv) ‘mere patient’ (who visits solely for medi-
cal 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 tour-
ist 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 supe-
rior 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 institu-
tionally, they engage in similar trips and
experiences to other medical tourists. This
book takes the perspective that such varied
subcategories are not always easily distin-
guishable 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 tour-
ist as ‘someone whose specific reason for trav-
elling 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 seek-
ing care, as they do themselves, while long-
staying ‘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 medi-
cal 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 particu-
larly problematic. In recent years several hun-
dred people a year have moved from Papua
New Guinea a few kilometres across the inter-
national 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 ‘humani-
tarian 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 diffi-
cult, 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 pro-
vided outside countries like Ireland and Por-
tugal (Gomperts, 2002). Such movements
exemplify how many people engage in trans-
national 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 sug-
gesting remedies and claiming cures, often
based on the use of local medicines and tech-
niques. Some acquired fame and notoriety and
stimulated a flow of overseas patients to desti-
nations 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 can-
cer 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 sug-
gest analogies to pilgrimage.
Tourism formally implies a stay of more
than 24 hours in a destination, otherwise it is
merely ‘visiting’, but quite complex proce-
dures 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 perspec-
tive, 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, vitamin-
complex 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 tour-
ism 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 eas-
ily be termed ‘transnational medical care’
(Sobo, 2009).
While some writers have continued to
use both ‘health tourism’ and ‘medical tour-
ism’ 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 distinc-
tion between passive experiences and more
active intervention seems essential. Medical
tourism may conceivably even be distin-
guished 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 move-
ments, 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’ suggest-
ing 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 arran-
ged 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 pos-
sible, 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 well-
ness tourism, or even such healthy activities
as hiking and bushwalking. Previously medi-
cal tourism was defined as tourism that was
‘deliberately linked to direct medical inter-
vention, and [where] outcomes are expected
to be substantial and long-term’ (Connell,
2006a: 1094) but that was limiting in exclud-
ing 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 contin-
uum from health tourism (or wellness) that
includes relaxation techniques such as yoga
and massage, cosmetic surgery (ranging from
dentistry to substantial interventions), opera-
tions (such as hip replacements and trans-
plants), reproductive procedures and even
‘death tourism’. Patients in each of these cat-
egories 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 dis-
covered and boosted by the media, notably in
the USA. Without extensive media coverage
not only would medical facilities in develop-
ing countries have largely remained invisible
and unknown to potential clients in devel-
oped 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 Bumrun-
grad 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 indi-
cated that problems were usually exceptional,
resulting in what amounted to a ‘media imp-
rimatur’ (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 acquisi-
tion 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 counter-
parts (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 light-
ening 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 hospi-
tals 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 dis-
crimination, 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). Paradoxi-
cally 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 news-
papers, 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-ten-
days/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 sub-
titled ‘an inspirational series which offers
hope where traditional medicine fails’, pre-
sented by a nutritionist that revolved around
a group of people trying to conquer their
‘embarrassing and intimate health condi-
tions’, 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 Make-
over pushing cosmetic dentistry ideals on the
public and making ‘porcelain veneers’ a
household phrase. The expansion of cosmetic
dentistry was much influenced by consumer-
ism and commodification, and a shift within
the industry towards direct-to-consumer
marketing, and the economic ‘need’ to mar-
ket 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 proce-
dures (Ballou, 2009). Some 40% of Americans
seeking health care overseas did so for dental
procedures (Apton and Apton, 2010), a simi-
lar proportion to that in Europe.
Despite such preoccupations with well-
being and attractiveness, growing numbers
of people are much less healthy. In many
countries there has been a steady growth of
non-communicable diseases (NCDs), occa-
sionally 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 afflu-
ence 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 every-
where. 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 spiri-
tual 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 fast-
est 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 attain-
ment 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 signifi-
cantly involved Asia.
Yet there is a more prosaic and less glam-
orous 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 med-
ical 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 agree-
ments finalized in 2008 have enabled signifi-
cant cross-border movements for health care,
as insurance policies have become interna-
tionally 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 propor-
tions 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 coun-
tries 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 treat-
ments there in 2008 (Glinos et al., 2010). Dis-
tance, conservatism and language differences,
but possibly also the continued efficiency and
reliability of the NHS, reduced response rates
in Britain.
New obsessions with personal well-
being, 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 nat-
ural 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 interna-
tional visions has encouraged a retreat into
personal ‘politics’ and private stories of trans-
formation – cosmetic surgery, makeovers of
home and person – because there is no viable
collective agenda for transformation. Increas-
ing 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 consider-
able 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 con-
sequences. It is quite different from the way
in which patients perceive themselves as hav-
ing personal relationships with family doc-
tors 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 ano-
nymity 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 govern-
ments 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 con-
ventional phrases, would draw on the
‘natural beauty’ of Thailand and the ‘hospi-
table’ characteristics of the Thai people. Situ-
ating 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 tour-
ism, discussed in the following two chapters.

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 pil-
grims, travelled from around the Mediterra-
nean 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 trav-
elled to gain physical benefits. From then
onwards particular therapeutic places and
landscapes, from springs and mountains to
temples and cathedrals, have played signifi-
cant 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 tour-
ism, and occupational psychology workshops
can be a form of wellness (Smith and Puczko,
12
2
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 recog-
nized as having healing powers and Hip-
pocrates, 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 proper-
ties 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 Epid-
aurus in Greece was the most celebrated heal-
ing centre of the classical world where
patients travelled long distances to seek med-
ical 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 ‘muse-
ums, guide-books, seaside resorts with drunk
and noisy holiday-makers at night, candle-lit
dinner parties in fashionable restaurants, pro-
miscuous hotels, unavoidable sightseeing
places, spas, souvenir shops, postcards, over-
talkative 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 min-
eral 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 coun-
tries 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 nei-
ther became popular until the next millen-
nium. 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 transmit-
ted 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 Otto-
man Empire constructed Turkish baths in the
9th century, and spas were developed in cen-
tral 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 restor-
ative 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 Euro-
pean 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
14 Chapter 2
possess distinct healing properties rather than
merely relaxing and restorative virtues. The
first modern hydrotherapy spa was devel-
oped 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 appro-
priate, often distant, therapeutic places.
The ‘golden age’ for spas throughout
most of Europe was the 18th and 19th centu-
ries 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 diver-
sions ranged from gambling to horse riding.
In the USA, at places like Saratoga Springs in
New York and White Sulphur Springs in Vir-
ginia, similar trends occurred but without the
more hierarchical class structures of Europe.
In the UK Harrogate was the north of Eng-
land’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 journey-
ing on to grouse shooting in Scotland. Drink-
ing 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. Bux-
ton also declined but was still actively seeking
visitors in the 1920s (Fig. 2.1). After the Indus-
trial 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 Scar-
borough (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 lime-
stone 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 opportu-
nity to bathe in naturally heated spring water.
Moree, Medlow Bath and Daylesford in Aus-
tralia all experienced similar decline and
sought revival in various guises. At Dayles-
ford, for example, it took the form of an alter-
native lifestyle centre, with accompanying
activities including massages, reiki, shiatsu,
acupuncture, aromatherapy, reflexology, spir-
itual healing and tarot reading, in a self-
proclaimed ‘spa country’.
In various circumstances, especially in
central Europe, spas have taken on more evi-
dent medicinal functions, with travel pack-
ages 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 (Erfurt-
Cooper and Cooper, 2009: 167, 190). Ameri-
can, and other, spas may offer Botox injections
and laser hair removal, though both are sim-
ple 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
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 com-
pensation 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 compe-
tition from the rise of seaside resorts rather
than complementarity with them, and, as at
15
Daylesford, embracing more holistic direc-
tions 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; Erfurt-
Cooper and Cooper, 2009), and in parts of
Asia, such as Japan, where they never lost
favour with local people. Poland, for exam-
ple, 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.
16 Chapter 2
In France Vichy has grown after World War II
to provide treatments for people with rheu-
matologic, gastroenterological and dermato-
logical 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 spe-
cific 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 natu-
ral hot springs draw millions of annual visi-
tors. 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 north-
ern Europe, where springs are absent, saunas
emphasize the role of water, but in con-
structed contexts rather than natural land-
scapes. 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-more-
detached bottled spring water that has
become a major global industry centred on a
continued belief in the pure and healthy qual-
ities 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 industri-
alization and notions of purity and authentic-
ity (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 environ-
ments, in some cases with the additional ben-
efits 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 desper-
ate 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 reli-
gious 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 tradi-
tional 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 contempo-
rary 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 Med-
jogurje, where the Buddha taught or rested
(including his birthplace at Lumbini in Nepal,
and Sarnath, near Varanasi, where he prea-
ched his first sermon), and Mecca, the birth-
place of the prophet Mohammed. Some
regions, like the Holy Land, have a prolifera-
tion 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, some-
times 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 misfor-
tune’ 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 (Kash-
mir), necessitating long journeys and real
separation from the everyday. Getting to,
often walking to, such places was and is
physically demanding and often costly. Pil-
grimage sites are often places of last resort
for cures to what have been incurable condi-
tions, 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 psycho-
logical outcomes. Thousands of people have
claimed to be cured at Lourdes, and in simi-
lar therapeutic places, and a combination of
spring water and baths, exercise, ritual pra-
yer, 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 Compos-
tela, 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 popular-
ity 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 Iver-
son, 2006). Culture and duty are here com-
bined. 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 assert-
ing spirituality, gaining spiritual sustenance
and revitalizing religious faith, or they have
even become more of a tourist activity, sim-
ply 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 dimen-
sions – largely took over from purely
spiritual dimensions, some such as Mecca
have remained primarily spiritual, open only
18
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 Collins-
Kreiner, 2006; Andriotis, 2009; Olsen, 2010).
Travel companies have emerged that focus on
spirituality, as in the case of the Indian com-
pany, 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 par-
ticularly surprising that many health practi-
tioners now argue that spirituality is at the
core of good health or wellness (e.g. Steiner
and Reisinger, 2006). Spirituality may, how-
ever, 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 well-
being, without any real spiritual or ritual
significance. Wherever feasible when Europe-
ans 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
Chapter 2
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 tem-
perate climates mountains were popular
summer destinations for ‘cooling off’ and
enjoying the scenery, so that the Alps, espe-
cially 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 sanato-
rium, mainly for lung diseases, and a military
depot and tea plantations, and it became the
informal summer capital of the Bengal Presi-
dency 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 sol-
diers 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 every-
where 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 proper-
ties, 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 con-
temporary 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 sul-
try 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 coun-
tries 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-bath-
ing 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 pre-
eminent 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
19
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 infrastruc-
ture 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 recom-
mended for their curative powers, both
through escaping urban miasma and benefit-
ing from sea air and salt water. Taking the air
at the coast was at least as important as sea
bathing, and guidebooks published by doc-
tors 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
20 Chapter 2
rivers) was seen as unusually refreshing so
that ‘neither dropsical, nor chloritic com-
plaints, 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 physi-
cal maladies’ (Lencek and Bosker, 1998: 74),
while cold sea water enhanced moral charac-
ter as much as it remedied physical condi-
tions. 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 nine-
teenth 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 strate-
gies for treating tuberculosis were found to
have better results, ‘the enduring presence of
pulmonary disease until the 1930s was conve-
nient and, although no resort was keen to
attract the sick, most were delighted to wel-
come non-infectious and profitable convales-
cents’ (Beckerson and Walton, 2005: 65). Yet
the specifically therapeutic functions of
beaches faded in the 20th century, only reviv-
ing 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’ (Preston-
Whyte, 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 exer-
cised, 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 spir-
itual healing’ (Lencek and Bosker, 1998: 201).
Beach wear became briefer and briefer, culmi-
nating 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, with-
out 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 thera-
peutic 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 experi-
ence – mainly in the mid-20th century – and
were supposedly pleasurable ways of com-
bining 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 edu-
cational 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 prom-
inence 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 recupera-
tion: 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
21
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 recu-
peration 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 tra-
ditional 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 benefi-
cial to well-being, but many exotic and expen-
sive 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 environ-
ments, social conditions and human percep-
tions 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 partici-
pating in community and sometimes healthy
22 Chapter 2
exercise. Most were linked to water in some
way, frozen into a lingam at Amarnath, bub-
bling from the ground in multiple sites or cas-
cading 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, pil-
grimages often took people further and
across national boundaries. In its link to spir-
ituality 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 par-
ticular 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 relax-
ation, recuperation and restoration. Two mil-
lennia later, the spiritual dimensions that had
often been a part of tourism were less obvi-
ously 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, spir-
ituality became reinvented by some in ways
that offered new links between health and
therapeutic places, though these were increas-
ingly constructed rather than directly involv-
ing elements of the natural landscape. At the
same time modern biomedicine (i.e. science-
based medicine) achieved an almost univer-
sal 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. How-
ever, 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 cre-
ationism, and opposition to evolution in
some Western societies). While older forms of
tourism, with their links to oracles, pilgrim-
age and particularly venerable sites, might
have been seen to emphasize ritual and reli-
gion, 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 West-
ern practices with health and well-being
becoming more holistic phenomena. Nurtur-
ing the mind and the spirit in various ways,
for long an important part of tourism, resur-
faced in new forms. This chapter primarily
© CAB International 2011. Medical Tourism (J. Connell)
examines more obviously all-embracing prac-
tices, where travellers sought some form of
enlightenment, and where various ideologies
were combined to promote particular kinds
of healthy bodies and minds, while recogniz-
ing that biomedicine never lost its domi-
nance, and cosmetic surgery stimulated a
vibrant new strand.
Secular Pilgrimage
Although religious beliefs dominated notions
of spiritual well-being, more secular philoso-
phies eventually played a greater part in trav-
els for health and wellness (Chapter 2) while
romanticizing and cherishing particular loca-
tions. Travelling itself became invested with
quasi-spiritual dimensions especially where
it took Western peoples away from familiar
material landscapes to distant, perhaps coun-
tercultural nirvanas where alternative cul-
tures were said to provide enlightenment,
peace and spiritual harmony. From at least
the 18th century onwards European explor-
ers 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 Middle-
Eastern and African deserts, Amazonian jun-
gles and Himalayan mountains in the quest
23
24 Chapter 3
for knowledge, bringing back stories of exotic
lost cities and intriguing cultures, that some-
times 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, rhap-
sodized 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, stimu-
lated 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 dif-
ferent 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 fam-
ous 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 possi-
ble. There were hints of elitism in this that
sometimes brought criticism of a ‘moder-
nist gospel of “less is more” applied to every-
thing 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 pro-
vide 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 prophe-
cies 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 north-
ern 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 con-
cept 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 pro-
cessed 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 ‘alterna-
tive’ practices such as therapeutic touch,
homeopathy and naturopathy, with hypothe-
ses (where they existed) and practices not
accepted by science-based medicine (biomed-
icine), which offered at least a strong placebo
effect. Ayurveda, meditation, yoga, acupunc-
ture 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 spiri-
tual focus (Smith and Puczko, 2009: 51–52).
25
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 pow-
ers 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 alter-
native healing, yoga and ‘chakra auditing’
(Connell and Gibson, 2009). Thus at Byron
Bay one local performer who mixed Aborigi-
nal references with tribal and mystical sym-
bols 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 mys-
tical beliefs have been used as sources of well-
being. Chakras, according to traditional
Indian medicine, are believed to be ‘force cen-
tres’ of energy permeating from within the
body. Knowledge of the chakras is central to
many different therapies and disciplines,
including Ayurveda (see below), aromather-
apy, reiki and crystal/gem therapy. Reiki
practitioners use their hands and crystal prac-
titioners 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 enlighten-
ment, and claimed to have found them in dis-
tant places and other cultures, displaced from
everyday work and domestic experiences.
The conservation practices and technical
26 Chapter 3
knowledge of environmental issues by
indigenous peoples with limited contact with
‘modern’ society stimulated a Western con-
cern with ‘learning from the past’, embodied
in distant cultures, and evident in the rise
of permaculture, some notions of deep ecol-
ogy 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 invalu-
able knowledge. Such assumptions have
never disappeared.
Other subsequent forms of travel com-
bined more specific notions of pilgrimage
and healing. African Americans travelling to
West Africa were not simply visiting the
ancestral lands that other diasporic home-
coming tourism involved, but were visiting
the sites of enslavement of their ancestors:
‘places that resemble shrines and are attrib-
uted 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 psycho-
logical necessity that strengthened commu-
nity 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 app-
roaches to life spilled over into an apprecia-
tion for complementary and alternative
medical practices such as meditation, home-
opathy 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 alterna-
tives for what they believed to be health-
enhancing measures. In 1997 some 14% of
Americans had sought the services and
advice of both a medical doctor and an alter-
native 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, osteopa-
thy, reflexology and aromatherapy); more of
these were women rather than men and
younger people were more likely to try alter-
native therapies (Thomas et al., 2001). Some
were practised by those for whom biomedi-
cine 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 perspec-
tives. 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 diver-
sity 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 ele-
ment 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. Contempo-
rary 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 tour-
ism, for most tourists in Kerala Ayurveda was
a secondary concern involving occasional
massages, rather than the central preoccupation
27
(Chitramani and George, 2009; Hannam,
2009). Such tourists were viewed dismissively
by local physicians. Like ashrams many
Ayurvedic retreats have taken on more luxuri-
ous elements where spiritual practices and
even exercise have been marginalized, and
core practices excluded where they are incon-
venient to foreigners (Spitzer, 2009). The Aus-
tralian 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 experi-
enced 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 rejuve-
nation. An annual retreat is the best health
insurance’ (quoted in Chapman, 2008: 36).
Many such resorts and retreats offered dis-
tinctive, 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
28 Chapter 3
yoga has also ‘come out of the ashram’
towards celebrity status (Rosin, 2006). In some
meditation retreats, many advertised in mag-
azines like the British Yoga and Health, its spir-
ituality remains central. Vipassana (silent)
meditation is practised at many retreat cen-
tres, in virtually identical forms, just as silence
and silent meditation are also present in par-
allel 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 medita-
tion 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) orienta-
tion 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 peo-
ple’, and included a ‘North Thailand Tradi-
tional Healers eco-tour’ (Inner Journeys, 2010):
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 person-
to-person levels and share knowledge and
experiences.
and also a ‘Shaman of Borneo eco-tour’ and
‘Sedona Encounters’.
Unique ecotourism adventure travel learning
of traditional medicines and spiritual paths
from indigenous people. Personal self-
empowerment, Reiki and spiritual retreats
exploring your own spirituality for
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, vipas-
sana meditation, Swedish massage, acupres-
sure, 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:
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)
A second American company, BodyMind-
SpiritJourneys, offers a very similar range
with the same perspectives. In recent decades
in numerous ways there has been a massive
 Mind and Matter
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 sup-
port 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 rup-
ture 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 extraor-
dinary spread of feng shui outside (and
inside) Asia has accentuated consciousness
that living with the environment is more ben-
eficial than challenging it, and that well-being
is affected by the physical and emotional envi-
ronment, so that particular physical environ-
ments 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 eso-
teric beliefs have been increasingly absorbed
into health-care practices.
The ‘journeys’ based on such premises
may also involve personal mental transfor-
mations that take on fragments of eastern
philosophies and practices without necessar-
ily 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 one-
day 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,
29
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 understand-
ing 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 flexibil-
ity, 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 per-
sonal 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 willing-
ness to suspend intellectual disbelief in a
quest for cures where biomedicine has thus
far failed. The scientific evidence for the ben-
efits 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.
30 Chapter 3
However valid alternative therapies may
or may not be they continue to exude a fasci-
nation, 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 liv-
ing, 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 medi-
tation 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 self-
help 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 vis-
itors have followed in search of Wayan’s vari-
ous 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 treat-
ments 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 pack-
ages (Fig. 3.1) combining spiritual practice
with deluxe accommodation, often centred in
Bali.
Many such journeys and ‘new pilgrim-
ages’ 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 vis-
ited and from whom they might have gained
valuable knowledge and experiences, how-
ever 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
 Mind and Matter
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 grandi-
osely 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
31
might include, becoming an expensive niche
in the health-tourism industry, centred on
spas, whether new or established. This has
accompanied rising affluence, status symbol-
ism 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
32
the luxury end of the tourism market. Spa
visitors, as in Australia, are mainly educated
and affluent women (Voigt et al., 2010). Sev-
eral 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 some-
times ambient music, and thus with some
limited convergence with ‘New Age’ philoso-
phies, 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, espe-
cially in North America, and most contem-
porary 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 …
Chapter 3
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 com-
prehensive and clearly defined wellness pro-
gramme 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: ‘mind-
ness’). 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)
 Mind and Matter
Although elitism may typify contemporary
spas, and account for somewhat artificial
invocations to benefit from alternative thera-
pies, spas have continued to combine certain
traditional techniques in a purpose-built con-
text, linked into the putative ambience of
relatively elite resorts. None the less for
many such spas linkages to place and tradi-
tion 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
33
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 nat-
ural 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 geogra-
phy has been scrambled in global processes
that stress authenticity and nature yet trans-
port techniques across continental boundar-
ies. 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
34 Chapter 3

