Medical

The term ‘medical tourism’ has come to characterise international travel for medical procedures that are not available or not easily accessible in one’s country of origin, either due to legislation or the healthcare system (skills, cost) (Hottois and Missa, 2001).

A questioned term

This definition immediately underlines the inappropriate nature of the term ‘medical tourism’ (Chasles, 2011), as it is primarily based on medical need and not tourism in the primary sense of the term. The objective of this form of travel is first and foremost to improve one’s health and not for leisure. Beth Kangas (2010) explains that the term ‘medical tourism’ implies recreation and masks the challenges patients face, and suggests more neutral terms be used such as ‘international medical travel’ or ‘transnational medical travel’.

Other authors refer to this simply as ‘medical travel’ (Ehrbeck et al., 2008), ‘medical mobility’ or ‘transnational healthcare use’ (Lunt et al., 2015). Anaïk Pian questions the relevance of the concept of ‘therapeutic immigration’ (Pian, 2012). Other authors continue to use terms such as ‘hospital tourism’ and ‘surgical tourism’.

The term ‘pharmaceutical tourism’ has also emerged (Segal, 2008). Pharmaceutical tourism is linked both to issues concerning the legality or illegality of the circulation of certain substances, their availability and their price. More recently, the term ‘vaccine tourism’ has emerged, referring to affluent residents from countries where vaccination efforts are slow going, who travel to the United States, for example, to be vaccinated. There have also been media reports of German citizens travelling to Russia to gain quicker access to the Covid-19 vaccine.

These various terms illustrate the challenge of defining a kind of travel of which the boundaries remain unclear. Nevertheless, authors such as Luce Proulx (2005) have shown that there can be a link between tourism and health in the sense that tourist mobility allows for self-care and therefore contributes to health and well-being.

Although health has long driven tourism at its foundation (e.g., balneotherapy), the expression ‘medical tourism’, which is more journalistic than scientific, has recently become popular to refer to travel seeking various kinds of care for sometimes serious conditions that require sophisticated and extremely technical medical procedures.

After a boom primarily in cosmetic surgery, for some years now ‘medical tourism’ has concerned all kinds of illnesses, ranging from heart defects to organ transplants (Chasles, 2011). Travelling for healthcare also involves a hotel stay during the patient’s recovery period and potentially for the accompanying relatives or friends, who may also consume tourism-related services. The number of medical tourists is estimated to be around 16 million per year worldwide (Keckley, 2009), with a turnover of over $60 billion (MacReady, 2007).

Rise and renewal of mobility

In addition to the misnomer, medical mobility is often presented in an overly simplistic way.

First, the flows that make up this phenomenon are diverse and significant changes have occurred over the last three decades. While travel for local care remains a reality, as in the case of intra-European or intra-Mediterranean travel, long-distance care has risen significantly, one such example being Americans seeking treatment in Asia. This evolution of spatial practices is accompanied by an evolution of destinations.

Prior to 1997, the United States and Europe were the centres; affluent patients from emerging and developing countries went there for treatment. The economic crisis known as the Asian financial crisis in 1997-1998 had an indirect effect: countries such as Thailand and Singapore found themselves with a large portion of the population in economic hardship and no longer able to pay full price for healthcare. Hospitals then saw these medical mobilities as a way to diversify their activity and sources of income. These countries then deliberately developed a strategy geared towards this niche.

Shortly afterwards, the attacks on September 11, 2001 and the ensuing tensions drove wealthy Middle Eastern patients East — patients who had been travelling to America for healthcare. South East Asia has benefited from these events to develop its medical services. While there is a lack of reliable data, it is estimated that Thailand receives the largest number of medical travellers (800,000 to one million on average per year). Singapore ranks second in Asia, with 200,000 to 350,000 patients per year. India is said to receive about 200,000 per year. North-South and South-South flows have therefore become largely predominant.

Another relatively recent change is the diversification of social profiles; patients differ from one another both in terms of spatial practices and the type of healthcare facility visited. While the higher social classes disregard distance and prioritise what could be called hotspots for medical travel (private hospitals in major urban centres), lower social classes favour nearby locations in more accessible care structures, particularly from a financial perspective.

The Internet is a recent notable change as it now gives service providers greater visibility and allows travelling patients to inform themselves, compare services and consult reviews and feedback online (Hallem and Barth, 2011). Eades (2015) highlights another effect of the internet — the package of medical tourism displayed as a unique product. One no longer has to search for flights, hotels, clinics, taxis, etc.; all-in-one offers are now available and very attractive.

However, access to insightful information is key, even if it involves a degree of uncertainty due to its subjectivity. There is a lack of verified information, despite the existence of certain sites such as Patients Beyond Borders, which publishes a well-regarded guide to resources in the field of medical tourism.

Geographical areas concerned, specialisation and clusterisation

Other countries have opted for specialisation. Some examples are detailed below from Eades (2015) and Connell (2006).

