Health of tourists, health of destinations

Despite the Covid-19 health crisis, tourism is still considered to be a major component of economic development in many countries (including France) and this is highly differentiated across territories. This results in tourist clusters (destinations) where the direct and indirect impacts of tourism can be seen (in terms of flows generated – human, economic, transport-related, infrastructure as well as a whole range of pressures exerted on the physical and social environment). As a result, the idea of sustainable tourism development has made headway. However, there is one component of sustainable economic development through tourism that is almost never addressed: health. With the notable exception of “medical tourism”, health is hardly addressed in tourism studies, although the global Covid 19 pandemic brought this industry to a halt.

Tourism and health: a relationship that goes back in time

The relationship between tourism and health goes back in time (tourism was born with the advent of baths, spas and more broadly of thermalism), is strong and multifaceted, even if all its facets are not equally felt by players on the ground. To understand the interactions between tourism and health, two points of view should be considered: the health of tourists and the health of the populations in the destinations. While the underlying issues and mechanisms overlap, they also differ.

From the point of view of the tourist, excluding health-related travel (cure, cosmetic surgery, Ayurvedic retreat for example), health is an issue not much thought about in tourist mobilities. Studies on the interactions between tourism and health often focus on the health of tourists and the health benefits that tourists can derive from their tourism practice.

The health of tourists

The Covid-19 pandemic that spread around the world via air transport has demonstrated, if need be, the extent to which planet Earth now works as a vast interconnected system. International tourism travel obviously contributes to this system, as does business travel. The flows and profile of travellers are well documented and literature is available on the main travel-related health risks and morbidity. Well before the coronavirus crisis, it was known that travel-related morbidity is largely dominated by communicable diseases (Le Bras et al. 1992; Bouchaud, 2003). “The proportion of travellers complaining of any health problem is around 60%, with differences ranging from 15 to 78% according to studies, and the well-known “turista” or traveller’s diarrhoea, affects nearly one traveller in two. On the other hand, some typical tropical diseases, particularly feared by travellers, are relatively rare not to say very rare: 2 to 3% for malaria, 3/100,000 for typhoid fever and 3/1,000,000 for cholera. Much less “exotic” health problems are more frequent and often serious: One third of medical repatriations are due to traumatic accidents, one third to cardiovascular accidents and nearly one tenth to psychiatric collapse” (Bouchaud, 2003).

Ill. 1. Incidence of major health events among tourists (source: Bouchaud, 2003)

While the health of travellers is a known problem and is a medical speciality, i.e., travel medicine, not much work has been done on the impact of health tourism on territories and populations.

However, the development of tourism involving the use of the health infrastructure in the destinations has potentially strong impacts. Firstly, on the medical profession: what happens when trained doctors (and other health professionals) find it more lucrative to work with tourists than in their local health systems? What happens more broadly to the health of populations in tourist destinations when the provision of care is more geared to tourism than to the local population?

Tourism as a factor for the improvement of health care and infrastructure that benefit the local population

The development brought about by tourism can have benefits for the local populations through its direct impacts (creation of infrastructure for example) and indirect impacts(spill-over effects, upgrading of health standards, among others). For example, we can mention one of the world’s leading tourist destinations: Bali. Primary health centres called “Puskesmas” have developed there, are staffed with more healthcare workers and now receive patients on a 24 hour/7 day basis to meet the needs of tourists, particularly in the north of the island, where the lower population density would not have justified the provision of these services. These Puskesmas are widely used by the local population who therefore benefit from this development.

Ill. 2. The Bali International Hospital, which now has more specialities thanks to funding by Australia which wanted to ensure the health security of their numerous nationals that go on holiday to Bali (Cl. Sébastien Fleuret)

A second example is the private hospital of Marrakesh. This very modern hospital has levels and standards of equipment that are largely equivalent to or even better than some hospitals in the West. It was developed to meet tourism-related needs but applies rates affordable to the local population, which can thus benefit from a higher level of service than what the deficient public health system offers.

However, tourism creates health problems

Conversely, imbalances can emerge in relation to health issues. The brutal confrontation of populations with very unequal living standards (especially in the case of international tourism where the destination belongs to a very different economic and cultural sphere) is also a source of imbalances: pressure on property prices can cause housing problems with health-related consequences, environmental pressure impacts food and access to water and can cause pollution with health-related risks. The massive presence of tourists in a destination can give rise to public health problems. This is the case, for example, around Cancún in Mexico, where tourism raises problems of alcohol and drug use, and of sexually transmitted diseases.

Another issue is that the health of workers in the tourism industry is impacted too and this aspect is overlooked. Tourism generates a range of precarious jobs with difficult working conditions, without social security, and occupational medicine is not very developed in the major regions receiving significant tourist flows. There are worrying issues such as particularly high rates of alcoholism and suicide among precarious tourism workers. Too little attention is paid to the impact of tourism on mental health (Marie-dit-Chirot and Fleuret, 2021).

Health, an opportunity for destinations

However, health can be an interesting lever in tourism development and it is helpful, for example, to analyse how promoters of tourism development rely on the key elements of health and well-being of the population to present health as a factor to attract tourists (whether through the environment – air, water, food or various so-called “healthy” activities). Territorial marketing increasingly leverages health to boost the attractiveness of certain territories. Some (Bell et al. 2015) even go so far as to “label” territories to certify their benefits. Hotels, outings, services, are backed by certifications related to public health security or to accessibility for example. This is an argument that appeals to pensioners seeking to feel reassured. Another driver of economic and tourism development consists in promoting the positive image of traditional treatments (e.g., massages in Bali, Mayan medicine in Mexico, Hammam in Maghreb, etc.). The recent Covid pandemic has given rise to new labels guaranteeing health security measures.

Finally, in addition to all the approaches mentioned above, other questions should be asked, not regarding the tourist destinations but the countries of departure. For example, the issue of seniors who combine leisure tourism travel and the search for a climate more suitable to their health is likely to redesign the tourism package of operators both at the sending and at the receiving ends. In general, it is important to characterise the overlooked element of health in tourism development, beyond the intrinsic scientific interest, in order to support decision-making in the choice of local and regional development, on the one hand, and to better design health systems in a globalised world, on the other.

Sébastien FLEURET


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