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 ‘experi-
ence packages may all be luxuriously pam-
pering they also address real health problems
such as weight management, stopping smok-
ing, 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 relax-
ation 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 mod-
ern and traditional approaches to health (that
tend to relate to exercises and diet) where they
‘aim to cater to three elements of their custom-
ers’ 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).
 Mind and Matter
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 phe-
nomenon, 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 Nord-
strand, 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 medi-
cal context, and some spa resorts have delib-
erately 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 possibili-
ties 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 biomedi-
cal practice, though they increasingly offer
more invasive, demanding (and costly) tech-
niques. The Terme di Saturnia Spa and Golf
Resort in Maremma, Italy, offers isophoresis,
an alternative to liposuction that uses ultra-
sound 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
35
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 conver-
gence 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 tour-
ism, 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, origi-
nal, 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 eco-
logically sensitive, using local ingredients.
More prosaically Asia has an advantage in the
existence of a tourism infrastructure, and rel-
atively 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
36 Chapter 3
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 wide-
ranging 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 peo-
ples have used, and continue to use, some
forms of bodily decoration and cosmetic
treatments, alongside cicatrization and tat-
tooing, 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 nei-
ther simple or trivial transformations. Per-
fumes, 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 some-
what 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 cen-
tury 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 augmen-
tation; (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 sur-
gery. Botox injections were the single most
common cosmetic operation, with 4.8 million
procedures in the USA alone in 2009, primar-
ily to reduce wrinkles. Botox, not surprisingly,
is the leading product in what has increas-
ingly 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 self-
focused and opportunistic, pressures to con-
form 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
 Mind and Matter
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 per-
sonal 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 pri-
macy, 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 pres-
ent it to them with love, kisses and their
blessings as a high school graduation pres-
ent’ (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 conver-
gence that challenges gender, racial and size
boundaries.
The media have played a key role in the
growth of cosmetic surgery, with ‘reality’ tele-
vision shows as the American Extreme Make-
over 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, intermit-
tently featured cosmetic surgery episodes.
Even programmes aimed at teenagers, such
as the Australian Girl TV, featured non-
surgical makeover themes, complete with
before and after shots that were similar in
style to cosmetic surgery programmes
(Keenan, 2004). Those who watch such pro-
grammes are more likely to seek cosmetic
surgery than those who do not (Markey and
Markey, 2010) and girls as young as 12 express
37
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). Maga-
zines 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 exten-
sion chastizing others, so playing on insecuri-
ties and possibilities. Home, garden and diet
makeovers, in magazines and television pro-
grammes, 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 depict-
ing body images that are unattainable for
most people, but raise unrealistic expecta-
tions 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 trans-
form, modernize and improve. In shows like
Extreme Makeover ‘episodes are about the pro-
cess of becoming – processes that begin dur-
ing surgery and then through recovery,
grooming and further “personal growth” in
everyday life’ (Jones, 2008: 53). Cosmetic sur-
gery 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 dec-
lining relative costs. As one Australian com-
pany, Gorgeous Getaways, has pointed out:
The sharp growth is a result of changing
attitudes as cosmetic surgery becomes
38 Chapter 3
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 moral-
ity which are historically contingent upon the
value placed on bodily aesthetics (Colls, 2006).
Commonly, fat in a Western context is consid-
ered 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 soci-
eties 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 con-
sumerism 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 them-
selves 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 prefer-
ences for modern medical care displaced the
resort to local knowledge and local practitio-
ners. 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 ser-
vices’ 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 prov-
inces 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 promi-
nence. 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 hos-
pitals 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 chil-
dren’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 pro-
jections 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 dif-
ferent language interpreters (Lambier, 2009).
Western cities have prolonged and some-
times enhanced an elite pre-eminence in an
increasingly competitive market.
39
Even while this book was being written
President Mubarak of Egypt was being
treated in Heidelberg, Germany for an inflam-
mation 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 Ger-
many. 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 exten-
sive criticism in Canada while declaring:
‘This is my heart, it’s my health and it’s my
choice’ (Telegraph Journal, 2010). Other lead-
ers have undertaken similar journeys, but
there is an irony here since Malaysia is a cen-
tre 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 estab-
lishment 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 interna-
tional (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
40 Chapter 3
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, Nige-
ria, Kuwait, the United Arab Emirates (UAE),
Greece, Cyprus, Libya and Egypt (Reisman,
2010: 71). Several Harley Street businesses
have moved even more obviously into medi-
cal 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 expan-
sion 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 inter-
national 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. Travel-
ling itself has long been a source of well-
being, 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-A-
Wish 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 holis-
tic 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 biomedi-
cine has grown too, and cosmetic surgery has
grown particularly fast, with the great hospi-
tals and specialist clinics of Western cities
retaining their significance, further adding to
a diversity of therapeutic possibilities. Glo-
balization has contributed to the greater flow
of knowledge and information, as much
about alternative therapies as about alter-
native 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 exter-
nal, of the healthy body, good body and body
beautiful.
 Mind and Matter
Health and wellness tourism, and many
alternative ideologies, attach particular sig-
nificance to space and places. Although medi-
cal tourism exists in certain particular places,
it lacks some of the direct therapeutic links to
place (evident in the role of water in thera-
pies) that its antecedents had and continue to
have. Even so, in many such circumstances,
places have been (re)invented as sites of tour-
ism, 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-improve-
ment, positive thinking and self-help in a
variety of forms (that parallel shifts in
41
evangelical Christianity) and urge the
triumph of attitude over circumstance,
enhanced by television series, that simultane-
ously raise possibilities, present ‘successes’
and offer choices and options. Most contem-
porary health and wellness tourists, and
those engaged in cosmetic surgery, are from
developed countries, and engaged in expen-
sive 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 biomed-
icine 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 contempo-
rary medical tourism, and has remained an
important destination, it has increasingly
given way to substantial new geographical
flows as modern medical tourism has flour-
ished. 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, medi-
cal tourism focuses on more physical matters,
where the emphasis is very much on biophys-
ical 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 inten-
tionally 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 evi-
dence of medical tourism existed (Goodrich
and Goodrich, 1987: 219–221). It emerged in
42 © CAB International 2011. Medical Tourism (J. Connell)
contemporary form in the 1990s from the
congruence of: (i) the rising cost of health care
and insurance in developed countries; (ii) lon-
ger 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 gen-
eration (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 devel-
oping countries (from sub-Saharan Africa to
Russia) a growing elite with capital and con-
tempt 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 unrea-
sonable 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,
 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 tour-
ist publications, in contrast to more elaborate
operations that are the outcome of consider-
able 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 bro-
chures in Budapest (Hungary), Chiang Mai
(Thailand) and a multitude of other tourist
destinations. For relatively simple proce-
dures, 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
43
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 recon-
structions have been as long as 18 months in
the UK, and over 2 years in Australia, Canada
and elsewhere, but surgery is almost instanta-
neous 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 non-
urgent 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 conse-
quently sought to set waiting times of 26 and
16 weeks, respectively, for non-urgent proce-
dures 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 wait-
ing lists (TRAM, 2006), and 15% of a sample of
British citizens were willing to travel any-
where in Europe to avoid lengthy waiting lists
(Beecham, 2002). Moreover where waiting
times are lengthy and queues long, consulta-
tion 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
44 Chapter 4
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 diagno-
ses, overcrowding has resulted in diagnoses
being made too hurriedly and travel overseas
was minimally to receive an accurate diagno-
sis (Kangas, 2002, 2007). Consequently in
many such countries, especially in sub-
Saharan 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 treat-
ment, this increases the probability of choos-
ing 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 nec-
essary operations’. However, in California at
least, the propensity to travel abroad for med-
ical 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 Vargas-
Bustamante, 2010). The highest concentration
of uninsured Americans is close to the Mexi-
can 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 over-
seas care (Reisman, 2010: 34). However, lower
prices of medical care in Mexico may even
encourage people to forgo insurance alto-
gether (Brown et al., 2009). The absence of
insurance has stimulated diasporic medical
tourism (see below).
Insurance provisions may impose strin-
gent 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 replace-
ments 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 proce-
dures 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 sur-
gery. Various forms of dental surgery, espe-
cially 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 employ-
ees, including providing living expenses and
overseas apartments (Kangas, 2007). Several
Mauritanian organizations have signed agr-
eements with Tunisian clinics for their emp-
loyees’ 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 pio-
neered 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 Mexican-
Americans, 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.
45
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 pos-
sibilities 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 off-
pump 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 technol-
ogies 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. Con-
versely, and unusually, some developing
countries offer possibilities unavailable in the
West. Some non-resident Indians, after work-
ing 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 ori-
gin. 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 work-
ers. Familiarity with such migrant health
workers has meant that treatment in hospitals
46 Chapter 4
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 stan-
dards of care at the best hospitals throughout
the world.
Growth of medical tourism has been facili-
tated 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 invalu-
able. When Ethiopia and Mongolia devel-
oped 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 straightfor-
ward, 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 Inter-
net 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 mar-
keting (in association with tourism) as medi-
cal 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 reassign-
ment), 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).
47
less sex changes, and also orchiectomy (better
known as castration), are routinely and casu-
ally 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 recu-
peration in a relatively alien environment
where they are quite unknown. Drug reha-
bilitation 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 exer-
cise (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,
48 Chapter 4
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 pri-
ority. In Australia, for example, breast recon-
struction 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 coun-
tries such as Ireland, they necessitate overseas
trips. Insurance companies and national hea-
lth 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 Zea-
land the Royal Australasian College of Physi-
cians 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 mobi-
lity even within medical tourism, following
developments in medical science. It involves
travelling overseas to undergo IVF, surrogate
pregnancy and other forms of assisted repro-
ductive technology, including freezing emb-
ryos for subsequent reproduction (Jones and
Keith, 2006), which raise ethical issues (Chap-
ter 8). Denmark has become the ‘sperm pow-
erhouse’ 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 dis-
count’ (quoted in Pavia, 2006: 4). Here as else-
where medical travel is increasingly part of
a tourist package (Chapter 9). Other rela-
tively controversial forms of medical tourism
include ‘transplant tourism’, ‘stem cell tour-
ism’ and ‘death tourism’, each of which raise
parallel controversial ethical issues. A final
form of medical tourism may be ‘transna-
tional retirement’: the establishment of over-
seas nursing homes, where patients effectively
stay permanently, as in Kenya, where con-
verted 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 cli-
mate is advantageous and some marry local
women as carers.
While a vast range of medical procedures
may be included under the umbrella of medi-
cal tourism some like ‘death tourism’ are rela-
tively trivial in terms of numbers (and
tangential to more obviously hedonistic
forms of tourism). Most medical tourism
involves no dramatic interventions and cen-
tres on such banal activities as screening and
routine check-ups and low level procedures
such as dentistry, rather than on cosmetic sur-
gery – where failures have featured in press
accounts – and such surgical procedures as
hip replacements. Such routine procedures
are more easily combined with standard tour-
ism 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 terror-
ism, the Asian economic downturn, Internet
access to price information, and the globaliza-
tion 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 mar-
keted by hundreds of MTCs and supported
by some insurance companies and other pri-
vate companies to reduce costs. Since 2006 no
fewer than five guidebooks on medical tour-
ism, four from the USA, have appeared: testi-
mony 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 seek-
ing cosmetic surgery. Politics and the difficulty
of getting to Cuba reduced its potential, and
assisted other Latin American countries, per-
haps not so ironic for the lone, formally social-
ist state engaged in an activity that exemplifies
the dominance of the private sector. Cuba has
received medical tourists from other Spanish-
speaking 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
49
health-care facilities, and emphasized the role
of the media in diffusing information on over-
seas 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 com-
pete 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 specializa-
tion. 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 else-
where; (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 med-
ical 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
50
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 sup-
ported by the Ministry of Tourism, have
sought to follow, none particularly success-
fully. It has, however, been claimed that Cali
(Colombia), formerly the ‘sports and salsa
capital’ of South America, has become a lead-
ing destination for medical tourism, with per-
haps 15,000 overseas patients a year, mainly
from the USA and Spain, particularly for
plastic surgery (Pease-Watkin, 2010). Else-
where 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 suc-
ceeded, 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 treat-
ment there in 2006 (Herrick, 2007); with a
national population no more than about four
million this would constitute one of the high-
est 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 rec-
ommended (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
Chapter 4
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 hos-
pitals have long attracted Americans for plas-
tic surgery and more recently hospitals in
traditional tourist destinations such as Can-
cun have promoted reduced-price surgical
procedures for retirees based in Florida and
the Gulf Coast. Dentistry and cosmetic sur-
gery 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 hos-
pitals 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 opposi-
tion 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 medi-
cal 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 natio-
nal and international standards, eight of
which were already certified by the Joint
Commission International (JCI). Initiatives
included training more bilingual Spanish-
English nurses (International Medical Travel
Journal, 2010), in order to reach a wider
population.
Outside the Americas medical tourism
has developed in various countries not previ-
ously 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 sur-
gery, and both have many diasporic returnees.
Latvia saw medical tourism as ‘a quick way of
getting a new image for the city, which has suf-
fered 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 Sic-
ily that ‘the best doctor is Alitalia’ (quoted in
Guerrieri, 1985: 240). West European countries
tended to have more comprehensive state
51
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 instru-
mental in planning for health tourism.
Hungary, for example, declared 2003 to be the
Year of Health Tourism, and tourism bro-
chures 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 sophis-
ticated 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 low-
cost 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. Ice-
land announced its entry into medical tour-
ism in 2010 with a proposed new hospital at
Keflavik, a location chosen mainly because of
the area’s experience of tourism.
52 Chapter 4
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 usu-
ally 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 Alba-
nia, 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 qual-
ity of national health services and increased
the availability of contemporary technologies,
primarily in the large urban centres of Istan-
bul, Izmir and Ankara. Turkey has more JCI-
accredited 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 for-
eign patients (Today’s Zaman, 2010). Malta
and Cyprus vie for primacy in the Mediterra-
nean. Both stress anglophone doctors (trained
in the UK or the USA), accessibility, a mild cli-
mate 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 coun-
tries, 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 trans-
plants and dentistry. While Georgia may be a
viable destination for expensive fertility pro-
cedures, 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 geographi-
cal 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 popula-
tions. However, rather like South America,
economic growth and the rise of the middle
class, especially in such ‘Asian tigers’ as
53
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 pri-
vate hospital instead of a public hospital’
(Niyomyath, 2009: 32) and that market gradu-
ally 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, per-
haps more than anywhere else, the rise of
medical tourism was effectively led by Indi-
ans returning home with capital and the
knowledge that new technologies and skills
had been acquired (Chapter 5). Most Asian
countries remain sources rather than destina-
tions. China has pioneered stem cell research,
but is not yet a significant destination. Hong
Kong has a number of internationally accred-
ited hospitals, and if these were able to link
into the substantial Chinese diaspora popula-
tion, 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 destina-
tions, hence are focusing on diasporas and
plastic surgery. The Philippines has recently
declared its interest, based on global familiar-
ity 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,
54 Chapter 4
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 trans-
plant 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 chal-
lenge. 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 neigh-
bouring 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 else-
where. 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 vis-
ited 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 neigh-
bouring 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 medi-
cal tourism destination, especially for travel-
lers 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 Middle-
Eastern 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 cor-
roborate 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 infer-
tility, 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 ini-
tially at Arab travellers visiting Lebanon for
anything from cosmetic surgery and dental
care to intestinal bypass operations, but sec-
ondarily 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 com-
pete 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 devel-
opment 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
55
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 Middle-
Eastern market and discourage Gulf medical
tourists from going to Asia. Unable to com-
pete on price the Gulf now largely seeks to
compete on quality, with Dubai bringing in
German doctors to guarantee high skill stan-
dards, and Lebanon stressing its many doc-
tors trained in Europe and America. Branding
is seen as important: ‘it remains to be seen if
DHCC will attract people … if there is a sin-
gle 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 espe-
cially 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 Feder-
ated 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
56 Chapter 4
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 sur-
gery 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 coun-
tries have succeeded; (iv) profitability is evi-
dent; 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 estab-
lished 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 ser-
vices 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 Mediterra-
nean 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. Inde-
pendent 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 coun-
tries and to diaspora populations; (iii) peace
and stability; (iv) good exchange rates; and
(v) a basic familiarity to a wider world. A par-
ticular 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 inte-
grating medical tourism into the national
development strategy. The rise of Asian medi-
cal tourism has been exceptional since it has
developed at some distance from Western mar-
kets, and been boosted by both diasporic migra-
tion 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 sig-
nificance for medical tourism, as potential
tourists have usually tried to minimize dis-
tances. Mexico has been a major beneficiary
of health tourism from the USA, with Mon-
terrey 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 impor-
tant. 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 sam-
pled residents in the Russian Far East who
had been overseas for treatment, the major-
ity went to China (Jego, 2009; Ho, 2010),
Bangladeshis go to India and South Africa
attracts tourists from nearby states in sub-
Saharan 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. Cross-
border 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) identi-
fies as many as 50 countries where it is
regarded as a ‘national industry’, the most
comprehensive listing of any of the guide-
books (see Chapter 6). SurgeryPlanet’s web-
site lists 72 countries and other companies
identify even more countries. In 2010 Wiki-
pedia 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 destina-
tion, 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 them-
selves in the Directory on the website of Treat-
ment 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, Tai-
wan and Tunisia), fall not far below that cut-off
and were also included on the map (Fig. 4.4).
Czech Republic
Germany
Austria
UK
Belgium
USA France Croatia
Spain
TunisiaMalta
Mexico
Cuba
Switzerland
Costa Rica
Brazil
Argentina
Fig. 4.4. A geography of medical tourism.
57
The inclusion of Cuba just once in the list high-
lights the political structure of this free enter-
prise phenomenon, and it too was added. The
UK was also added since it gained few refer-
ences 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 arbi-
trary 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 facili-
ties exist. Along with the actual number of ref-
erences 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
Poland
Latvia
Lithuania Slovakia
Hungary
Turkey Romania
South Korea
Cyprus
Israel
Egypt India Taiwan
Greece Thailand
Philippines
Malaysia
Singapore
South Africa
58 Chapter 4
Hospital (China), Medical Center Chaim
Sheba (Israel), Jordan Private Hospital
Association (Jordan), Vilnius Heart Surgery
Centre (Lithuania), Medical Travel GmbH,
University Medical Centre Freiburg, Deutsch-
Medic GmbH, Medcurator Ltd, Medclassic
(Germany), Genolier Swiss Medical Net-
work (Switzerland), Premiamed Manage-
ment 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 mid-
dle 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 pro-
cesses 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 per-
haps 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 Afri-
cans 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 com-
bined 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). How-
ever, 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 access-
ing health care there; and (iii) a preference for
Mexican care (Chapter 7). Most migrant soci-
eties 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 cate-
gorization provides a socio-economic pers-
pective 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 con-
tributing to the emergence of Central Amer-
ica and Asia as destinations. Alongside them
are those who move for cheaper and neces-
sary services, for example when their insur-
ance is inadequate. These are the subject of
almost all the literature, the targets of guide-
books and websites and the popular concep-
tion 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 socio-
economic status, from relatively affluent
Maltese and Koreans to less affluent Mexi-
cans, 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-estab-
lished 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 lux-
ury or a choice, and who would have pre-
ferred local treatment. ‘Medicated tourists’,
who meet with misfortune on holiday, and
resident expatriates have been excluded.
These categories and this typology are nece-
ssarily 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.
59
Much medical tourism has developed
without market persuasion. Diasporic medi-
cal 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 geog-
raphy of medical tourism have been funda-
mental 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 des-
tinations 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) cos-
metic procedures boom; and (iv) disposable
capital is available. Destination countries
seek foreign exchange and new means of
economic growth. As technology has imp-
roved 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
60 Chapter 4
enthusiastic, and governments have become
supporters and promoters, through national
development planning and tourism cam-
paigns (Chapter 9). Some governments have
taken out equity in particular ventures. Sev-
eral 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 realis-
tic 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 conser-
vative 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. Conse-
quently 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 cul-
turally 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 obvi-
ous 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 ack-
nowledged. 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 med-
ical tourism is Asia. In terms of numbers of
medical tourists Thailand is almost certainly
© CAB International 2011. Medical Tourism (J. Connell)
the most important country involved. It
became known as a destination for medical
tourism as early as the 1970s because it spe-
cialized in sex-change operations, and later
moved into cosmetic surgery; about 100 for-
eigners had undergone sex-change opera-
tions 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 mar-
ket rather later than South-east Asia but has
developed extremely rapidly with shifts in
technology and the development of sophis-
ticated hospital chains. Singapore has belat-
edly 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 Phil-
ippines and Taiwan, are now seeking to be
involved. This chapter examines the emer-
gence 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
61
62 Chapter 5
income generated, are speculative, based on
estimates, without clear definitions and
remarkably rounded. Numbers are compli-
cated 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 whit-
ening, 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 indepen-
dent body. The numbers stated by some
countries and hospitals are substantial exag-
gerations, but inflated figures imply growth
and success, and encourage private-sector
investment and national support. As one ana-
lyst has said: ‘By definition almost every offi-
cial 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 resi-
dent expatriates. Another group of scholars
‘found a lack of hard data on the magnitude
of medical tourism, with anecdotes, broker-
age claims and theoretical conjectures substi-
tuting 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, pro-
vides some numerical data, most are little
more than crude estimates and must con-
stantly be subject to caution and qualification.
They have been included primarily to give a
crude sense of comparability between coun-
tries. Calculations based on data from two
Thai hospitals (see below) indicate how over-
inflation 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, how-
ever 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 supe-
rior health care and the presence of major
international airline hubs and airlines. Inc-
reased numbers of expatriates and the new
middle class provided key markets for pri-
vate-sector hospital growth and subsequent
medical tourism. As the Chief Executive Offi-
cer (CEO) of Bumrungrad International Hos-
pital (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 health-
conscious 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. Expa-
triates 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 posi-
tive, 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 eco-
nomic 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 cus-
tomer base and several revised their market-
ing strategies to target overseas patients, for
whom devaluation meant that prices effec-
tively halved (Turner, 2007a: 115–116; Anon.,
2010b), as a more entrepreneurial state emer-
ged. 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 subse-
quent domestic economic growth brought
new employment structures, local middle-
class demand and considerable success. Most
Asian governments have consequently pro-
moted 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).
63
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 neigh-
bouring 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 ser-
vices in 2002, but most were resident in Thai-
land, contributing about US$477,000 to the
economy (Henderson, 2004: 115). The north-
ern 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 busi-
ness people and half were ‘retired ordinary
64 Chapter 5
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 mak-
ers 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 foreign-
ers 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 (vis-
iting 33 private hospitals) were expatriate resi-
dents 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, Thai-
land 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 Thai-
land 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 expa-
triates, 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 for-
eign 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 sud-
denly 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 med-
ical 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 pres-
tigious hospitals such as Phuket Hospital and
Dusit Medical Services, with hospitals in Pat-
taya, Phuket and Koh Samui, are located in
the main tourist areas.
The diversity of patients is reflected in
Phuket Hospital’s claim to provide interpret-
ers in 15 languages, and receive about 200,000
international patients a year, while the Bang-
kok General Hospital has interpreters for 26
languages and a wing specifically for Japa-
nese visitors. BIH in Bangkok – perhaps the
single most famous global destination for
health tourism – claims to employ 70 inter-
preters, 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 pub-
lishes publicity material in several langua-
ges, 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 symp-
toms – 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 facili-
ties 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
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 JCI-
accredited hospital in Thailand, with a staff of
950 full- or part-time doctors. After the Asian
financial crisis it increasingly targeted over-
seas clients, underselling hospitals in Singa-
pore, 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
65
suites were created and chefs brought in to
redevelop menus (Turner, 2007a: 116; Chap-
ter 9). In a sense the contemporary elite med-
ical tourism industry, as it is widely imagined,
was born then and there.
By the end of the 20th century Bumrun-
grad was supposedly handling about a quar-
ter 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
66 Chapter 5
Thailand itself claimed some 1.4 million for-
eigners visiting for medical treatment. In 2009
it claimed to have served just over one mil-
lion patients, of whom 400,000 were interna-
tional 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 mem-
bers of the United Nations, though this prob-
ably 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). Inter-
national numbers were boosted after the 9/11
Fig. 5.3. Bumrungrad International Hospital, Bangkok.
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
 Medical Tourism and the New Asia 67

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 specifi-
cally for some procedure, as are the smaller
numbers from China and Japan, whereas
American, European and Australasian
patients are more likely to be accidental hos-
pital patients (Kenneth Mays, personal com-
munication, March 2010). BIH state that the
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 tour-
ists is relatively small, especially from devel-
oped countries in Europe, North America and
Australasia.
Bumrungrad has overseas representa-
tives’ offices in Angola, Australia, Bahrain,
Bangladesh, Cambodia, China, Ethiopia, Ger-
many, 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 Bang-
kok 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 num-
bers amounted to about 6000 a year. How-
ever, 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,

UK Germany
Ukraine Mongolia East Asia
North America
Europe 24,492
25,934 Portugal 25,214 Middle East South Korea
Kuwait Nepal China
99,596 Bangladesh Taiwan
Africa Bahrain
UAE Hong Kong
14,756 South Asia
Yemen Vietnam
33,965 Cambodia
Ghana Sudan Oman
Nigeria South-east Asia
Ethiopia Sri Lanka
771,248
Singapore
South America Seychelles Myanmar
Angola
363
Oceania
8,246
Australia
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).
68 Chapter 5
and has obvious parallels elsewhere, were
data available. It would almost certainly simi-
larly reveal that the actual number of ‘genu-
ine’ medical tourists specifically travelling to
Thailand (and elsewhere) for medical treat-
ment 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 coun-
try’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 mar-
kets are the Middle East, Japan and Europe
but in 2009 it saw ‘a rapid increase in cus-
tomers from China and Australia, due to
their increase in income and trade, but num-
bers from the United States dropped’ (Bang-
kok 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. Accord-
ing 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 sig-
nificance of the Gulf compared with Euro-
pean and regional sources (see pp. 115–117),
there is no means of collecting or verifying
these data. Beyond these formal if crude esti-
mates, 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 Singa-
pore (Bangkok Post, 26 May 2009). However,
although Thailand is well known for a diver-
sity of procedures, and perhaps infamous as
the centre for gender reassignment, the major-
ity of procedures are actually routine tests
without significant surgery or dramatic out-
comes, 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 larg-
est privately owned airline, is building ‘well-
ness 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 Air-
ways owns three Bangkok hospitals. Patients
at the Bangkok Hospital Medical Centre, the
Bangkok Hospital Group and Samitivej Hos-
pital can obtain frequent-flyer points for their
treatment costs. Bangkok Airways has con-
structed a wellness centre on a golf course on
the edge of KhaoYai National Park, 120 km
from Bangkok, to ‘complement our core busi-
ness 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 pri-
vate 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 part-
ners 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 interna-
tionally well known with strong presence in
their respective regions, thereby providing
important sources of new investment oppor-
tunities 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 man-
aged 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 hospi-
tal 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 oppor-
tunities there, Bumrungrad itself, with Star-
bucks 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 public-
sector health care.
India
India is sometimes regarded as the contem-
porary global centre for medical tourism,
69
advertising itself as offering everything from
alternative Ayurvedic therapy to coronary
bypasses and cosmetic surgery. Indian hospi-
tals 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 expan-
ded and been given government support to
import technology and other medical goods
with reduced tariffs, so bringing infra-
structure in the best hospitals to Western
levels. Indian medicine has become involved
in assisted reproduction technology, includ-
ing 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 For-
eigner 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 compara-
tive 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 sala-
ries increased, so doctors returned from
overseas. Many had international qualifica-
tions 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
70 Chapter 5
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 accredita-
tion 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 trans-
national 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 gen-
eration ethnic Indians from countries such as
Mauritius and the Seychelles are also signifi-
cant. 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 neigh-
bouring countries or are NRIs (Hamid, 2010).
Many simply cross to adjoining states so that
most medical tourists from Bangladesh, Bhu-
tan 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 interna-
tional numbers, though growing, may actu-
ally 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 syn-
ergy 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 pharmaceu-
tical 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 represent-
ing 4 continents and 56 countries’ (Fortis
Hospitals, 2010). The New-Delhi-based
Fortis, originally set up by Ranbaxy Labora-
tories, the largest drug company in India,
owns other smaller hospital groups, includ-
ing 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 over-
seas linkages to a total of over 62 hospitals,
making it the largest hospital network in
Asia.
Medical tourism in India is highly local-
ized 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 receiv-
ing 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.
71
Singapore
Within Asia Singapore is a high-cost health
service provider, has at least 13 hospitals with
JCI accreditation and seeks to compete glob-
ally through quality, and regionally, specifi-
cally to its populous neighbour Indonesia,
through ease of access and low travel costs.
Prior to the Asian financial crisis that pro-
pelled Thailand into medical tourism, Singa-
pore 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 life-
style. The government took a lead in develop-
ing 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 Myan-
mar, 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 num-
ber, 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,
72 Chapter 5
especially neighbouring Indonesia, rather
than from developed countries (p. 114). That
distinction, in a relatively high-cost Asian
destination, suggests that even developed-
country medical tourists are substantially
driven by economic imperatives for non-
essential procedures.
Since most medical tourists are from
within the region, competing with Thailand
and Malaysia is difficult, where costs in Thai-
land are about 15–20% less than in Singapore
(and the cost of living is also less). Cosmetic
surgery is expensive and Singaporeans them-
selves, with access to excellent medical facili-
ties, 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 trans-
plant. In seeking to attract medical tourists to
a small country of just five million, Singapore
has sought to retain high-level speciality ser-
vices, 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 eco-
nomically efficient. Despite claims to techno-
logical prowess, some Singapore providers
have incorporated traditional Chinese medi-
cines 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 hospi-
tals are part of international chains, typified by
Parkway Holdings, the main Singapore hospi-
tal chain, with its flagship Mount Elizabeth
hospital, which by the mid-2000s had become
a regional conglomerate. It owned and man-
aged hospitals, dental surgeries, diagnostic
labs and research facilities in several Asian
states alongside being engaged in the sale of
properties, and diverse investment and trad-
ing activities. In 2005, when it claimed that
40% of its income came from foreign patients,
it had marketing offices in 15 countries (Kha-
lik, 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 invest-
ment 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 inter-
nationalization, new relationships between
countries, new forms of private-sector invest-
ment 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 link-
ages with other Muslim countries in and
beyond the region (though the notion of a
‘harmonious plural society’ is nationally
prominent, and also promoted within medi-
cal tourism), and near neighbours such as
Vietnam and Myanmar. Its origins, as else-
where, are closely linked to the Asian finan-
cial 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 num-
ber of foreigners visiting Malaysia for medi-
cal 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 major-
ity 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. Malay-
sia has concluded an agreement with Singa-
pore 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-
73
sia (Doshi, 2008: A-21). National data, of
doubtful value, suggest that fewer than 8% of
medical tourists come from developed coun-
tries (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 opera-
tors who organized tours especially to Mala-
cca 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. Medi-
cal tourism is loosely coordinated through
Malaysia Healthcare, a ‘one-stop destination’
that provides links to diverse providers, air-
lines 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 multi-
ple entry visa. Political stability and English-
language 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 medi-
cal tourists are substantially smaller than
frequently publicized numbers. Easen’s
74 Chapter 5

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 Sin-
gapore as 2.3 million, with 1.2 million in Thai-
land, 600,000 in India and 500,000 in
Singapore, whereas the analysis above sug-
gests 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 evi-
dent that most medical tourists are either dia-
sporic 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 Tai-
wan, hindered by relatively high costs and
language differences, and from the Philip-
pines. 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 cul-
turally 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 for-
mer Soviet Union, and been proactive in
encouraging overseas delegations and diplo-
mats to visit hospitals and examine facilities.
One such delegate, the wife of the ambassa-
dor of Uzbekistan, commented: ‘I don’t smell
agents used in hospitals here. Music was play-
ing in the lobby and the smooth mood, luxuri-
ous VIP bedrooms and other facilities made
me think I was in a six-star-hotel!’ (Korea
Times, 2010). Mongolia has signed a memo-
randum of understanding with three Seoul
hospitals, as a growing number of Mongo-
lians arrive for medical treatment. As much as
anywhere else in the region, Korea has become
actively engaged in promoting medical tour-
ism, 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 num-
ber was said to be steadily increasing. Rather
like Singapore the official goal is a million for-
eign 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 dif-
ferent source estimated some 60,000 medical
tourists (Basit, 2010). The Korea Health Indus-
try Development Institute, established and
funded by the Korean government to pro-
mote Korean health care and develop a medi-
cal travel insurance programme, runs three
overseas marketing offices in New York, Bei-
jing 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:
75
‘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 approxi-
mately 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 ser-
vices ranging from comprehensive health
screening to cosmetic surgery, which mainly
centres on eyelid surgery, rhinoplasty, face-
lifts and skin lightening. Previously, people
went to Korea for less invasive cosmetic sur-
gery procedures, like Botox injections, but
foreign patients are now said to seek out pro-
cedures developed by Korean surgeons, like
autologous fat grafts and facial-bone correc-
tions. While Thailand may be the largest
medical tourism destination in South-east
Asia, Korea is attractive to young Thais, influ-
enced by the spread of Korean popular cul-
ture and seeking the k-pop look of big eyes
and white skin.
Taiwan, like Korea, has focused on
attracting Chinese speakers elsewhere, espe-
cially in the USA diaspora and China, but
numbers are small. Something of a break-
through 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.
76 Chapter 5
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 speak-
ing, 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 Interna-
tional 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 Fili-
pinos, 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, lim-
ited familiarity with the Philippines (if not
Filipinos) in potential Western markets, con-
cerns 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 prob-
lems. 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 Phil-
ippines, 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 des-
tination, 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 spi-
nal injuries, looking for experimental stem-
cell 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 eco-
nomic 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 coun-
tries, like Japan that have been long-term
sources, are seeking to ‘fight back’ via special-
ization 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 interpre-
ter,’ 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,
77
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 tour-
ists to Japan to 100 a year, a more realistic
objective than most countries, oriented ini-
tially 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 pop-
ulation. 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 weal-
thy 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 (Interna-
tional 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 con-
texts, through diverse means. Whereas both
Malaysia and Singapore have a medical tour-
ism 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 pro-
vider to becoming an international provider.
The number of countries seeking to compete
78 Chapter 5
is growing, though most are middle- or high-
income countries, rather than such impover-
ished nations as Laos or Myanmar. Asian
successes have also prompted growing glo-
bal 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 imper-
sonally, 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 construc-
tion 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, market-
ing very particular services in destinations,
and guaranteeing their quality, is highly
important for potential visitors who may be
quite unfamiliar with both countries and ser-
vices, 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 tour-
ism, 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 interna-
tional 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 reluc-
tance, despite cost savings. Medical tourists,
other than diaspora tourists, must be con-
vinced to travel, sometimes in the face of
opposing advice from their own practitio-
ners, and at least initially through anonymous
© CAB International 2011. Medical Tourism (J. Connell)
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 par-
allels in other forms of niche tourism, that are
the outcome of web searches, brochures and
the suggestions and experience of others. Vir-
tually 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 devel-
opment, 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 remark-
ably, 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 medi-
cal tourism, the only print media advertise-
ments are in in-flight magazines or (usually)
small advertisements in English-language
79
80 Chapter 6

publications (newspapers or tourist brochures procedures. Only recently has the Internet
or even occasional street posters), in countries been supplemented with the presence of
such as Slovakia, India and Thailand (Fig. guidebooks, but websites and guidebooks are
6.1), which tend to advertise limited drop-in interconnected. Marketing and branding in

Fig. 6.1. (a) Dental tourism advertise-

ment (source: Sawaddee, Thai Interna-
tional’s in-flight magazine, April 2010).
 Marketing Medical Tourism
Fig. 6.1. (b) Sukhumvit street sign, Bangkok.
various forms have been crucial to the estab-
lishment of medical tourism.
Is It Healthy?
The single most crucial challenge that medi-
cal 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 avail-
able 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 inter-
national visitors. That the elite from devel-
oped 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
81
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 hos-
pitals (and MTCs), who publish positive testi-
monials, and the professional bodies, who
record and repair misadventure, have obvi-
ous 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 cos-
metic surgery where disappointments and
failures may be more frequent. Indeed cos-
metic surgery is never universally successful,
even in the best possible contexts, with some
infamous examples of failure (Jones, 2008).
Outcomes are largely dependent on proce-
dures. Though many so-called ‘smile spas’ in
various parts of Europe have no qualified
dentists, most do little more than teeth whit-
ening where issues of quality and longevity
are less significant. More complicated proce-
dures are more challenging. The focus on
botched procedures has largely centred on
cosmetic surgery, partly because the media
can obtain startling ‘before’ and ‘after’ photo-
graphs, or the fewer but particularly chal-
lenging transplant operations (see Chapter 8),
rather than on more straightforward proce-
dures such as dentistry, where most interven-
tions 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 exam-
ple, warns about compromised standards in
hygiene and poor techniques and, perhaps
more significantly, about adopting the wrong
advice and thus procedures. As a representa-
tive 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
82 Chapter 6
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 opera-
tions 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 complica-
tions which need to be fixed. Of course we
will treat them, but it is not fair to the tax-
payer 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 complica-
tions), and no indication of how many
women (or men) undertook cosmetic proce-
dures 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 sur-
geons 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 over-
seas procedures, though they had collectively
seen 215 patients in a single year, and a quar-
ter of these required emergency surgery, at
some cost to the NHS which became the
‘safety net’. A similar survey in Greater Lon-
don found that 60% of 35 plastic surgeons
had seen complications from ‘cosmetic tour-
ists’. The most popular procedures that
required remedial surgery were breast aug-
mentation, 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 testi-
monials from 376 patients from a range of
countries over several years (see below).
While failures will not produce positive
testimonials, the absolute number of suc-
cesses compares favourably with the British
and Australian numbers on failures. How-
ever, 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 invol-
ved cosmetic surgery patients who: (i) went
to facilities that may not have been ade-
quately assessed; (ii) had too many proce-
dures performed simultaneously; (iii) had
pre-existing conditions that made success
difficult to achieve; or (iv) simply had unreal-
istic expectations of outcomes and comp-
lained 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 destina-
tions 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
83
websites imply high ‘take-home baby’ rates
because of the quality of care provided and
because hospitals do not have to follow West-
ern guidelines for the number of embryos to
be implanted, actual success rates have been
excluded and, when queried in India, ‘doc-
tors simply avoided the question’ (Mulay and
Gibson, 2006: 88). Formal analysis of compar-
ative success rates for this and other proce-
dures is conspicuous by its absence. Since
technology has become much the same as in
the West, and doctors are experienced in con-
temporary 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 prob-
ably much the same as anywhere else; several
measures of success rates and errors of omis-
sion indicate that success rates at good hospi-
tals are little different the world over
(Reisman, 2010: 54–56). The quality of post-
operative 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 follow-
ing self-funded medical treatment abroad’
(Lunt and Carrera, 2010: 27). Where some
long-term care is needed evaluating out-
comes is more problematic since care takes
place in different countries. Long-distance
travel may itself add complications. Of con-
cern to many potential patients is after-care –
what happens if something goes wrong when
they return home and their tourism destina-
tion and friendly hospital is far away? Usu-
ally 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 reme-
dies do exist, the difficulty and cost of using
these from a distance). It has been argued
that, despite Bumrungrad having offices for
84 Chapter 6
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 liabil-
ity 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 pro-
viders include coverage and treatment for
possible complications in their package
prices, and patients may also take out indi-
vidual insurance policies (Herrick, 2007:
18–19). Organizations such as ISAPS have
sought to develop the first international insur-
ance 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 coun-
tries, 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 over-
seas treatment. Infectious diseases exist in
some tropical countries (many of the princi-
pal 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 deterio-
rate to the point where attention is essential.
Many Mexicans returning from the USA for
dental treatment left it so late that minor cavi-
ties 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 treat-
ments (Kangas, 2007: 298). In such circum-
stances treatment is more challenging and the
probability of success reduced.
The few surveys of medical tourists after
treatment have found that most were satis-
fied. In a group of European countries the
likelihood of going overseas for treatment
was strongly correlated with previous treat-
ment 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 con-
sultancy 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 sur-
gery (in Malaysia) was safe and how the fears
of relatives could be overcome responded
overwhelmingly positively, while demon-
strating 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 tour-
ism – and have reduced the potential of medi-
cal 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 suc-
cess 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 dis-
incentive to medical tourism: a throwback to
the concerns of Deutsche Welle in 2005. Percep-
tions, 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
85
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, opu-
lence, 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 conser-
vatism and self-interest of domestic medical
practitioners and their professional organiza-
tions. Moreover ‘information on quality is not
readily available to patients, and what is avail-
able 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 mis-
leading (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 well-
known. 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 bar-
rage of pharmaceutical and technical terms
[that] purport to make the process appear
complicated, scientific and, most of all, pro-
fessional’ (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 sig-
nificance to health professionals rather than
patients.
86 Chapter 6
The JCI, originally established to accredit
American hospitals participating in Medicare,
is the key global regulator of health-care stan-
dards, and has been inspecting and accredit-
ing 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 institu-
tions 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. How-
ever, the JCI, like other accreditation organi-
zations, 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 accredi-
tation organization, the International Stan-
dards 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 global-
ization of medical care.
A number of independent, non-profit
organizations also endorse standards of qual-
ity 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 stan-
dards for health clinics and medication centres.
However, many hospitals are actually accred-
ited 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 organi-
zations, ministries of health and global
organizations in over 80 countries. In 2006 it
opened regional offices in Dubai and Singa-
pore to cater for growing demand for accredi-
tation in the Gulf and South-east Asia. In
early 2010 its website claimed that it had cer-
tified ‘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 sim-
ply 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 web-
sites 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 partner-
ships with facilities in 40 countries, including
the Wockhardt Group, and DHCC. The other
large Indian chain, Apollo, is partnered with
Johns Hopkins Medicine International. Implic-
itly such linkages provide accreditation, add
prestige and imply global standards. Hospi-
tals 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 cer-
tain biases. To some extent the guidebooks are
oriented to Internet-illiterate users of the baby-
boom generation, offering advice on how to
use it to search for medical facilities. Intending
87
patients will turn either to guidebooks or to
the websites of MTCs and finally to the web-
sites of the facilities where they may go. Before
they do that they are likely to have been influ-
enced 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 uncer-
tain 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 exis-
tence of overseas facilities in a way that
would not otherwise have happened. The
extent of media coverage (and the contempo-
rary use of web pages for detailed informa-
tion) 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 tour-
ism, only after the media ‘discovered’ the
new trend and produced stories and televi-
sion programmes about its significance, and
the cost savings that were possible. Overcom-
ing 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 tour-
ism, 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 dra-
matic features in the tabloids (complete with
88 Chapter 6
accompanying ‘before’ and ‘after’ photo-
graphs). 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 honey-
moons – 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 espe-
cially 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 Tour-
ism’ to the extent that there was a joint web-
site with comments from former and poten-
tial 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 recom-
mendation. But patients also have concerns
and financial problems and some web post-
ings 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 qual-
ity. 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 par-
ticular 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 Bumrun-
grad 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 cru-
cial. 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 peo-
ple 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’ dis-
criminates 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 sensational-
ism, 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 English-
language 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 destina-
tions, where there are both tourism and expa-
triates, including Malaysia (Fig. 5.5), India
and Singapore.
89
Websites, guidebooks and MTCs empha-
size 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) compa-
nies that market or advise on global destina-
tions (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, usu-
ally 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 solu-
tions 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
90 Chapter 6
on the price listed on the website. Talk to
someone at the hospital first.
4. 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 accommo-
dations and plane tickets and add those to
the cost. Be sure to factor in any recovery
time.
5. 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.
6. 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.
7. 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 com-
parative 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 per-
spective on the provision of medical tourism.
These include Treatment Abroad in the UK,
RevaHealth based in Ireland, PlacidWay,
SurgeryPlanet, Health-Tourism.com and All-
MedicalTourism in the USA. Most other
MTCs limit themselves or are limited to par-
ticular markets, destinations and procedures
(see below). Such global companies provide
wide-ranging information on medical tour-
ism opportunities for different procedures,
the distinctiveness of particular places and
ultimately which can be recommended for
what activities (usually including both proce-
dures and tourism). Their websites have
multiple linkages to countries, hospitals and
clinics, patient stories and testimonials (some-
times in videos), press reports, company poli-
cies and interactive sections for obtaining
quotations. Some offer virtual tours of facili-
ties. 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 errone-
ous, 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 acu-
puncture (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 prospec-
tive patients were encouraged to contact
them. Thus the Chrysovalantou Cosmetic
Surgery Clinic in Cyprus suggests that
patients write in along the lines: ‘I am inter-
ested 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 testi-
monials and provides free quotations. Site
users can specify procedures, gain informa-
tion 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 irresist-
ible and breathtaking natural beauty, inspir-
ing temples, renowned hospitality, exotic
cuisine and pristine beaches.’
Treatment Abroad covered 54 destina-
tions 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 guide-
books) 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 den-
tal surgery to fertility treatments and major
surgery (AllMedicalTourism, 2010). Surgery-
Planet (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 indi-
vidually 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 accommoda-
tion, 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 desti-
nations. 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 Aus-
tralia 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 destina-
tions were: (i) Croatia (US$3773); (ii) Hungary
(US$1244); (iii) Thailand (US$1433); (iv) Mex-
ico (US$588); and (v) Brazil (US$514). All-
MedicalTourism (2010) then indicated that
their ‘top destination’ was Thailand: ‘Thai-
land’s combination of English speaking sur-
geons and nurses, World Class facilities and
highly competitive prices, makes Thailand’s
capital Bangkok, a strong choice for your pro-
cedure overseas’. Selecting a different home
country, the UK, gave five rather different
‘top destinations’ (Croatia, South Africa,
91
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 hospi-
tals. Singapore’s site www.singaporemedi-
cine.com provides a link to the Singapore
edition of Patients Beyond Borders, and pro-
vides detailed information on prices, facilities
and procedures. It starts ‘In addition to a
seamless and timely experience with state-of-
the-art medicine and treatment rendered by
92 Chapter 6
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 possibili-
ties. 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 rejuve-
nates your body and mind’ (Malaysia Health-
care, 2010).
A handful of companies have sought dif-
ferent 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 devel-
oping contemporary medical tourism has
been the rapid growth of MTCs (or broker-
ages) that market medical procedures in dis-
tant countries and arrange linkages between
patients and hospitals, travel and accommo-
dation and the tourism that often goes along-
side that. One industry definition of an MTC,
in this case a dental tourism facilitator, is ‘a
person or company offering a service to pro-
spective dental patients: to help them navi-
gate the world of international dentistry and
find the best quality care abroad, at the same
time helping them to realize major cost sav-
ings’ (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 health-
services 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 rela-
tively unusual set of destinations, that indi-
cates 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 testimo-
nials going back to 2006, but make the com-
pany 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 plea-
sures associated with visiting the game parks
of Africa and cosmetic dentistry in the Carib-
bean. Though destination MTCs are more
likely to tout the charms of their country, and
source country MTCs offer more comprehen-
sive 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)
93
MonterreyHealthcareCity is a group of ten
hospitals in Monterrey, Mexico, which adver-
tises itself as being the closest medical tour-
ism 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 desti-
nations such as India, Spain and Cyprus,
while the few large ones are in source coun-
tries 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 indus-
try (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 approxi-
mately 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
94 Chapter 6

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 expe-
riences. 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 subsid-
iaries 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 representa-
tion 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
95
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 med-
ical tourism is emerging more slowly and the
market is smaller, most companies are part-
time operations with no more than an owner-
worker 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 busi-
nesses’ 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 Aus-
tralian 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
96 Chapter 6
come together then I will charge A$54.50 per
day each.
(Gold Coast Escorts, 2010)
Blogs on the site indicated she used Bumrun-
grad. Many MTCs reflect their owner’s par-
ticular 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 exclu-
sive ties to India, where she previously
worked as a doctor, and could build on previ-
ous 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 pro-
portion 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 grow-
ing. Plenitas’ global figures suggest similar
numbers. Surgeon and Safari in South Africa
received about 30 clients a month in the mid-
2000s (Witepski, 2005). Other Australian com-
panies have far fewer. The British dental
travel MTC sends about 60 patients a month
to Hungary (Haslam, 2007). American com-
panies 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 Gor-
geous 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 usu-
ally evolved from bilateral relationships with
a single country to offering multiple destina-
tions. Planet Hospital sells packages in 13
countries, but most work with providers in
no more than six or seven countries. MedRe-
treat, 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, Malay-
sia, 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 straight-
forward:
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 health-
care providers in each of them. WorldMedAs-
sist 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 compa-
nies 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 over-
seas 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 English-
speaking, 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
97
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, pro-
vide weekly chartered vans to take dental
patients to partner facilities in Los Algodo-
nes, Mexico, where treatment is normally
completed in a day (Hyo-Mi et al., 2009). Des-
tination 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
98 Chapter 6
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 insur-
ance 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 refer-
ral fees that are built into the cost of treat-
ment, 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 com-
mercialism. Like several other large MTCs,
MediTravels include a category on their web-
site 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 cre-
dentials of staff and the testimonials of recent
patients. Some address this in global terms.
Thus the Texas-based Medical Tourism Cor-
poration 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 coun-
tries 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 first-
hand 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 MedRe-
treat, ‘Only the best hospitals, hotels and des-
tination program managers have met our
stringent criteria and have been chosen to par-
ticipate’ (MedRetreat, 2010; my italics). Like-
wise, 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 guide-
book 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 indepen-
dent 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 pack-
ages labelled Yummy Mummy, Fabulous
Facelift, Zap the Fat and even Designer Vagina
(Weaver, 2008a). Many MTCs encourage
99
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 depar-
ture 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, reinforc-
ing 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 conven-
tional images of hospitals and medical proce-
dures. The merits of particular countries (and
their peoples) as tourist destinations are usu-
ally covered. Thus MedRetreat state: ‘Imag-
ine 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 com-
bining 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 Presi-
dent of one MTC has argued that Thai medi-
cal tourism lacks effective marketing and
promotion since hospitals have been unwill-
ing 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
100 Chapter 6

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, Mel-
bourne, Canberra, Gold Coast, Cairns, Perth) and New Zealand (Auckland, Christchurch, Welling-
ton) 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, conversa-
tions 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 proce-
dures, 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 sto-
ries 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 Inter-
net-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 through-
out 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 shop-
ping 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 recom-
mended 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.
 Marketing Medical Tourism 101

Fig. 6.3. Gorgeous Getaways flier, 2010.

hospitals are confident they already have Guidebooks

their own markets and need not depend
much on tour agents’ (quoted in Chinma-
neevong 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.
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
102 Chapter 6
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 hos-
pital 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 coun-
try-specific versions (for Korea, Malaysia, Tai-
wan, 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 men-
tion ‘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 perspec-
tives to those of the global MTCs, and there is
little difference between them and explor-
atory websites such as Ehow, other than the
greater detail in the books, and more exhaus-
tive 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-or-
less global coverage of relevant places and
offer advice on choices of destination. Each
assume that readers have minimal knowl-
edge 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 dia-
sporic 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, Han-
cock and Schult, write from their own experi-
ence, and others have obvious connections
with the industry; Marsek runs the Med-
Retreat MTC, Gahlinger has a medical back-
ground, and Woodman is described as ‘an
outspoken advocate of global consumer
healthcare and medical travel’.
Each of the guidebooks initially discus-
ses what medical care is possible and the nor-
mality of undertaking procedures overseas.
The first has ten separate chapters on differ-
ent possibilities ranging from cosmetic sur-
gery 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 bud-
geting to ensure that travel is feasible. All also
discuss fares, choosing an MTC, recupera-
tion, 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 trav-
ellers. ‘Often the customs and traditions over-
seas may be very different from what you are
used to at home’ (Marsek and Sharpe, 2009:
87). Most provide advice on obtaining pass-
ports 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 coun-
tries referred to as “the third world” or
“underdeveloped”. So you think poverty,
crime, poor transportation or a lack of ameni-
ties [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 obser-
vation that sewing cash into undergarments
can be a wise precaution (2006: 15) may coun-
teract 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
 Marketing Medical Tourism
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 out-
come’ (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 rela-
tively 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 sug-
gesting 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 tour-
ism information about particular countries,
such as what to see and do. They err on the
side of caution – that tourism is not the prin-
cipal objective, tourism should be gentle, per-
haps 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 Wood-
man 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-
103
nies, hospitals and countries, and to use
e-mail to get more specific information. Gah-
linger, 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, adver-
tisers 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 simi-
larly 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 ques-
tions 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 metropoli-
tan 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 compre-
hensive 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 street-
vendor 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) pref-
erences about climate; (iv) language and cul-
tural diversity; and (v) what tourist activities
are preferred and how they might be com-
bined 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
104 Chapter 6
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 Fer-
tility Centre), but discusses 45 countries. Gah-
linger 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 experi-
ence; 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 per-
ceived negatively. Gahlinger refers to politi-
cal instability in Syria, and suggests nearby
Turkey, Jordan and Iran, but elsewhere
observes that in Jordan ‘many arriving medi-
cal 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 ver-
sions 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 medi-
cal 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). Some-
what 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 associ-
ation’ that promotes itself as objective, and
medical tourism as positive, and links hospi-
tals, MTCs, insurance companies and govern-
ments ‘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 Associ-
ation (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:
 Marketing Medical Tourism
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 cost-
effective 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 maga-
zines. The Medical Tourism Magazine, subtitled
‘Your Guide to International Medicine’, is an
industry publication that began in 2007; ori-
ented 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 perspec-
tive, 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 Interna-
tional Medical Travel Journal is published
online by a subsidiary of Treatment Abroad
and distributed to a broad spectrum of busi-
nesses 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 organi-
zations and magazines and even the promo-
tion 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
105
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 web-
sites are centred on available procedures, reli-
ability, 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 ele-
ment. 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 domi-
nant. Elegant websites, in English (but occa-
sionally 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 Hos-
pital in Bangkok has a website in Thai, Japa-
nese, 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 transla-
tion. 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 journal-
ists, 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.
106 Chapter 6
Hospitals primarily stress various facets
of quality, which is invariably linked to mod-
ern 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, along-
side a photograph of a soberly suited sur-
geon, 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 cre-
dentials of doctors and surgeons, and poten-
tial 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’ photo-
graphs 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)
 Marketing Medical Tourism
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 ‘unquestion-
able 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-of-
the-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 neurosur-
gery (Turner, 2007a: 121). The Wockhardt hos-
pitals 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
107
while respecting the needs of the human
spirit’ (Vejthani, 2010). Fortis Hospitals in
Mumbai are ‘proud of our tradition of com-
passionate 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 ser-
vice’ (Yanhee, 2010). The implication of caring
is more evident in the large numbers of atten-
tive nurses in many photographs. Wockhardt
Hospitals’ website has a smiling nurse subti-
tled ‘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 reliabil-
ity are, however, attached greater significance.
Tourism is more distant in hospital web-
sites, 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 youth-
ful, and nurses as beautiful, as on the tele-
vision 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 heli-
copter 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’, tech-
nological expertise, caring and clinical excel-
lence, especially where they are combined as
Apollo Hospitals suggest:
At Apollo Hospitals, India, we unite
exceptional clinical success rates and superior
108 Chapter 6
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 hos-
pitals are testimonials of success, most from
‘ordinary’ people who have benefited from
medical procedures. Testimonials take pre-
dictably standard forms, covering precisely
what providers are also seeking to demon-
strate: (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 challeng-
ing 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 testi-
monials. The Dr Sunil Dental Clinic in Bang-
kok 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
 Marketing Medical Tourism
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 over-
seas surgery, there is little scope for dissent on
monitored sites and few variations on the
form of endorsement. Enthusiasm is posi-
tively 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.
… balanced approach, emphasizing that
3. Media Interview
Journalists are always looking to interview
people who have had surgery. These are
109
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 testi-
monials 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 web-
sites of MTCs and providers, with their ubiq-
uitous 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 vitupera-
tive criticism of Bumrungrad has been on an
evocatively titled website (www.bumrun-
graddeath.com/index.cfm) where an Ameri-
can claimed that the hospital had ‘murdered’
his son. But alternative websites took a more
unusual deaths occur in all hospitals (http://
medicaltravelsite.com/blog/2006/10/09/
disturbing-press-releases-regarding-a-death-
110 Chapter 6
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 coun-
tries’ (a claim that is, however, unproven) so
that, as the website continues, ‘I’m not the
only one who travels for surgery’ (Bumrun-
grad, 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’ (Phil-
ippine 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 pro-
viders offer extensive concierge services and
airport meeting and greeting (even before
passport control). Some hospitals offer air-
port limousine services and passport and visa
assistance. Medical tourism may conceivably
be fun. Yanhee’s website provides a video
tour and discussion with native English-
speaking 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 internation-
al 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 seam-
lessly 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 ser-
vices, deluxe accommodation, translation,
visa assistance, shopping and dining
designed to significantly enhance your visit-
ing 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 Japa-
nese wards, with design elements with dis-
tinct cultural components. Reassurance over
common languages, but above all of English
speaking, is common, and several Bangkok
hospitals have recruited Filipina nurses pri-
marily 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
111
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 natu-
ral light and green cleaning products; (iv) recy-
cling 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 informa-
tion and it is impossible to assess their ‘success
stories’ in a vacuum.
Over time, although dependence on the
Web has intensified and diversified, the expe-
rience of friends and relatives has become
more important, while the Web and personal
perspectives are more important than the for-
mal 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 perspec-
tives have become probably the most effec-
tive 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 uncer-
tainty and fear, even xenophobia, and trust
overseas hospitals and health workers in dif-
ferent cultural contexts (even though dia-
sporic 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 plea-
sure while hospitals have promoted technol-
ogy, reliability and certainty. Who have
responded to these blandishments, and the
extent to which an economic rationale is
dominant, can now be examined.

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 medi-
cal tourists vary enormously, partly because
this defies easy measurement: are they sim-
ply 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 Proce-
dure’ as one option and India having a spe-
cial visa for long-staying medical tourists.
Even were there to be such a category on
arrival cards there is a reasonable presump-
tion that many medical tourists would ignore
it, and specify tourism rather than risk refer-
ring 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
7
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 Yan-
hee in Bangkok post many testimonials in
Japanese) and by their use in public-relations
campaigns. Much of what follows must there-
fore be subject to some doubt and debate.
Who Are the Medical Tourists?
Global flows
Beyond ‘temporary’ medical tourists under-
taking minor cosmetic procedures it is usu-
ally assumed that there are two distinct
tourist groups: (i) those from more developed
countries, unable or unwilling to pay sub-
stantial 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 esti-
mates 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 clos-
est available care’ thus excluding substantial
cross-border mobility. Omitting such groups
revealed that the largest single segment, with
40% of medical tourists, were patients seek-
ing 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 nec-
essary procedures or discretionary proce-
dures (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
113
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 sev-
eral 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 medi-
cal 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 exagger-
ated to boost the industry, and destination fig-
ures would have been much greater had that
number of people left the USA. These data do
little more than suggest that flows are proba-
bly 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 devel-
oped European countries, especially the UK,
the USA and Australia, the majority of medi-
cal tourists almost certainly come from neigh-
bouring countries (and, in most statistics at
least, include people already in the destina-
tion countries, as workers or tourists) and
from the Gulf. While accounts of medical
114 Chapter 7
tourism in the Western media emphasize
transcontinental journeys most movements
are intra-regional. The projected image of
medical tourism, in the media and on web-
sites, is rather different from reality.
Geography and culture influence mobil-
ity. 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 sig-
nificant differences in the costs of treatment
and hence considerable mobility. In the EU
region, somewhat ironically as skilled health
workers – nurses and doctors – migrate west-
wards (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 neighbour-
ing 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 expendi-
tures. This favours short distances and low
costs. Insurance companies too are rarely
anxious to fund distant travel, unless proce-
dures 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 med-
ical treatment came mostly from neighbour-
ing 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 Mid-
dle East, alongside greater numbers of ethnic
Chinese from a diversity of sources. Rich Java-
nese tend to make the short flight to Singa-
pore, 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 check-
ups and minor treatments and those from
developed countries for more intensive proce-
dures (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 tour-
ists at five hospitals in and around Kuala Lum-
pur 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, Mon-
tenegro, Saudi Arabia, Switzerland, the UAE
and Ukraine (Doshi, 2008: A-21). This geo-
graphical 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 tour-
ists were from other parts of South-east Asia
and from the Middle East. However, testimo-
nials 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 Thai-
land, 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 Bum-
rungrad are from the Gulf this unrepresenta-
tive 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 Cau-
casian, and also young and seemingly healthy
(Fig. 7.1). A larger sample of 376 patient testi-
monials 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 prob-
ably indicative of the Indian diaspora. At For-
tis Wockhardt, after 54 testimonials from
India, there are three each from the UK
and the USA, and one each from Afghani-
stan, 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
115
UK and Uzbekistan. Rather earlier one Chen-
nai (Madras) hospital claimed patients from
Oman, the UAE, Bahrain, Qatar, Saudi Ara-
bia, Mauritius, the Seychelles, the Maldives,
Sri Lanka, Bhutan, Nepal, East Africa, Ger-
many, 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 Singa-
pore (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
116 Chapter 7

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 check-
ups’ (Gulf News, 2005). There are niche mar-
kets within medical tourism, while cultural
sensitivity is particularly important in a
health context.
Testimonials from Clinica Biblica in
Costa Rica indicate the predictable domi-
nance 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 (Wite-
pski, 2005; Easen, 2009). Patients of Surgeon
and Safari itself did, however, come from
greater distances, mainly from the UK fol-
lowed by the USA, were aged between 45 and
65, usually single, and stressed economic fac-
tors (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 pri-
marily 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 domi-
nates 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
117
diaspora tourism and regional cross-border
movements which may be about something
as inconsequential as check-ups or as neces-
sary as eye surgery. Media attention is invari-
ably 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 avail-
able, 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 com-
plex procedures, hence check-ups are absent.
Despite the great differences between proce-
dures, 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 quanti-
tative 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 Coali-
tion 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 mar-
ginally 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
118 Chapter 7
liposuction) and 19% were having other sur-
gical 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 poten-
tial for accompanying ‘tourism’.
The Rationale for Medical Tourism
The main global influences on the growth and
structure of medical tourism have been eco-
nomic, whether for local moves or long-
distance 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 eco-
nomic 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) ‘mod-
ern and up-to-date medical treatment’;
(iii) ‘reputable medical services’; (iv) ‘excel-
lent track-record of medical services’; and
(v) ‘wide range of medical services’. By con-
trast the five factors that were least important
were: (i) ‘amenities offered for medical prac-
tices’; (ii) ‘halal food is easily available’;
(iii) ‘relatives and friends are here’; (iv) ‘cul-
tural 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 irrele-
vant, 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 abor-
tions, Mexicans travel from the USA, Indone-
sians 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 med-
ical 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 Vargas-
Bustamante, 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 clan-
destine migration into Australia, Thailand
and elsewhere, is of the poor and often des-
perate. 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. More-
over, 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 esti-
mated 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 medi-
cal 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 suggest-
ing over 40,000 people a year, since facilities
for some critical problems are absent. Mum-
bai (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 con-
siderable 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 oth-
ers 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 destina-
tions, 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. Mos-
cow offered possibilities but Yemenis were
discouraged by crime and the hostile environ-
ment, while Saudi Arabia, seen as comparable
119
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 well-
off businessmen or senior government offi-
cials. Choices were further influenced by
knowledge of particular places, past experi-
ence, 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 Cen-
tral 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 tour-
ists 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 over-
seas 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 com-
pared 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
120 Chapter 7
from 88% in Cyprus to just 26% in Finland,
where most people professed themselves sat-
isfied 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, plas-
tic surgery and diagnostic procedures; ‘alter-
native’ medical treatments overseas elicited
the greatest interest whereas cosmetic proce-
dures 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 two-
thirds of Americans would not consider seek-
ing 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 con-
sider obtaining treatments outside the coun-
try; in the West they were the most willing.
However, even American college students
were generally unfavourable to medical tour-
ism, again centred on uncertainties about
quality of care that largely resulted from lim-
ited 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 proce-
dures 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) doc-
tors in middle-income countries earn less than
half the salaries of those in developed coun-
tries; (ii) nurses and allied workers (radiolo-
gists, 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 hos-
pital costs, in Singapore it is 44% and at Bum-
rungrad 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 con-
strained as insurance companies, govern-
ments 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 per-
sonal out-of-pocket expenditure is more sig-
nificant. 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 experi-
enced 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 mal-
practice 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 work-
ers, 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)
121
Some of these are also present in other devel-
oped 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]$4,000.
(IndUShealth, 2010)
Such differences inevitably translate into sub-
stantial price differentials.
Data on price differentials vary within
countries and over time (and advertised data
rarely include all costs, often excluding essen-
tial transport and accommodation costs,
which in any case frequently change). Numer-
ous attempts have been made to depict cost
differentials, many by MTCs and in the
guidebooks. IndUShealth, for example, an
MTC which exclusively links the USA and
India, posts a set of comparative economic
statistics on its web page (Table 7.1) and
explains the inclusions and points out that
these may not be final:
The hospital costs shown include hospital
stay, operating theater costs, doctors’ fees,
anesthesiologist fees, pre and post-surgical
diagnostics, medications, nursing care, and
rehab. The combined costs shown also add
the typical costs of passport/visa fees, air
travel, local transportation, hotel stay and
meals. Please note that in certain cases, costs
may exceed those shown due to special needs
or constraints established by the patient’s
medical history or condition.
(IndUShealth, 2010)
As in this context many cost differentials are
so substantial that smaller differences in
hotel costs and the need to obtain passports,
etc. are inconsequential. Arguments have
been made by opponents of medical tourism
that the initial and obvious costs may not be
all, and the costs of any complications and
122
Table 7.1. Comparative prices (US$) of procedures, March 2010 (source: IndUShealth, 2010).
Median US cost
Type of procedurea (US$)
Hip replacement/resurfacing 50,000
Knee replacement 45,000
CABG (heart bypass) 100,000
Heart valve replacement 125,000
Heart pacemaker/defibrillator 60,000
PTCA (angioplasty) with stent 70,000
Spinal fusion 75,000
Gastric bypass 45,000
Laparoscopic surgeries (gall 20,000–60,000
bladder, hysterectomy, etc.)
aCABG, 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 fly-
out’ or ‘itinerant surgery’. Yet the cost differ-
entials are evident.
Other tabulations reveal similar situa-
tions. Comparisons from two other American
MTCs, TourNCare (Table 7.2) and Surgery-
Planet (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 calcu-
lated. Overall multiple price comparisons
(repeated in the guidebooks and on numer-
ous 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 differ-
ences 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 car-
ried 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$150,000 in the USA
Chapter 7
Typical Indian hospital Combined travel and
cost (US$) treatment cost (US$)
7,000–9,000 9,000–14,000
6,000–8,000 8,000–13,000
6,000–9,000 8,000–14,000
7,500–10,000 9,500–15,000
4,000–6,000 6,000–11,000
4,000–7,500 6,000–12,500
5,000–8,000 7,000–13,000
8,500–10,000 10,500–15,000
1,500–5,000 3,500–11,000
but in India it cost between US$3,000 and
US$10,000 depending on how complicated
the procedures were. Heart valve replace-
ment 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 opera-
tions in India are about a sixth of the cost
in Malaysia, hence India has cornered a sub-
stantial part of the market for expensive
procedures.
Price differentials for cosmetic surgery
are considerable since cosmetic procedures
are not usually covered by insurance. A face-
lift 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 coun-
try. Tunisia has attracted patients from Europe
since it is relatively close, hence transport
costs are low, and because such plastic sur-
gery 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 proce-
dures undertaken overseas and their location.
 The Economics of Medical Tourism 123

Table 7.2. Comparative prices (US$) of procedures, May 2010 (source: TourNCare, 2010).

Country

Treatment for Costa Rica India Mexico Thailand Singapore USA

Angioplasty 11,000 10,500 16,500 14,500 14,500 61,500

Heart bypass 29,000 11,000 26,500 13,000 22,500 127,000
Heart valve 18,000 12,000 21,500 11,500 15,500 170,000
Hip replacement 13,500 10,500 17,000 13,000 13,500 44,500
Hysterectomy 5,000 5,000 7,000 5,000 7,000 20,000
IVF No data 5,000 No data No data 9,500 14,000
Mastectomy No data 9,000 No data 10,000 14,500 24,000

Table 7.3. Comparative prices (US$) of procedures, April 2010 (source: SurgeryPlanet, 2010).

Country

Surgery USA Costa Rica Singapore Thailand India

CABG (heart bypass) 152,000 25,000 32,000 23,000 8,000

Heart valve replacement 180,000 29,000 23,000 22,000 12,000
Hip replacement 101,000 11,000 16,000 13,000 8,000
Knee replacement 66,000 12,000 19,000 12,500 7,500
Spinal fusion 104,000 16,000 21,000 10,000 8,000
Hysterectomy (vaginal) 32,000 5,000 10,000 4,000 3,500
Economy travel costs (from USA) 0 1100 1,400 1,200 1,800

Routine procedures such as colonoscopies A reasonably typical account of the dom-

and obstetric examinations are much cheaper
and more affordable (and less demanding of
recuperation time). Similarly, while price dif-
ferentials for dentistry are usually not so sub-
stantial, complex procedures can be expensive
and insurance coverage is rare. As one Austra-
lian 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 pro-
cedure, 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.
inance 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 mastec-
tomy 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
124 Chapter 7
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 pro-
viders, 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 reason-
ably well understood, since the prices of par-
ticular procedures are formalized, knowledge
of associated costs can be slight, especially
where patients are unfamiliar with destina-
tions. A post on Gorgeous Getaways’ discus-
sion 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 uncer-
tainty is a deterrent to travel to distant places.
Even though economic factors are critical,
though less relevant in elite Western destina-
tions, 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 familiar-
ity with destinations and personal recom-
mendations are almost as important.
Ultimately price differentials have pri-
macy hence MedRetreat, after 7 years’ experi-
ence, 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 psy-
chological factors (such as fear, worry, doubt
and anxiety) that may discourage those who
could afford it from actually becoming
involved. Similarly the McKinsey report con-
cluded 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 Euro-
pean dental tourists was £3200 in 2007 (Reis-
man, 2010: 99–100) and this was then about
US$6300. Many medical tourists make sub-
stantially 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 devel-
oped 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 inade-
quate insurance) but also because of: (i) cul-
tural 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 peo-
ple have been making these journeys for sev-
eral 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
125
USA, the ability to spend longer periods with
a doctor) among migrants who carry with
them ‘perceptions and expectations gener-
ated 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 over-
whelm 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 experi-
ence 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 treat-
ment 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 com-
prehension 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 low-
cost 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
126 Chapter 7
families pay for relatives to go overseas for
medical care to prove that they did every-
thing possible for them. Yemenis also chose
their destinations according to economics,
language, health problem and existing migra-
tion 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 wide-
spread, 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 treat-
ments, may lend themselves to a form of dia-
sporic 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 Japa-
nese 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. Simi-
larly language ties routinely take franco-
phones 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 Rus-
sian. India and the Philippines stress their
English-language credentials, just as many
websites of hospitals feature translation
facilities, or the training of staff in, usu-
ally, English-language contexts. Mexico has
sought to train bilingual English-speaking
nurses. Indonesians travel to Malaysia where
Malay is comprehensible, and also to Singa-
pore, 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 stimulat-
ing markets. The Muslim state of Malaysia
has sought to attract Muslims from else-
where, 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 complica-
tions of care in their home countries. In Saudi
Arabia and Yemen patients are often shel-
tered from the truth about life-threatening ill-
nesses 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 impor-
tant, many choices of destination (and also
procedures) are made on little more than
hearsay and friends’ recommendations,
though they usually align with costs, geogra-
phy and language ties. Evidence for idiosyn-
cratic 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 destina-
tion; this isn’t a holiday’, despite participat-
ing 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 resi-
dent 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
127
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, part-
ners 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 fear-
ful of some aspects of destinations, from secu-
rity 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 commu-
nities and discussion boards, such as that of
Gorgeous Getaways, provide means of avoid-
ing 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].
128 Chapter 7
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 medi-
cal 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 per-
sonal contacts play a considerable part in
basic knowledge about the world and about
medical tourism, and that the media contrib-
ute 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) pro-
vided 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 des-
tination 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’ con-
tacts that websites or guidebooks cannot.
Previous experience is invaluable, and per-
haps 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 recommen-
dations, 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 pro-
viders 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 abdomi-
nal 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 conduct-
ing 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 hos-
pital 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
129
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 high-
quality 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 transi-
tion has meant that doctors in developing
countries are thoroughly familiar with life-
style 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 medi-
cal 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 satis-
faction 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-some-
mutant-drug.html)
130 Chapter 7
A version of the placebo effect may thus be
important for some, but the familiarity that
comes from well-known cafés and home lan-
guages 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 step-
ping outside their comfort zone. The redesign
of the atrium of Bumrungrad to include Star-
bucks, McDonald’s and Au Bon Pain, ‘had a
powerful effect on lower-income and middle-
income 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 moder-
nity, is probably even greater. Diverse cul-
tural 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 individ-
uals and households make decisions about
destinations, durations and what activities to
engage in, it has become increasingly an insti-
tutional phenomenon. Medical tourists have
been seen to be moving away from the some-
times 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 collu-
sion within state systems, as patients are
encouraged to move within Europe to take
the burden off some national systems, insur-
ance 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 compa-
nies 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 fly-
ing 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 Kol-
kata (Calcutta, India) hospital has signed an
agreement with the British-based transna-
tional 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 com-
pany 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 pio-
neer 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 dis-
tinctive advantage of medical tourism. Some
Japanese companies have sent their employees
to Thailand and Singapore for routine exami-
nations, 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 electron-
ically 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 com-
mon 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 Book-
man, 2007; Herrick, 2007). The Blue Shield
insurance company of California, for exam-
ple, 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 air-
fare, 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, Tur-
key, 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
131
care for their workers, to avoid high domes-
tic costs. Such proposals have been strenu-
ously 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 out-
sourced. 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 treat-
ment 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 devel-
oped 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 liv-
ing in the USA, who would travel to El Salva-
dor 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 consoli-
dation of international institutional linkages.
In other countries similar institutional affilia-
tions 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
132 Chapter 7
ensure a steady and substantial flow of
patients, rather than merely be the benefi-
ciary 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 econo-
mies can be substantial. However, there is lit-
tle data and, once again, estimating the
numbers of medical tourists, let alone those
who travel with them (and would not other-
wise 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 mini-
mal 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 bil-
lion in 2003 (Taffel, 2004), while medical tour-
ists 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 mil-
lion 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 for-
eign 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 ‘consid-
ered one of the main contributors to the
national economy’, it is said to bring in reve-
nues that reach US$1 billion annually (Jordan
Times, 29 June 2010). Two juxtaposed esti-
mates 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 mil-
lion. Another version has the average expen-
diture 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 reli-
able 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 indi-
cations. How fast expenditure has grown, in
which countries and from which sources, and
who are the major beneficiaries, are all impos-
sible 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 substan-
tial gains. In 2009 medical tourism was said to
be worth some 5% of all Tunisia’s service
exports, significant in a country where ‘stan-
dard’ 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 expen-
diture of medical tourists on health alone
(clinic costs, doctors’ fees and pharmaceuti-
cals) was estimated at US$55 million in 2004,
about a quarter of the total earnings of all pri-
vate 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 visi-
tors 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 out-
side the health sector, broadly within tourism-
related service sector activities.
Every estimate suggests that medical
tourists spend more than standard tourists,
and usually about twice as much, as in Singa-
pore (despite the second Tunisian estimate
above), because of the high costs of medical
services. Another estimate for Tunisia sug-
gests that medical tourists spent between
?2500 and ?4000 compared with the ‘usual
tourists’ who spent ?300–400 (Tourism-
Review.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 stan-
dard tourists. A large sample of medical tour-
ists in Malaysia spent an average of US$8720,
of which the single largest component was
the cost of medical treatment (US$3742), fol-
lowed by international airfares (US$1187)
and accommodation (US$1038). Food and
drink (US$468) and domestic transport
(US$159) also took up large sums. Expendi-
ture on evidently tourism-related activities
included US$678 for shopping, alongside
133
entertainment (US$180) and organized tours
(US$489), while there were significant miscel-
laneous costs (US$779). Almost all medical
tourists in Malaysia (108 out of 121) travelled
with at least one other person, usually a rela-
tive (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 medi-
cal 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 Bumrun-
grad patients in 2009 travelled with a com-
panion (Anon., 2010b), a little less than the
83% in the MTA’s more general survey
(Anon., 2009). Observations at several hospi-
tals, 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 spend-
ers, especially from the UAE, where the gov-
ernment 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 consider-
able since the UAE government pays the full
cost alongside return airfares for two com-
panions and a US$4000-a-week allowance to
cover the cost of hotel and other expenses,
and such ‘high-roller’ patients stay in expen-
sive hotels (Straits Times, 17 April 2006).
Occasionally tourists make their own assess-
ments 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
134 Chapter 7
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 impover-
ished 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 sur-
gery 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 over-
seas. 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 out-
side the health sector, other benefits include
the possibility of return visits, after a taste of
the country has been acquired, and the diffu-
sion 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 coun-
tries are particularly prone to the leakage of
local expenditure. In some places the impacts
of medical tourism are visible. Around Bum-
rungrad 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, res-
taurants and stores are oriented to a Muslim
clientele (Fig. 7.2). Palestinian restaurants jos-
tle with Pakistani restaurants, halal food is
widely advertised, some hotels are almost
exclusively occupied by a Gulf clientele of
relatives and recuperating patients, and Ara-
bic-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 consid-
erable local income. Dental tourism has sub-
stantially 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 expendi-
ture estimates are gross generalizations
based on uncertain numbers, unknown pat-
terns 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 popula-
tion is said to be high, there are no estimates
of the economic significance of medical tour-
ism. However, for small countries like Costa
Rica and Singapore, where numbers seem
substantial, and growth is occurring, the
national economic effects may be very sig-
nificant, while some local effects are even
more substantial.
 The Economics of Medical Tourism 135

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

136 Chapter 7
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 ben-
efited Central America as many North Ameri-
cans 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 signifi-
cantly following the GFC as they did else-
where in Thailand. Similar unrest a year later
brought further declines with the largest pri-
vate hospital operator experiencing a down-
turn of 20% in the number of overseas visitors,
especially from Europe and the Gulf, com-
pared with the previous year, and a second
group experiencing a 10% decline (Wiri-
yapong, 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 (Shana-
han, 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 Gen-
eral Manager of Singapore’s National Health-
care Group has said: ‘Cost should not be the
deciding factor in selection, but more empha-
sis should be placed on accreditation, clinical
outcome indicators, affordable healthcare, and
PEST (Political, Economic, Social and Techno-
logical) factors’ (quoted in Chan, 2007: 49).
If the economic benefits from medical
tourism have proved elusive to quantifica-
tion they are none the less substantial and
account for the enthusiasm of many countries
to participate and, correspondingly, for grow-
ing attempts by some source countries to dis-
courage mobility and retain patients. In some
circumstances economic benefits have seem-
ingly even overwhelmed ethical consider-
ations, 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 concen-
tration 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 par-
ticular 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 consider-
ations than most forms of welfare and service
provision. Ethical questions have largely cen-
tred 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 over-
seas abortions); and (ii) organ transplantation
(and surrogate parenthood) that are per-
ceived as highly exploitative of poor resi-
dents 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 stan-
dards, safety, information disclosure and
legal liabilities, alongside familiar issues of
reliability and ‘value for money’. Cosmetic
surgery has also been criticized for being con-
cerned with modifying appearance rather
than health or longevity, while ‘pregnancy
© CAB International 2011. Medical Tourism (J. Connell)
tourism’ or ‘birth tourism’, where women
move to give birth to their children in coun-
tries where citizenship is particularly coveted
(Bookman and Bookman, 2007: 42), is
opposed for quite different reasons. The eth-
ics of media depictions of body shapes and
invocations to change have also been ques-
tioned. Although euthanasia, transplantation,
stem cell surgery and surrogate parenthood
have raised most questions, and are dis-
cussed 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 over-
sight 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 cul-
tures. Going offshore, often long distances,
for procedures that are banned or discour-
aged at home poses certain basic ethical and
moral questions, which may also be directed
at local practice.
137
138
In a wider context the development of
medical tourism raises ethical and practical
questions at different scales over the appro-
priate 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, par-
allels the rise of exotic spa resorts oriented
to a luxury market and requiring local obse-
quiousness (Chapter 3) and raises similar
questions about tourism, ethics and inequal-
ity. Otherwise the ethical concerns raised
by medical tourism are rather different from
those in most other tourism contexts. Altho-
ugh, as Henderson points out, and is evident
here, tourism ‘may not always be conven-
tional … when the physical condition of the
tourist severely restricts mobility. Anxiety
may also preclude the taking of pleasure in
common tourist pastimes such as sightsee-
ing’ (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 over-
seas 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 sim-
ilar situations occur in other developed
countries. Demand for organs has intensified
as populations age and hypertension and
obesity become more common. A parallel
Chapter 8
process, ‘xenotourism’, involves animal-to-
human transplantation, notably of pig insu-
lin, and raises issues of trans-species viral
infection (De Luca, 2006). Transplant com-
mercialism, the trafficking of organs across
international borders, accounts for an esti-
mated 5–10% of kidney transplants, despite
its contravening international conventions
and creating political stigma, while ‘trans-
plant tourism’ involves travelling for over-
seas transplants.
Most overseas transplants take place in
relatively poor developing countries (Scheper-
Hughes, 2000, 2005) and are highly contro-
versial because of the potential negative
medical impact on the ‘donor’ and, in some
countries, their excision from executed pris-
oners. Durban and Johannesburg, for exam-
ple, 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 mar-
ket’, outside the range of moral market trans-
actions, 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 pay-
ers 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 politi-
cal economies where individuals are forced to
resort to considering transplant commercial-
ism 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 after-
effects (Anon., 2006b). Despite some cultural
variations, ‘the flow of organs follows the mod-
ern 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 ille-
gal purchase of organs in countries such as
India, China, Brazil and South Africa (Shima-
zano, 2007). Organs for transplantation have
been removed without permission from exe-
cuted 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 execu-
tions (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 beneficia-
ries. 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 travel-
ling 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 trans-
action, as in India, Moldova, Pakistan and the
Philippines (Scheper-Hughes, 2005; Naqvi
et al., 2007; Turner, 2007a; Epstein, 2009). Ven-
dors are exploited; the poor have less chance
of receiving organs and transplantation suc-
cess 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 squat-
ter settlements, with dependent relatives and
a ‘desperate need for cash’ (Mendoza, 2010:
259). Simultaneously patients in developed
139
countries die because organs are locally
unavailable for transplant, posing global ethi-
cal 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 criti-
cisms 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 mil-
lion 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 avail-
able 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, selec-
tion 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 trans-
plants in China were perceived less favour-
ably 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, fur-
ther marginalizing people who cannot ‘out-
source’ themselves, raising financial burdens
on patients and insurance companies and
intensifying global competition for patients,
140 Chapter 8
organs and investments in transplant ser-
vices, a process that disadvantages everyone
(Epstein, 2009: 135). But the main losers are
those who sell organs.
Criticism has grown, with those count-
ries that hitherto had liberal policies on trans-
plant 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 for-
eigners 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 con-
doned. In India the IndUShealth company
stated in 2010 that ‘Transplants are not per-
formed unless the patient makes arrange-
ments to bring a matching, consenting donor
who is known to the recipient and can estab-
lish his/her legitimate desire and reason to
offer his/her organ to the recipient’ (IndUS-
health, 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 par-
ticular 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 adop-
tion (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 ‘test-
tube babies’ to ‘designer children’ (notably by
sex), with cloning perhaps waiting in the
wings.
Fertility centres exist in several coun-
tries, from the USA and Israel to small island
states such as Cyprus and Barbados. Unlike
most other contexts where major ethical prin-
ciples 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 vir-
tually impossible to obtain eggs (Bookman
and Bookman, 2007: 82). Countries such as
the UK and Sweden, who only permit non-
anonymous 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; par-
ents 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 cen-
tred primarily within developed counties that
are the main sources and destinations, involv-
ing 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 ser-
vices, and bypasses restrictive regulations,
long waiting lists, legal constraints and some-
times high costs. Such ‘global fertility tour-
ists’ have consequently been seen as
‘desperate to break free from not only finan-
cial but also legal and ethical constraints’
(Prasad, 2008: 37). As the website of one
Spanish clinic states: ‘The present law gov-
erning 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 proce-
dures that would not pass scrutiny in many
contexts; thus Georgia permits procedures
that are banned in Europe: surrogate egg dona-
tion 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
141
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 repro-
ductive technologies, whereas Israel offers
strong support, and Ireland has major con-
straints on abortion. Belgium and Italy have
little legislation on assisted reproduction and
are popular destinations within Europe. That
Spain and Slovenia are both significant desti-
nations 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 indi-
vidual 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 dona-
tion, 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 sin-
gle 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 phe-
nomenon. India has been seen as an ideal des-
tination since Indian women rarely smoke
and drink, and it more obviously offers ‘First
World medical services at Third World
142 Chapter 8
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 avail-
able 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), coinciden-
tally known as ‘the milk capital of India’,
early in 2008 over 50 women, mostly poor vil-
lagers, were pregnant with the children of cou-
ples 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 sur-
rogate babies born in India and Australia Sur-
rogacy, an MTC that organizes international
surrogacy, stopped working in India because
of massive delays and citizenship require-
ments 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 coun-
tries like the USA (Hodge, 2010). Studies
of surrogacy suggest, however, that the
majority of surrogates are satisfied with
their surrogacy experience, do not experi-
ence 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 moth-
ers 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 surro-
gacy 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 differ-
ent 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 intrica-
cies 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 citi-
zenship. 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 Danish-
Indian genetic origin, but knowing little of the
two individual donors (Prasad, 2008). Techno-
logical change has transformed the mechanics,
location and ethics of reproduction.
With rare exceptions, such as Malta,
throughout the northern hemisphere abor-
tion is legal in certain circumstances, but
availability ranges from ‘on demand’ to
severely constrained as in the mainly Catho-
lic 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 resi-
dent 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 Portu-
guese 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
143
Barcelona described as ‘Europe’s abortion
mecca’, where people from much of the conti-
nent 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 typi-
cally 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 criti-
cized 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 adver-
tising campaign by a pro-abortion group in
Poland that mimicked a Mastercard adver-
tisement 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 own-
ership 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 medi-
cal tourism. The rich can afford to travel fur-
ther 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
144 Chapter 8
cost. Anonymity is also important. However,
abortion tourism is largely confined to middle-
income and developed countries and is
unrelated to diasporic tourism.
Contraception is globally more accessi-
ble 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 intra-
uterine 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 treat-
ments 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 treat-
ments. None the less proponents of stem cell
therapy have promised improvements in, or
even cures for, several neurological or devel-
opmental disorders, such as Down’s syn-
drome, 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 estab-
lished precursor of embryonic stem cell ther-
apy) involves treatments for cancers and
leukaemia. Both forms of stem cell treatment
remain somewhat experimental. Embryonic
stem cell therapy largely takes place in coun-
tries with ‘regulatory gaps’ or very few regu-
lations, 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 Medi-
cal Research adopted guidelines that discour-
aged 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 thera-
pies 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 malar-
key’, 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 restric-
tion 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 (Mac-
Ready, 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 ther-
apy 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 proce-
dures, 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 con-
tinue 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 eutha-
nasia. 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 coun-
try where euthanasia was briefly permissible)
and, similarly, Americans to Oregon. Since
2007 Switzerland has come under consider-
able 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
145
a biotechnical sense, in debates over eugen-
ics and the criteria of death and in a mar-
ginal 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 life-
support 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 eutha-
nasia is impossible so that they may commit
suicide, without themselves or more particu-
larly 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 law-
yer, 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 Digni-
tas 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 con-
cludes 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 ‘devel-
oped’. 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 tak-
ing over ‘family duties’, including funerals,
146
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 tour-
ism, 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. Effec-
tively 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 individ-
ual, 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 signifi-
cant political and philosophical debates wher-
ever 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 ‘dias-
pora 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 lon-
ger able to work, and nostalgia for once
familiar places and people has renewed sig-
nificance. Even in death, and perhaps par-
ticularly here, therapeutic landscapes are
important.
Chapter 8
Pilgrimages in Hope?
In each of these areas, despite the wider pres-
ence 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 cul-
tural 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 des-
perate people with severe conditions are will-
ing 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 recov-
ery, even where experimental procedures
are yet to be adequately verified. Somewhat
similarly sick people travel thousands of kilo-
metres and invest enormous sums in pil-
grimages 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 ther-
apies, legal in some countries, are illegal in
others. An Australian patient, deemed incur-
able, spent over A$30,000 in search of an ille-
gal cure in Italy, while strongly rejecting any
notion that this had any relationship to a holi-
day (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 experi-
mental 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 peo-
ple 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 regu-
latory role of the state, like the bulk of medi-
cal tourism, despite increased attempts at
control. Reproductive tourism, like stem cell
tourism, organ transplants and even suicide
tourism, ‘reflects a conflict between the indi-
vidual [and households] and the nation-
state’ (Martin, 2009: 257), which the privileged
and affluent can escape. Moreover trans-
plant tourism and surrogacy exist because
poverty and inequality also exist. In these
extreme situations where access to very lim-
ited and sometimes experimental provisions
is expensive the extent of inequality is great-
est. Scheper-Hughes consequently writes of
‘biopiracy’ and questions whether ‘those liv-
ing under conditions of social insecurity and
economic abandonment’ are really the own-
ers of their bodies – a fundamental premise
of Western bioethics (2000: 197). This com-
modification of the body and the resultant
‘bionetworking’, both legal and illegal across
international borders, has created a new
‘global geography of human experimenta-
tion’ (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 pejo-
ratively by the broad medical profession
precisely to deride something that is very
different from any standard concept of tour-
ism, rather being in every sense ‘deadly seri-
ous’. To describe such hopeful and desperate
journeys as tourism would be to thoroughly
trivialize their rationale.
A New Inequality?
Health-care systems in developing coun-
tries, some of the main destinations of medi-
cal 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
147
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 con-
jecture’ (Lautier, 2008: 102), detailed analy-
sis 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 some-
times harsh reality of majority health care in
particular countries. This is particularly evi-
dent in India where the divide between the
public sector and the advancing private sec-
tor 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, mod-
ern 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:
148 Chapter 8
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 market-
ing 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 tour-
ists ‘with the sleek furniture and lush floral
arrangements of a boutique hotel … flat
screened TVs and views of manicured gar-
dens’, 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 sup-
port this proposition. In the lone medical tour-
ism guidebook that considers such issues
euphoria reigns: in the Philippines ‘the
income from medical tourism serves to under-
write 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 health-
care 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 pro-
moting medical tourism, via the tourism indus-
try, 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 condi-
tions in the public sector, and both deteriora-
tion and duality extend far beyond India.
 Extremes, Ethics and Inequality
Migration
One direct outcome of medical tourism has
been the more rapid growth of a private
health-sector labour market in medical tour-
ism 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 profes-
sionals) to meet national needs. India has
just four doctors per 10,000 people whereas
the USA has 27, and accelerated interna-
tional 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 fol-
low both the rise in demand for care and the
challenge of developing priorities in devel-
oped countries, this demand and these wait-
ing lists are partly being transferred to
relatively poor countries.
Where medical tourism has been accom-
panied by a shift of workers from elsewhere
in the health-care system, uneven develop-
ment is likely to be intensified. In both Thai-
land 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. Att-
ractive 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.
149
However, a substantial part of the disease
burden in India are chronic infectious dis-
eases such as malaria and tuberculosis, that
are given limited attention and have no rela-
tionship 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 health-
care 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 Founda-
tion 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 func-
tions effectively and ‘patients have the opp-
ortunity 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 ‘inter-
nal 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)
150 Chapter 8
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 pri-
vate 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 med-
ical expenses are beyond the financial capac-
ity of much of the resident population
(Saniotis, 2007). However, migration from
regional areas was occurring before the estab-
lishment of medical tourism, and inadequate
capacity to pay is a function of the Thai econ-
omy, taxation system and structure of health-
care 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. Out-
side Latin America similar forms of replace-
ment 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 tour-
ism 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 popula-
tion 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 well-
paid 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 pro-
fessionals 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 techni-
cians 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 aggra-
vated 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
 Extremes, Ethics and Inequality
return. Unless numbers otherwise increase,
by accelerated training, the diversion of hea-
lth 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 primar-
ily because of the migration of health workers
rather than diversions to medical tourism
(Idris, 2008; Connell, 2010). Potential expan-
sion 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 institutional-
ized privatization of health care will only fur-
ther marginalize poor Filipino patients’
(quoted in Gahlinger, 2008: 87). Sensitive to
criticisms that health tourism was unaccept-
able, and the Philippines national health sys-
tem 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 priv-
ileged (Ramirez de Arellano, 2007; Bergmark
et al., 2008). In this case, at least, a large number
151
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 Mexi-
can migrants with illegal undocumented sta-
tus 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 middle-
class Indian patients may experience bank-
ruptcy, 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 insur-
ers 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 dis-
advantaged.
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 eco-
nomic growth, some 40% of India’s popula-
tion 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 inade-
quate 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
152 Chapter 8
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 conse-
quently 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 auton-
omy 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 Ser-
vices 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 evi-
dence 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 pri-
vate sector limited the possibility of price dis-
crimination. 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 homoge-
neous 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 equita-
ble 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 vulnerabil-
ity 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 esti-
mated 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 cardi-
ologists 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 deworm-
ing 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 tour-
ists and rich patients, and the extent to which
this is merely a cosmetic exercise. The Apollo
Group was said to have provided free hospi-
tal 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
 Extremes, Ethics and Inequality
no independent monitoring of any of these
activities. In the mid-2000s an ABC television
programme seeking to find evidence of provi-
sion 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 criti-
cized for devoting disproportionate num-
bers 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 Bumrun-
grad 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 Thai-
land. A handicraft-training project in Nong
Kong village, Mukdahan province, was also
initiated to provide supplementary income to
underprivileged people, and they have sup-
ported 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
153
needy are unlikely to access websites. Though
a few Latin American hospitals seem to sup-
port 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 tech-
niques, including in areas such as telemedi-
cine, but that too is immeasurable. Medical
tourism is most likely to have a role in
national health care, not by its direct contri-
bution through charitable programmes or
because hospitals focused on medical tour-
ism 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 con-
siderable flow of foreign exchange, that
directly benefits the health, tourism and
related sectors, and thus the national econ-
omy, 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 indus-
try, investment must be made into ancillary
activities, not least costly education and train-
ing programmes, but also transport, electric-
ity, 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 Get-
aways alone employs 11 people in Malaysia
from office managers to four drivers – all
154 Chapter 8
outside the health system. Other MTCs have
created similar jobs. New employment inside
and outside the health system was an impor-
tant reason for countries to seek involvement
in medical tourism. In Latvia the economic
downturn following the GFC meant a sub-
stantial 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 link-
ages 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 redistrib-
uted to develop public health care, but this
depends on strong economic and public
health policy, whereas such redistributive
policies are elusive in most emerging middle-
income 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 some-
what 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 Tuni-
sia. The Barbados Fertility Centre has a slid-
ing 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 cou-
ples’. 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, increas-
ing 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 medi-
cal 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 acqui-
red 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 con-
cessions were given to medical tourism pro-
viders. National support for medical tourism
(through more active promotion, tax conces-
sions 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 privati-
zation, 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 obli-
gations 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,
 Extremes, Ethics and Inequality
especially in India where the private sector
provides nearly three-quarters of all health-
care 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 unre-
corded) to have had a significant bearing on
such issues as national equity and inequality.
It is just one part of the shift towards privati-
zation of medical care and its considerable
impacts.
Source countries
Medical tourism serves those with the ability
to pay, even where patients are under-
insured. At source medical tourism is inequi-
table. 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 over-
seas, but the people who haven’t two brass
farthings to rub together are always the peo-
ple who lose out’ (Graham, 2006: 9). While
fertility tourism is particularly expensive and
exclusive, in Yemen and elsewhere the rela-
tively 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)
155
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 los-
ing over US$67 million in 2010 from trans-
ferred domestic health-care expenditure
(Sobo, 2009: 327). Were foreign exchange
losses of countries such as the USA to contrib-
ute 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 medi-
cal 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 onco-
logy 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-devel-
oped 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 Minis-
ter of Health: ‘many people in the country die
while seeking funds to be able to travel over-
seas 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
156 Chapter 8
members and friends run raffles, pass around
the collection plate, organize dances and par-
ties, 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 Nether-
lands 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 stan-
dards 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 cos-
metic 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 inad-
equate number of public patients would
result in the production of surgeons with lim-
ited 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 coun-
try or place to become considerable, there is
some possibility of a reduction in the viability
of local programmes and facilities. Such cir-
cumstances 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 enter-
ing areas where prices were low and compe-
tition 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 treat-
ment 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 reduc-
ing 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 con-
struction of DHCC indicates, possibly as
many as have considered restructuring
health-care systems to serve national popula-
tions. 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 tour-
ism partly to reduce the migration of local
health workers to better paid jobs in medical
tourism destinations elsewhere, ‘to the detri-
ment 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 proce-
dures that made use of excess capacity in
hospitals, with the profit providing health
care for British Columbians, so ‘rather than
 Extremes, Ethics and Inequality
competing with local residents now on wait-
ing lists, surgical tourists would enable health
regions to provide more services, thus reduc-
ing waiting times’. Arguments were made
that health tourism would bring in much-
needed revenue, help retain Canadian-
trained 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 subsi-
dizing 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 stron-
gest opponents of medical tourism, but sig-
nificantly in developed countries, rather than
in the developing countries where it is most
needed. Medical tourism has wide-ranging
ethical and political dimensions.
157
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 espe-
cially 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 acces-
sible 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 empha-
sized 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 coun-
tries the poor have restricted access to medi-
cal 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
158 Chapter 8
view of the health system where medical ser-
vices 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 cos-
metic surgery and diet and exercise. The
incursions of capitalism and commodifica-
tion 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 epito-
mized in the principle centres of medical
tourism offers examples of places and pro-
viders that are not only sites of treatment but
key elements in emerging and highly com-
petitive neo-liberal landscapes of discretion-
ary 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 sig-
nificant as those with pharmaceutical com-
panies (Chapter 10). Medical tourism
consequently ‘represents the full integration
of medicine with global capitalism’ and,
where service is purely a function of the abil-
ity 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 fail-
ures of privatization and national health-
care systems. There is little evidence that: (i)
it has attracted beneficial foreign invest-
ment, 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 privati-
zation, albeit both epitomized in medical
tourism, and implicitly of the failings of
health systems, especially in developing
countries, to provide more effective and equi-
table health care. Part of that criticism stems
from repugnance at situations where foreign-
ers availing themselves of cosmetic surgery
must be ‘sheltered’ from adjacent poverty
and pestilence, where citizens are marginal-
ized. 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 ‘neo-
liberal landscapes’ of corporate well-being,
patients have been obvious beneficiaries,
some moving away from difficult local cir-
cumstances (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). How-
ever, inadequately measured or simply
ignored, medical tourism has also contrib-
uted 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 trickle-
down effects. In this emerging nexus of
complex privatizations, links with compo-
nents of the tourism industry provide insti-
tutional 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 bargain-
basement 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 holi-
days? Are not holidays supposed to be about
pleasure not pain? At the very least medical
tourism seems very different from most con-
ceptions 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. Tour-
ism 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 cul-
tural tourism, with notions of tourism as a lear-
ning experience, learning was expected to be
relaxing, undemanding and pleasurable. Tour-
ists need not necessarily be hedonists, totally
absorbed in pleasure, but they anticipate enjoy-
able days and nights. Yet medical tourism is
© CAB International 2011. Medical Tourism (J. Connell)
largely detached from more hedonistic forms
of tourism and even from the relaxed and min-
imal 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 rest-
fully, experiencing the country, its people and
cuisine, and so on. While such possibilities
may reduce the tensions involved in opera-
tions 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 long-
distance 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 cir-
cumstances where insecurity and helpless-
ness 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
159
160 Chapter 9
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 fre-
quently asked question on interactive web-
sites 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 medi-
cal tourism and how different versions link to
a more ‘orthodox’ tourism also varies. While
the previous chapter described certain proce-
dures 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 cultur-
ally 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 encom-
passed a diversity of activities, involving
active and passive experiences and prefer-
ences for different destinations. While the
20th century seemed dominated by mass
tourism, and this century by its Asian deriva-
tives, especially in rapidly expanding coastal
resorts, such resorts varied considerably as
did the activities of tourists, from passive
sunbathing and reading to more active swim-
ming 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 eve-
nings devoted to eating, drinking, experienc-
ing concerts and other forms of entertainment,
and expenditure on both specialisms and
‘standard’ tourist activities. Many such niches
have evolved, expanded and become differ-
entiated 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, house-
holds had more disposable income available
for leisure pursuits, second holidays were
possible, and personal transport enabled
avoiding the ‘masses’ as car ownership bec-
ame more common. Holidays could be frag-
mented and divided with time for both
‘standard’ family holidays, perhaps still
dominated by typical coastal vacations, and
specialist activities. Birdwatching, for exam-
ple, 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, par-
ticularly 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 nostal-
gia. Most niches, such as birdwatching,
contained both relatively passive partici-
pants and highly active members, where
costs and time posed few constraints. Many
included obsessives, perhaps none more
than the Japanese tourist who travelled with-
out a break to see the Mull of Kintyre in Scot-
land, 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, plan-
ning 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:
161
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 (visit-
ing friends and relatives) tourism, since a sig-
nificant 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 visit-
ing 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 par-
ticular 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 connec-
tions, rediscovering ‘roots’ and enhancing and
revitalizing memories, alongside discharging
162 Chapter 9
economic obligations or investing, but other
practical pursuits such as obtaining health
care are often inherent. Although many medi-
cal 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 sup-
port 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 tour-
ism, 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 tour-
ism has become successful its promotion has
intensified, as have its links to other compo-
nents 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 exempli-
fied 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 along-
side 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 govern-
ment has been to convert the country into a
world medical power’ (Benavides quoted
in Bookman and Bookman, 2007: 71). Simi-
larly Chile sought to ‘add surgical operations
and cutting edge medical treatments to its
traditional exports of copper, wine and sal-
mon’ (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 infor-
mation 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 cover-
age of Ayurveda, hi-tech healing and spas.
‘Malaysia Truly Asia’ has invocations to exp-
erience 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 Depart-
ments of Tourism and Health were combin-
ing 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 excep-
tions, where medical tourism has become
significant it has also become important
enough to be more evidently part of the tour-
ism industry, at least in the eyes of govern-
ment, and has been as actively promoted as
other facets of the tourism industry.
Despite government support, like most
other forms of niche tourism medical tour-
ism 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 sepa-
rate 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 dis-
cussed how shopping and other forms of
tourism could be combined with cosmetic
surgery in Malaysia, and ‘Incisor trading’
(Haslam, 2007), on dental tourism in Hun-
gary. 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 moun-
tain areas claimed to offer valuable recuper-
ative 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 head-
ing ‘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 tour-
ism 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. Conven-
tional 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
163
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 guide-
books 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 govern-
ment tourist publications, on the assumption
that tourists might avail themselves of small-
scale procedures such as dentistry, during
otherwise standard tourist visits. Thai Inter-
national’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 holi-
day 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 proce-
dures are more obviously part of tourism
advertising, and dentistry offers greater pos-
sibilities 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
164 Chapter 9
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 reputa-
tion 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 provid-
ing 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 activi-
ties when: (i) particular procedures are famil-
iar; (ii) recuperation times are short (or non-
existent); 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 desti-
nations 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 recu-
perate’ 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 activ-
ities, 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 Bang-
kok hospitals offer and organize night mar-
kets 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 medi-
cal tourism experiences (Chapter 7). Some
85% of international Bumrungrad patients
stated that they and/or their companions had
done some tourist activities such as sightsee-
ing, 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 incor-
porates 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 cos-
metic 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 sur-
gery has produced significant structural
changes, shopping for new clothes may be
more necessary than entertainment. As in
other forms of niche tourism there are special-
ized and standard components.
Marketing naturally stresses the plea-
sures of the destinations. Goa Tourism’s bro-
chure 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 compa-
nies developed packages that combined
enjoyment of World Cup football matches,
with medical procedures and tourism. The
Johannesburg-based Medi-Sculpt clinic, laun-
ched 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
165
low-key and undemanding safari! Fertility
tourism lends itself to some degree of tour-
ism. 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 other-
wise 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 pati-
ents 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
166
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 visit-
ing relatives (Doshi, 2008: A-24). Tourism in
the aftermath of medical attention may neces-
sarily 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 avail-
able. 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
Fig. 9.1. Bumrungrad International Hospital (BIH), first floor.
Chapter 9
technology is about leisure rather than
medicine, alongside private marble bath-
rooms 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 shop-
ping mall. An enthusiastic American health
tourist was moved to comment: ‘the hospital
looks quite modern and even the faint hospi-
tal 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 tour-
ism have transformed themselves from the
dowdy, functional and clinical public hospi-
tals that preceded them. Hospitals in Costa
Rica have IMAX cinemas and helicopter land-
ing pads. Samitivej offers wireless Internet
access to all international patients. Bangkok
Hospital provides cable television with vari-
ous language channels, microwave ovens
and guest sofa-beds. Its Phuket branch
 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 hospi-
tals 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 addi-
tion, there is a range of retail and food and
beverage outlets’ (Samitivej Hospital, 2010).
Singapore is expected to open the first ‘medi-
cal 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 equip-
ment 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’. Bum-
rungrad participates in a ‘Great Chefs’ pro-
gramme where top hotel chefs design 12
special menus, each featured for 1 month of
the year. The Barbados Fertility Centre relo-
cated its entire facility to provide sea views.
Fig. 9.2. Hospital room in Bangkok Hospital, Phuket.
167
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 pro-
jected ‘the corporate hospital as anything but
a hospital’ (Lefebvre, 2008: 102). The newest
projects such as the Indian hotel chain Wel-
comgroup’s Fortune Park Lake City hotel
claims to be a hotel within a hospital, being
on the grounds of the Jupiter Lifeline Hospi-
tal in Mumbai, and part owned by the hospi-
tal: 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.
168 Chapter 9
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 facili-
ties 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 treat-
ment. 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 sur-
gery 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 com-
panions (though short-term dental patients
are somewhat different) and stay for signifi-
cant periods of time. The number of compan-
ions 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 medi-
cal tourism market. Many have acquired affil-
iations 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 rela-
tives (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 week-
ends’. 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 seri-
ous matters’ (Ritruangdej, 2009: 34). In other
words the hotel, like others, has carefully inte-
grated 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 func-
tionally integrated into the tourist industry.
Bumrungrad owns 74 serviced apartments
and 54 hospitality suites for patients and fam-
ilies, with a swimming pool and fitness facili-
ties. The Raffles Medical Group in Singapore
arranges airport transfers, books relatives
into hotels and helps arrange local tours.
Indian hospitals have similarly become inte-
grated into a wider network, and hotels in
 But is it Tourism?
Malaysia have become horizontally inte-
grated with hospitals. In an advertising sup-
plement 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 foreign-
ers 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 stan-
dard hotels but also staffed by nurses and
interns, where patients can recover in a con-
text 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).
169
Tourism is not merely a separate part of
medical tourism.
Hospitals have also become linked to air-
lines. As the Bangkok Hospital Phuket’s web-
site 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 pre-
ferred travel provider for patients travelling
from there. The press release that accompa-
nied 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 afford-
able, preserving the price advantages of
medical tourism’ (AllBusiness, 2010). In
October 2009 Turkish Airlines announced
that they were working with the major natio-
nal 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 offer-
ing 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 mainland-
ers, 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 inter-
national visitors are particularly important,
have integrated themselves into wider ele-
ments of the travel industry, to encourage
greater numbers and profitability by provid-
ing a more wide-ranging service. Such hospi-
tals have become more like MTCs, part of
170 Chapter 9
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 preferen-
tial arrangements with particular hotels, air-
lines and other companies. In some contexts
that integration has gone much further with
hospitals becoming part of much larger con-
glomerates (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 travel-
lers 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 experi-
ences. 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 recom-
mended for anyone with a weak physical
condition or a recovering patient’ since tuk-
tuks, 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, res-
taurants, taxis, etc.) benefits considerably
from this new niche. Indeed, since for a sig-
nificant 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 tou-
rism. Medical tourists who are visiting rela-
tives may stay even longer. Where hospitals
171
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 com-
ponents 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 danger-
ous – 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 tour-
ism, the last where tourists often travel inde-
pendent 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 medi-
cal 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.

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 well-
being 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 bio-
medical 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
10
health-care facilities, big and small, through
landscapes and places of ‘natural’, ‘tradi-
tional’ 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 proce-
dures, they are not inseparable. As ‘clusters’
have developed, where clinics, hospitals,
medical institutions, spas and related indus-
tries 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 well-
ness together conceptually and physically.
The boundaries between biomedical and
alternative therapies have become blurred
though never indistinguishable, even as ‘exp-
ertise 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 cul-
tural that it was assumed to be highly local-
ized, 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 regu-
lation, 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 fol-
lowed a growing emphasis on technology
and private enterprise, and the attitude that
health care can be bought ‘off the shelf’. Medi-
cal technology has constantly evolved, raising
new ethical issues as the body has increas-
ingly become a playground for ‘experimenta-
tion and insight’ (Schultz, 2004: 110). This has
posed complex bioethical questions, espe-
cially for new and experimental procedures
where a variety of differentiated and geo-
graphically distinct practices are subordi-
nated 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 appro-
priate 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 fol-
lowed the earlier diasporic travels of the rela-
tively 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 rich-
world 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, incor-
porated bidirectional flows and become
increasingly complex. Globalization has inten-
sified, expanded and diversified such move-
ments in the ever shifting interplay of centre
and periphery, as the ‘new’ medical care has
shifted from core towards periphery. Yet, as
173
the significance of local flows suggests, whe-
ther from Indonesia to Malaysia, Bangladesh
to India or from the Andes to Chile, contem-
porary medical tourism may not be greatly
different from older hierarchical movements
to London. Trade in health services is grow-
ing, becoming more competitive, and creating
new dimensions of globalization.
Yet doubt surrounds the impact and sig-
nificance of medical tourism in terms of the
particular players in origins and destinations
(whether countries, hospitals or clinics), in
patient numbers and procedures and, weak-
est 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 predic-
tions 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 pro-
viders and why such confidentiality reigns,
even in a competitive arena. For a better
understanding of medical tourism more ade-
quate 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,
174 Chapter 10
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 long-
distance 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 cross-
border and regional mobility than the trans-
continental mobility much favoured in media
accounts. Elite Europeans may continue to
dominate the media and promotional bro-
chures, but there is greater mobility from the
Gulf, and many medical tourists are very far
from elite. Cosmetic surgery may be memo-
rable, sex changes dramatic and stem cell sur-
gery 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 market-
ing quite intimate procedures in distant,
sometimes unknown and perhaps imper-
sonal 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 over-
come, is difficult. Even in developed coun-
tries 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, over-
coming 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, with-
out main-street travel agencies, medical tour-
ism 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 interna-
tional tourism was yet to become important,
and niches unrecognized. This raises philo-
sophical and practical issues about what tour-
ism 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 trivial-
ized as tourism. Surgery demands proper
recuperation rather than tourism, and insur-
ance companies are unlikely to appreciate
‘tourism’ as part of an insurance package.
However, at the very least, the notion of ‘tour-
ism’ makes medical tourism seem pleasant
and enjoyable and less serious and fearful,
just as ‘cosmetic surgery’ seems more pleas-
ant and benign than corrective surgery.
Almost everywhere patients have some
time for conventional tourism. That may not
be strenuous or energetic, but shopping, sun-
bathing 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 hospi-
tals 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 oper-
ations and hospitals become quasi-hotels:
‘hospitels’.
The countries that have gained most
from medical tourism are those with reason-
able 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 poten-
tial for recuperation in a resort. A partial leg-
acy of past health tourism, and the reputation
of the national tourism industry, has proved
helpful. While that might seem to offer oppor-
tunities for established tourism destinations,
only those where high quality health-care ser-
vices 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 proce-
dures and herbal remedies (e.g. Chambers
and McIntosh, 2008), this has rarely been fea-
sible and, with minor exceptions in India and
Singapore, has neither been tried or suc-
ceeded. 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 develop-
ment 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.
175
Governments have, however, increasingly
played a role in marketing, supported tour-
ism 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 cre-
ated conflict between practitioners in rich-
world 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 neighbour-
hood health-care provider, the growth of
medical tourism is quite remarkable. It has
offered greater choice to patients (increas-
ingly referred to as ‘health consumers’) in all
countries, but alongside a cult of indivi-
dualism, 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 hospi-
tals, 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 with-
drawal of national planning. Inherent
inequality has excluded the poor and geo-
graphically 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 invari-
ably more than half the patients are local
(albeit relatively well off). While private hos-
pitals in developing counties could not sur-
vive 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 frag-
mented 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),
176 Chapter 10
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 tour-
ists their absence may stimulate some restruc-
turing, 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 medi-
cal care overseas; the tragedy is that they (and
many others) cannot receive effective care at
home. The main beneficiaries of medical tour-
ism 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 hospi-
tals and who have reduced access to public
health services, whether in source or destina-
tion countries.
The Epitome of Globalization?
Globalization manifestly offers new opportu-
nities 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 glo-
balization is far from a uniform process. The
globalization of the market for medical treat-
ment parallels what has become a global mar-
ket 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 global-
izing themselves. Medical tourism epito-
mizes contemporary globalization in its
technological base (from biotechnology to the
Internet), its capitalist structure and legal sys-
tems, and its increasingly pervasive spread to
embrace markets and destinations (many
countries acting as both) alongside the with-
drawal of the regulatory state and reduced
social obligations. Labour and capital markets
have become more closely integrated along-
side the shift towards a network society.
Long-distance travel for health care has
grown at the same time that national health-
care 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 cross-
border 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 move-
ments 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 over-
seas 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 individ-
ual phenomenon, like other components of
tourism, it has acquired some institutional
characteristics as governments have become
involved. Greater collusion within state sys-
tems 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 Luxem-
bourg, Belgium and France), insurance poli-
cies provide for and even encourage medical
care overseas and some companies ‘export’
workers for health checks. Singapore’s deci-
sion 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 hospi-
talization 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 impor-
tance 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 sophis-
ticated range of medicines and procedures
and shortages of health workers, health costs
everywhere can only increase so encourag-
ing 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) trans-
national diagnostic laboratory companies
(like Quest Diagnostics); (iv) global NGOs
such as Médecins sans Frontières; (v) a rise in
international aid programmes mainly tar-
geted at specific diseases (notably the Global
Fund); (vi) the emergence of international
hospital groups, such as Apollo (as health-
centred 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, along-
side 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. Imposi-
tion 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 phar-
maceutical goods and sperm (directed by
Internet orders); (ii) the globalization of
surgery via robotics and telemedicine; (iii) web-
177
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 direc-
tions (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 varie-
gated 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 cul-
tural and economic factors, conservatism,
intellectual property laws, basic education
and, above all, incomes, even within particu-
lar countries. Class, poverty, inertia and
uncertainty challenge crossing borders so
that, despite the primacy of economics (that
permits access to certain advanced or expen-
sive 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 invalu-
able, 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 middle-
income Asian, and also Latin American coun-
tries – but notably the Asian ‘big four’ – where
the conditions have been right, including the
178 Chapter 10
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 transnational-
ism, both the return of skilled health workers
from developed countries to their home coun-
tries 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 tour-
ism 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 doc-
umented 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 treat-
ment 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 insur-
ance providers become further involved –
which also means the need for accreditation
of standards – so global collaboration will
increase. Again institutional contexts are criti-
cal 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. Simultane-
ously MTCs scour the world for new and
attractive destinations. Asian success has
prompted growing regional and global inter-
est 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 medi-
cal 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) indus-
try 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 econ-
omy, 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 con-
trolled by Asian economic interests, remains
to be seen.
Rich countries can rarely compete and
restore the exclusive old order across the pan-
orama of medical care. Since they can only
effectively compete on innovation and qual-
ity there will always be scope for undercut-
ting 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, Bang-
kok 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, Eng-
land 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 Ameri-
can market. However, there is still inadequate
hospital capacity in the Americas and stan-
dards are weaker – Singapore has 13 JCI-
accredited 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 web-
sites, 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. Prosper-
ous 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 car-
bon reduction pose problems, so that remote
places such as Mauritius will be disadvan-
taged, and newcomers deterred. Regional
markets are likely to grow with greater pros-
perity, 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
179
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 promo-
tion 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 devel-
oping ‘world standard’ care (and marketing
this), without affecting local health-care sys-
tems, would be an almost impossible chal-
lenge. 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 (Chap-
ter 4) proved unfounded, due to absent skills
and regional competition, despite an estab-
lished tourist economy.
Estimates of future numbers are invari-
ably 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 consid-
erable pressure and there is some resentment
at levels of immigration. Perhaps most opti-
mistic 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 oppor-
tunities 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
180 Chapter 10
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 hospi-
tal 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 tour-
ism and commerce (e.g. Singapore or Malay-
sia)’ 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 eventu-
ally 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 coun-
tries were initially important, and links were
formalized in other ways. A Malaysian hospi-
tal announced in 2009 its scheduled signing
of a memorandum of understanding with
Australia’s Macquarie Neurosurgery to
enable renowned surgeon, Dr Michael Mor-
gan, 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 conti-
nents, preferably in Europe and North Amer-
ica, through both accreditation and affiliation
with respected hospitals there, medical tour-
ism providers moved on to becoming part
of transnational companies (some with inter-
ests far beyond health care) and by establish-
ing branches in or close to the markets.
Expanding the global reach of medical tour-
ism, especially from Asia, where chains and
conglomerates are most visible, is both insti-
tutional and structural. Some of the new con-
glomerates took in more than even the health
and travel industries. Various hospital chains
have sought to conclude insurance deals with
Western and international insurance compa-
nies 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 main-
land 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 global-
ization 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 oper-
ates 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 globaliza-
tion 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 posi-
tioned 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 Hruday-
alaya signed a joint venture with the Cayman
Islands government to build a Health City
(a 2000-bed hospital) with Indian special-
ists, a ‘large facility for assisted living for eld-
erly 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 expan-
sion and corporate control the role and con-
tent of health care itself was never prominent.
181
Emerging, expanding and evolving
chains, conglomerates, medical cities (below)
and institutional linkages have involved
increasingly complex transnational relation-
ships gradually embracing hotels, hospitals,
travel agents (including the rapidly expand-
ing MTCs, with their websites and guide-
books) 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 prof-
itability of health care and the incorporation
of hospitals in transnational business circuits.
Rather differently localized conglomer-
ates have been more loosely created in emer-
ging ‘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 hospi-
tals, 90 clinics and branches of globally fam-
ous 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 pro-
claimed itself a health-care city but integra-
tion of facilities is limited. At a much smaller
scale, Villa Medica, a subsidiary of a residen-
tial development company, Nusasiri, built a
‘boutique resort and hospital’ in Phuket
(Thailand), offering alternative and conven-
tional medicine, surgery, spa therapy and
rehabilitation. Phuket was chosen, according
to the company’s Vice President ‘because for-
eigners 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 Health-
care), providing a variety of health-related
businesses, from beauty clinics and organic
supermarkets, to Korean surgery and oph-
thalmology, connected to a prestigious ser-
viced apartment complex (Cabrera, 2009c). A
182 Chapter 10
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 ambi-
tious 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 cir-
cumstances. 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 Dallas-
based International Hospital Corporation has
built and operated hospitals in Mexico that
meet American standards. Harvard Medical
International has given affiliations, and there-
fore imprimatur, to emerging hospitals in
their own search for profitability. This ‘multi-
nationalization’ 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 indus-
trial 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 quot-
ing business gurus such as Peter Drucker, in a
world of clients and consumers rather than
patients. The executive summary of Bumrun-
grad’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 lever-
age its brand and intellectual property to
open future business opportunities’ (Bum-
rungrad Hospital Limited, 2010: 56; my ital-
ics). 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 Per-
fect 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 con-
sumers and the healthcare system is becom-
ing part of the consumer’s world’ (Kearns
and Barnett, 1997: 173) not least in the physi-
cal form of ‘hospitals as hotels’. Indeed some
have seen the emerging relationships between
hotels, hospitals and nearby places of con-
sumption 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 politi-
cal 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 Thai-
land, 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 consider-
able 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 geo-
graphically uneven, not just in the relatively
small number of countries who are the pri-
mary beneficiaries, but because, with excep-
tions, the new medical tourism is a
metropolitan and middle-class phenomenon
183
that has taken advantage of the best hospitals
and practitioners in particular countries and,
alongside privatization and deregulation,
has skewed, however slightly, national struc-
tures 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 dis-
eases 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 medi-
cal tourism from the Russian Far East. Cruise-
ship medical tourism may take patients out of
countries but not into new jurisdictions. Con-
servative 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, espe-
cially 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 tanta-
mount to lifestyle. A further post on the same
Gorgeous Getaways discussion board a
couple of days later read:
184 Chapter 10
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 cul-
tural dissonance at home, by becoming medi-
cal 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 Bum-
rungrad now have wellness centres) than
purely medical interventions. Good health
demands a holistic approach, which in terms
of medical tourism involves greater integra-
tion of spas and surgery, but perhaps also
some withdrawal from materialism, individ-
ualism 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 mate-
rialism, the continued obsession with body
shape, self-indulgence and the distortion of
health care in various countries raises ques-
tions. 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 globaliza-
tion. The Internet and global media have led
to a democratization of health information.
Convenience and speed are central to moder-
nity, 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. Ironi-
cally, 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 tour-
ism mirrors the inadequacies of national
health-care systems.
 Appendix I
Destinations and Delivery

Destination country where MTCs offer

Country treatmenta Country where MTCs are based

Antigua and Barbuda 0 1

Argentina 10 5
Australia 3 10
Austria 10 9
Bangladesh 1 0
Barbados 1 1
Belgium 34 26
Bolivia 1 1
Brazil 14 8
Bulgaria 5 5
Canada 4 9
China 2 1
Colombia 4 2
Costa Rica 14 6
Croatia 31 24
Cuba 1 1
Cyprus 54 44
Czech Republic 17 12
Dominican Republic 2 1
Ecuador 1 0
Egypt 9 5
El Salvador 3 1
Estonia 2 2
Finland 1 1
France 25 15
Germany 20 18
Greece 17 15
Guatemala 2 2

(continued )

© CAB International 2011. Medical Tourism (J. Connell) 185

186 Appendix I Destinations and Delivery

Continued

Destination country where MTCs offer

Country treatmenta Country where MTCs are based

Hungary 69 49
India 116 89
Indonesia 1 0
Ireland 3 5
Israel 5 4
Italy 6 5
Jordan 3 1
Korea (South) 11 5
Kyrgyzstan 0 1
Latvia 7 4
Lebanon 1 0
Lithuania 6 5
Macedonia 3 0
Malaysia 16 8
Malta 16 8
Mauritius 2 3
Mexico 16 8
Mongolia 0 1
Morocco 1 0
Nepal 2 1
Netherlands 6 5
New Zealand 1 5
Norway 3 2
Oman 0 1
Pakistan 2 1
Panama 4 3
Peru 3 2
Philippines 12 7
Poland 37 27
Portugal 3 2
Romania 13 10
Russia 6 3
Serbia 6 4
Seychelles 1 0
Singapore 13 7
Slovakia 6 5
Slovenia 2 2
South Africa 23 19
Spain 79 66
Sweden 0 2
Switzerland 8 7
Syria 2 1
Taiwan 5 4
Thailand 37 15
Tunisia 6 5
Turkey 50 38
UAE 4 1
UK 3 74
Ukraine 3 2
 Appendix I Destinations and Delivery 187

Destination country where MTCs offer

Country treatmenta Country where MTCs are based

USA 14 33
Venezuela 2 1
Vietnam 3 3
Not specified 9 41

Regions Region where MTCs offer treatment Region where MTC is based

Asia 3 –
Africa 1 –
Europe 3 –
Indian Ocean 1 –
Latin America 2 –
West Indies 1 –
Worldwide services 8 –
Total 957 820
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 Argentina 49, 50, 57, 91, 92, 96, 99, 185
Abu Dhabi 69, 117, 155, 182 aromatherapy 14
accreditation 2, 3, 11, 51, 52, 63, 65, 70, 71, 85–7, Asian financial crisis (late 1990s) 61, 62, 63–4, 65,
130, 156, 177, 178, 180 66, 71, 73
global acceptance of standards 177, 178 astrology 10, 69, 165
Joint Commission International (JCI) 51, 52, Au Bon Pain 69 130, 166
63, 65, 71, 86, 86–87, 105–7 Australia 4, 5, 11, 12, 14, 24, 25, 27, 28, 32, 36, 37,
marketing role 85–87, 98–99, 106 39, 43, 44, 45, 48, 56, 58, 63, 67, 68, 81, 82,
acupuncture 6, 10, 14, 25, 26, 90, 113 84–5, 86, 87, 89, 91, 93–100, 103, 113, 114,
advertising see marketing 115, 118, 123, 125, 127, 128, 133, 134, 136,
aesthetics x, 7, 8, 31–2, 37–8, 129 141–2, 145, 146, 155, 156, 157, 162, 163, 164,
affluence xi, 9, 24, 42, 50, 53, 56, 118–9, 125, 160–1, 169, 180, 185
173 Austria 51, 57, 58, 143, 185
luxury health and spa tourism 31–33 authenticity 3, 16, 22, 30, 33, 35, 40, 172, 175
Afghanistan 24, 55, 115, 119 Ayurvedic medicine 25, 27, 33, 35, 40, 45, 69–70,
ageing 2, 29, 35, 36, 37, 42, 77, 120, 138 162, 165
baby-boomers, demands and expectations Azerbaijan 52
35, 42, 120
transnational retirement 1, 48, 73, 76
agriculture 8, 10, 16, 134, 162 baby boomers 35, 120
aid 4, 5 Baden-Baden (Germany) 13
air transport 2, 5, 46, 68, 71, 97 Bahamas 28
business links (airlines and hospitals) 68, Bahrain 67, 115
169, 170 Bali 30, 31, 33
Albania 52 Bangkok Hospital 68, 107, 111, 130, 164, 167, 169,
Angola 67, 117 182
anonymity 47–48, 124, 144 Bangladesh 56, 67, 68, 70–2, 114, 115, 118, 119, 150,
Antigua 49, 93, 185 173, 180, 185
Apollo Hospitals 69, 70–71, 85, 87, 115, 128, 131, Barbados 56, 67, 68, 70–72, 114, 115, 118, 119, 150,
150, 152–153, 168, 177, 180 173, 180, 185
international expansion 71, 180 bariatric surgery 50, 117
marketing 107–108, 147–148 Bath (UK) 13, 14, 19

203
204 Index

bathing 12–13, 19–20, 32 Chile 50, 162, 173

Beach Boys 110 China 8, 9, 17, 56, 67–9, 71–2, 75, 76–8, 114, 115,
Beatles 25 134, 139–40, 144, 145, 148, 178, 180, 185
beauty x, 7, 8, 31–2, 37–8, 129 cosmetic surgery demand 8, 38
beauty treatments 31–32, 165, 169, 181 middle class 62, 75–76, 78
Belarus 51, 143 traditional medicine 53
Belgium 10, 13, 185 transplant organ sources 139, 140
Berlin 3, 178 Chiva Som (Thailand) 33–5
Bermuda 45 Chopra, Deepak 29
Bhutan 28, 70, 115 class 3, 8, 14, 19, 20, 34, 42, 53–4, 58–9, 62–4, 76, 78,
blogs 91, 105, 109–110, 129, 177 143, 157, 169, 173, 175, 178, 183
Blue Cross/ Blue Shield 131, 180 Cleopatra 12
body image 7, 37–8, 41, 183–184 cloning 140
Bolivia 50, 185 coastal resorts 14, 19–21, 24, 71, 160
Borneo 28 Colombia 45, 49, 50, 83, 85, 122, 126, 185
Botox injections 14, 36, 75, 165 colonialism 18–19
Botswana 117 compensation 15, 82, 84, 98, 157
brain drain 149, 150, 152 complications 81–4, 122, 139 see also legal liability
Brazil xi, 49, 50, 57, 86, 91, 96, 103, 125, 138, 139, confidentiality see anonymity
179, 185 contraception 1, 140, 141, 144
breast surgery 7, 36, 48, 82, 85, 90, 95, 100, 122, Cook Islands 5
123–124 Coronation Street xi
Brighton (UK) 19–20 corruption 20, 139, 153
Brunei 71, 72, 73, 126, 165 cosmetic surgery x, 1, 2, 5, 6-7, 8, 9, 10, 23, 35–8,
Brych, Milan 5 39–41, 42–4, 47–8, 50, 51, 56, 59, 61, 63, 68,
Bulgaria 185 69, 81–4, 74–5, 93, 100, 101, 106–7, 115, 117,
Bumrungrad International Hospital, Thailand 122–3, 134, 137, 164, 183
(BIH) 7, 48, 62, 63–9, 66, 76, 89, 92, 96, 104, see also dentistry
109–10, 115, 117, 120, 129, 130, 133, 136, Costa Rica 3, 50, 57, 83, 85–6, 95–6, 102–4, 115, 117,
149, 153, 163–7, 168–9, 175, 177, 180–2, 184 122, 123, 129, 130, 131, 133, 134, 141, 144,
marketing strategies 65, 105, 106, 108–109, 150, 166, 169, 179, 185
115, 116, 164, 166, 166 costs see prices
translation facilities 64, 65 counterculture 24, 25–26, 30, 32
bureaucracy 70, 120, 121, 148, 153, 155 crime 50–51, 102
Burma (Myanmar) 5, 67–8, 71–3, 77, 114, 131 Croatia 57, 91, 185
bushwalking see hiking cross-border medical tourism 5, 10, 43, 45, 51, 56,
Buxton (UK) 14, 15 58–9, 64, 67, 77–8, 113–7, 118, 174, 178, 180,
Byron Bay (Australia) 25 181, 183
cruise-ships 12, 21, 162, 183
Cuba xi, 3, 49, 52, 57, 85, 86, 104, 107, 114, 120, 132,
Cambodia 64, 67–8, 72, 76, 115, 118 150, 153, 162, 185
Campbell, Naomi xi health-care quality and accreditation 86, 107
Canada 3, 4, 21, 39, 43, 45, 54, 68, 70, 86, 92, 98, marketing image 85
114, 115, 117, 128, 129, 141, 156, 165, 178, sources of medical tourists 49
185 culture in medical tourism 2, 4, 17, 23–4, 30, 45,
equity issues 156–157 58–60, 68, 73, 74, 79, 87, 92, 100, 107, 111,
waiting lists, non-urgent surgery 43 114–5, 111, 125–6, 130, 146, 161, 176, 178
cancer 5, 9, 20, 26, 36, 40, 44, 48, 58, 73, 76, 77, 92, see also diasporic medical tourism, ethnicity,
118–9, 120, 123, 129, 144, 146, 147, 155 language
capitalism 69, 95, 157–158, 166, 176, 181–183 Cyprus 40, 52, 55, 57, 89, 93, 120, 140, 185
cardiac surgery see heart surgery Czech Republic 13, 15, 32, 51, 57, 96, 143, 163, 185
Caribbean 20, 35, 39, 49, 54, 55, 93, 103, 154, 165
Carson, Rachel 24
Casteneda, Carlos 25 data see statistics
Cayman Islands 181 ‘death tourism’ (euthanasia) 48, 145–146
celebrity culture xi, 26, 35, 36, 37, 48, 75, 175 Denmark 10, 26, 48, 141
children 39, 40, 48, 58, 122, 140–2, 152, 153 infertility tourism 48, 141
 Index 205

dentistry 48, 51, 84, 85, 106–7, 113, 117, 118, 123, eugenics 141, 145
134 European Union (EU) 3, 10, 43, 46, 56, 114, 115,
cosmetic 7, 8, 11, 43, 68, 80, 81 119, 130, 143, 151, 155, 179–80
tourism x, 2, 5, 6, 9, 88, 97, 123, 128, 134, euthanasia (death/suicide tourism) 1, 7, 48,
163–164, 168, 169, 170 145–146
detoxification xi, 1, 27, 34 exercise x, 9, 12, 20–2, 27, 29, 34, 35, 38, 98, 158, 177
DHCC (Dubai Healthcare City) 55, 156, 181–182 expatriates 4, 54, 59, 62–4, 67–71, 89, 113–4, 156,
diasporic medical tourism 1, 4, 10, 26, 49, 50, 45, 181
54–5, 58, 59, 70, 71, 89, 114, 125–6, 146, expenditure 45, 100, 102, 132–5
161–2, 178, 179 see also shopping
Mexico 44, 45, 50–51, 58 eye surgery 3, 8, 35, 36, 37, 43, 49, 73, 75–6, 117,
diets x, 6, 7, 9, 10, 27, 28, 34, 35, 37, 38, 42, 158, 160 119, 152, 165
Dignitas 145–146 see also Lasik eye surgery
diseases 13, 15–16, 18–20
non-communicable (‘diseases of affluence’) 9,
129, 176, 183 facelifts see cosmetic surgery
see also cancer, obesity, tuberculosis family see relatives and friends
doctors 6, 11, 19, 27, 38–40, 43–6, 52, 55, 58, 63, 77, Fatima (Portugal) 12, 17, 40, 146
83, 85, 88, 92, 98, 103, 105–8, 114, 120–1, Federated States of Micronesia (FSM) 55, 76
125–9, 140, 181 feng shui 10, 29
migration 51, 63, 69, 70, 149–151, 154, 156 fertility treatment (IVF) 39, 48, 53, 54, 56, 83, 90–1,
Dominican Republic 49, 91, 104, 145, 185 104, 117, 126, 140–4, 154, 155, 157, 165–7,
‘drop-in’ procedures 4–7, 51, 52, 62, 80, 118, 168, 177–8
174 Harley Street 40, 182
Drugs 24–5, 145 Fiji 32, 55, 56
Dubai (UAE) 55, 69, 86, 104, 115, 156, 181–2 Finland 15, 120, 185
Dusit Medical Group 64, 68 Flight Centre 158, 169
food 28, 118, 134
Fortis Healthcare 71, 72, 107, 115, 178–81
ecology 24, 25–6, 111 France 10, 12, 13, 14, 17, 19, 34, 36, 44, 54, 57, 68,
economic impacts 62, 132–4, 136, 142, 147–8, 153–6 114, 126, 130, 164, 176, 185
ecotourism 28, 50
Ecuador 49, 50, 104, 185
education 33, 114, 153, 161, 177 gender reassignment (sex change) 36, 47, 48, 53,
Egypt 13, 39, 40, 44, 55, 57, 79, 92, 112, 114, 119, 61, 137, 106, 171, 174
139, 185 selection of children 140–1
El Salvador 96, 131, 185 General Agreement on Trade in Services
elitism 3, 12, 16, 18, 19, 24, 33, 34, 38–40, 42, 48, 54, (GATS) 176, 184
56, 59, 76, 81, 113, 117–9, 130, 132, 152, 154, Georgia 52–3, 60, 141, 142, 157, 179
157, 173–4, 177–8 Germany 10, 13, 14, 21, 32, 34, 51, 54–8, 67–8, 81,
emotion 17, 26, 29, 60, 142, 161 114–5, 119, 141, 143, 163, 178, 185
employment see work Ghana 67
entitlement x, 2, 10, 37, 172, 183 Gilbert, Elizabeth 30
environment 10, 16, 21, 22, 24–5, 29 global financial crisis (GFC) 11, 36, 51–52, 66, 136,
see also therapeutic place 183
Epidaurus (ancient Greece) 12, 13, 16 globalization 11, 40, 49, 60, 92, 138, 172–173,
Equatorial Guinea 54 176–177, 178, 182–184
equity 21, 133, 138–9, 149–53, 155–8 see also transnationalism
see also uneven development Gorgeous Getaways 37–8, 100, 153
Estonia 185 business growth 93, 96, 97–99
ethics 34–5, 48, 92, 98, 137–138, 146–7, 157, 179 discussion board 124, 127–128, 133–134
death tourism (euthanasia) 145–146 marketing and advertising 87–88, 99, 100,
organ transplants 138–140 101, 109, 128
reproductive (fertility) tourism 140–144 government policies 11, 14, 39, 44–45, 49–56, 60,
stem cell therapy 144–145 69, 73, 133, 154, 155–156, 162
Ethiopia 46, 67, 70–1, 115, 117 Greece 12, 13, 16, 40, 55, 57, 185
ethnicity 8–9, 36–7, 45–6, 63, 115, 116, 142–3 Guam 55, 76
206 Index

Guatemala 185 International Medical Travel Association 104

guidebooks 6, 13, 24, 87, 88–9, 101–4, 162–3 International Medical Travel Journal 105
Gulf states 38, 44–5, 55, 59, 63, 66, 67, 68, 70, 86, International Standards Organization (ISO) 86
115, 130–4, 156, 174, 178, 180 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,
hair restoration x, 44, 47–48, 53, 66, 91, 106 123, 126, 140–3
Harley Street, London (UK) 3, 38–40, 41, 174, 178, Iran (Persia) 12, 55, 104, 139
182 Iraq 54, 119
Harrogate (UK) 14 Ireland 5, 17, 27, 43, 48, 86, 90, 115, 131, 141, 143,
Harvard Medical International 71, 87, 181, 182 156, 186
health (wellness) tourism xi, 5–6, 7, 12, 21, 26–35 islands 4, 19, 32–3, 44, 55
healthcare provision, national 3, 143, 150–7 Israel 17, 54, 57–8, 60, 115, 126, 132, 138, 140, 141,
healthcare cities 55, 87, 156, 181–2 154, 178, 186
health insurance 1, 2, 10, 42–5, 48, 49, 50, 54, 58–9, Italy 12, 13, 30, 35, 39, 51, 54, 68, 86, 141, 146, 156,
60, 73, 83–4, 98, 114, 118–23, 130–1, 136, 186
153, 174, 176, 177, 180
heart surgery 45, 54, 55, 72, 83, 86, 98, 120, 153
comparative costs 122, 122, 123 Jamaica 49, 179
conscious coronary artery bypass (COPCAB) Japan 9, 13, 14–16, 35, 37, 48, 55, 63–4, 66, 67, 68,
45, 107 70, 73, 74, 76, 77, 91, 93, 105, 107, 111, 112,
herbal medicine 10, 27, 29 114, 115, 126, 130, 131, 140, 142, 161, 166,
hiking 1, 7, 160 169, 174, 178
hill stations 14, 18–19 Jerusalem 17
hip replacements x, xii, 7, 10, 43, 45, 70, 76, 131 Joad, Cyril 21
cost comparisons 72, 122, 123 Joint Commission International (JCI) 65, 86–7, 95,
hippie trail 24, 25 106–7, 113, 177, 179
Hippocrates 12, 13 Jordan 44, 54, 55, 58, 84, 104, 114, 119, 132, 186
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 Karlovy Var, Karlsbad (Czech Republic) 13
hospitals 64–68, 67, 107, 129–130, 166–168, 167, Kashmir 17, 18
166–168, 167, 170 Kazakhstan 52
transnational chains 68–69, 70–73, 177, 180–2 Kenya 28, 48, 54, 179
see also individual hospitals Kerouac, Jack 24
hot springs 13, 14, 16, 34 kinship see family
hotels 4, 13, 31–3, 78, 92, 124, 133–4, 171, 182 Kiribati 114
hospital linkages 55, 166–170, 175, 182 knee reconstructions 10, 43, 83, 120–23
Hungary 13, 43, 51, 57, 89, 91, 93, 96, 114, 118, 128, Korea, South 9, 68, 74–5, 76, 86, 89, 91, 96, 102, 107,
134, 162–3, 179, 186 114, 125–6, 133, 144, 161, 178, 181, 186
Kuwait 40, 67, 70, 115
Kyrgyzstan 15, 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, language 10, 49, 54, 56, 58, 59, 64, 73, 74, 91, 105,
43, 53, 56, 57–9, 61, 63, 64, 68–71, 72, 73, 74, 110, 111, 115, 119, 120, 126, 179
76, 77, 78, 81, 83–6, 87, 91, 93, 95–6, 97, 98, bilingual staff 50, 51, 126
99, 103, 104, 106, 107, 109, 114, 115, 119, interpreters 39, 64, 65, 77, 107
121–3, 125, 126, 128, 129–33, 137, 139–44, Laos 68, 77
145, 147–55, 157, 161–2, 165, 167–8, 173, laparoscopy 122
175, 178, 179, 180, 181, 186 Lasik eye surgery 35, 43, 44, 91, 168, 169
health worker shortages 149 Latvia 51, 57, 114, 154, 183, 186
public and private sector inequality 147–148, Lebanon 55, 79, 186
152–153, 155 legal liability 83–84, 121
Indonesia 35, 62, 71, 72, 73, 77, 91, 114, 115, 118, Libya 40, 44, 54–5, 71, 114, 126, 156
126, 132, 155, 165, 173, 186 liposuction 35, 36, 37, 83, 118, 122
insurance see health insurance 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 Spain 2, 17–18, 19, 43, 48, 50, 54, 57, 93, 115, 130,
qualifications 95–96, 105–8, 127 140–3, 186
spas 1, 12–16, 22, 32–35, 34, 51, 52, 138, 160, 162,
165, 178, 184
Raffles Medical Group 168 spirituality 10, 12, 16–18, 21–22, 23, 26–30, 40, 42,
recreation 19, 21, 22, 166 172
recuperation 20–21, 22, 97–8, 169, 170–171 sport 12, 20–21, 160, 174
referrals 44, 59, 69 springs 13, 14, 16, 22
relatives and friends 2, 4, 62, 128 Sri Lanka 67, 70, 71, 72, 115, 145, 180
accompanying medical tourists 4, 127–128, Starbucks 129, 130, 166
133, 168, 170 statistics xi, 7, 42–3, 61–2, 74, 82, 83, 112, 113, 173,
financial support for medical travel 125–126, 179
155–156 stem cell therapy 1, 5, 48, 53, 76, 137, 144–145, 151,
religion 12, 14, 16–18, 25, 55, 68, 87, 141, 126, 134 157
reproductive tourism 5, 48, 53, 140–44 Sudan 67, 114
see also fertility treatment suicide see euthanasia
resorts 12, 13, 19–20, 24, 27, 32–5, 138 sunbathing 20, 21
retirement 1–2, 48, 44, 48, 50, 63, 73, 76, 134 Surgeon and Safari 92, 93, 117, 124, 170
rhinoplasty 36, 44 SurgeryPlanet 57, 90
Roman Empire 12, 13, 19 surrogacy 53, 69, 126, 137, 140–144, 147, 158, 173
Romania 57, 91, 92, 114, 186 Sweden 10, 52, 114, 115, 141, 143, 186
Rotorua (New Zealand) 13 Switzerland 6, 18, 32–3, 54, 56, 57, 58, 90, 114, 115,
Russia 42, 52, 56, 58, 72, 74, 76–7, 119, 126, 143, 145–6, 186
183, 186 Dignitas 145–146
Syria 54, 104, 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
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 209

transplants 1, 7, 54, 69, 72, 106, 139–40, 171, 179 Uzbekistan 52

organ trafficking 138–139, 140
success rates 83, 128–9, 157
transport 2, 3, 5, 20, 46, 66, 71, 169, 170, Vanuatu 39, 44
travel agents/agencies 55, 79, 134, 166, 174, 181 Vatican City 17
Treatment Abroad, website 57, 90, 91, 93, 104–5, Vejthani Hospital (Thailand) 105, 107
134 Venezuela 49, 187
trickle-down 134, 148, 153–155 VFR (visiting friends and relatives) tourism 161,
tuberculosis 18, 20, 21, 149 171
Tunisia 45, 54, 57, 58, 89, 110, 114, 122, 126, 132–3, Vietnam 14, 62, 64, 67, 68, 72, 73, 76, 118, 126, 131,
152, 153, 154, 155, 186 141, 142, 187
medical tourist expenditure 132–133 visas 39, 46, 69, 70, 76, 77, 110, 155, 166
Turkey 13, 52, 55, 57, 86, 91, 96, 102, 104, 131, 139,
162, 169, 186
Turkmenistan 52 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,
Ukraine 51, 58, 76, 72, 114, 118, 41, 143, 186 150, 157
uneven development x, 4, 35, 133, 147–8, 149, 153, water 12–16, 15, 19–20
175–6, 183–4 websites 88–92, 105–109
United Arab Emirates (UAE) 40, 44, 45, 55, 67, 68, whiteness 8, 9, 115, 116
71, 72, 69, 86, 96, 104, 114, 115, 131, 133, Wikipedia 7, 57, 134
156, 181–2, 186 Winfrey, Oprah 30, 88
United Kingdom 9, 10, 13, 14, 16, 20, 21, 27, 28, 34, Wockhardt Hospitals 45, 69, 71, 87, 97, 107, 152
39, 40, 43, 44, 45, 48, 541, 52, 53, 54, 55, 56, Women on Waves 5
57, 58, 59, 63, 67, 68, 70, 82, 86, 88, 90, 91, World Bank 156
93, 95, 101, 107, 110, 113, 114, 115, 117, 119, World Health Organization (WHO) 10, 107
122, 124, 125, 126, 130, 141, 142, 143, 145,
152, 155, 162, 163, 168, 174, 178, 180, 182,
186 xenotourism 138
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, Yanhee Hospital (Bangkok) 82, 107–8, 110, 112,
87, 88, 89, 90–1, 92, 93, 95, 06, 97, 98, 101, 115
103, 110, 113, 114, 115, 117, 118, 119, 120, Yemen 5, 44, 45, 59, 67, 71, 84, 114, 118, 119,
121–2, 1213, 124, 125, 126, 129, 130, 131, 125–126, 133–4, 151–2, 155, 158, 160, 174,
136, 139, 140, 141, 142, 143, 144, 145, 149, 177
150, 151, 152, 155, 157, 168, 169, 172, 174, yoga 4, 7, 10, 23, 25, 26–28, 30, 31, 35, 163, 165
177, 178, 180, 181, 183, 187
health insurance cover 44, 183
urban bias 147, 149, 153, 175 Zambia 117