Hungary is particularly attractive for dental care as is Antigua in the Caribbean. Thailand has built a strong reputation in niche markets such as gender affirmation and cosmetic surgery. The anonymity of distance has been shown to be an asset. Cuba specialises in skin conditions. Turkey is well known for hair transplant surgery. South Korea is also present in the cosmetic surgery market but for some time has focused on hyper-specialisation, developing services in oncology for specific organs (stomach, liver and uterine) and in liver transplants.

Mexico has attracted a North American clientèle for orthopaedic surgery as well as plastic surgery in Yucatán, in addition to a broader range of healthcare services in northern border cities and in Mexico City, the capital. This hyper-specialisation is therefore also geographical. For example, Dubai has German doctors to ensure the standard of care and to attract German-speaking patients. Malaysia and Singapore are particularly attractive to European and American expatriates living in Asia.

The phenomenon of geographical specialisation can also be seen in initiatives such as the construction of a healthcare town on the island of Jeju in South Korea, where healthcare infrastructure and tourist facilities are combined and made easily accessible through relaxed visa requirements for patients and their relatives. The same approach can also be observed in the United Arab Emirates in Dubai Healthcare City.

More broadly, a phenomenon of clusterisation seems to be emerging, with or without unity of place. Medical tourism requires several sectors of activity: international and local transport, hotels and catering, care (surgical and post-operative) and potentially complementary leisure activities (e.g., sightseeing excursions). From theory to practice, it seems that there is still a significant gap, as examples of successful clusterisation are still rare and, ultimately there is little ‘classic’ tourism in medical tourism.

Motivations for medical travel

There are many reasons why travellers seek care abroad. The low cost of care in emerging and developing countries is the primary motivation. According to the Centers for Disease Control and Prevention, 750,000 people from the United States go abroad each year for treatment that is five to ten times cheaper. Cardiac surgery costs about $150,000 in the United States, compared to $11,000 in Thailand (Lunt, 2011). At the same time, the air transport sector has evolved with low-cost fares which further reduce the costs of care abroad.

Another factor is the long waiting time for treatment. In the wake of the neoliberal shift and supply-side restructuring policies, some industrialised nations have reduced hospital capacity to cut healthcare costs, resulting in undercapacity and waiting lists of up to several months. This is the case in the United States, Canada and the United Kingdom, and more recently in France for certain specialities such as eye surgery. It may then be tempting for individuals to cut the queue by going abroad for treatment (Turner, 2007).

Another reason for medical travel is the lack of quality care and specialised care (e.g., in the field of cancer) in the country of residence. About 500,000 wealthy patients from Gulf countries seek care abroad each year. Before the Arab Spring, more than 30,000 Libyans sought treatment in Tunisia each year — Tunisia being a destination for both Western patients and a South-South flow which fed the expansion of private clinics (Rouland, Fleuret, Jarraya, 2016). India has clearly developed a strategy towards this clientèle and today new destinations (e.g., Morocco) are trying break into this market.

Beyond these typical factors, others are more nuanced, but no less real. International medical travel can also be a way to skirt legislation deemed too restrictive — such as for elective abortion, fertility treatments, weight-loss surgery or stem cell therapy. In another sense, leaving one’s everyday surroundings guarantees a degree of anonymity that is necessary in the context of certain forms of healthcare considered sensitive.

Lastly, numerous studies on the health of migrants have shown that returning to one’s country of origin for treatment is relatively common. There are many reasons for this. Some have to do with medical beliefs, cultural preferences, language barriers or difficulty integrating into the host country (Gany, 2006). One may consider that the healing process is not only influenced by the level of medical qualifications but also by cultural and emotional proximity to the place of care. For example, diasporic groups make up a significant portion of medical tourists (Connell, 2013).

Impacts on destinations and sending countries

In response to the reservations expressed in the introduction on the improper use of the term ‘tourism’ applied to healthcare, one may wonder about the tourist dimension in travelling for healthcare, as tourist amenities are not mentioned among the main factors of appeal, but what is really the case? What are the links between health and tourism? What is the impact on the countries concerned, particularly in terms of tourism… This last question in particular is worth examining further.

There is extensive literature on the motivations of medical travellers (Connell, 2006), but few studies have focused on the impact of this form of travel in tourist destinations. They do exist, however. One study carried out in Thailand on medical travel showed that through direct and indirect effects, it ‘exacerbates the shortage of medical personnel by diverting more and more workers from the private and public sectors to hospitals treating foreigners. This turns into substantially higher costs in private hospitals and is likely to do the same for public hospitals and the universal health insurance that covers most Thais’ (NaRanong and NaRanong 2011).

In addition to these considerations, other questions should be asked not in tourist areas but in the countries of departure. For example, when health insurance providers in the United States offer packages with accessible care not in the United States, but in Mexico, is medical travel not generating outsourced care?

The nuance is subtle, but this is not an issue of seeking a certain degree of comfort or savings when resorting to medical travel. This is a system which chooses to relocate services abroad to save money, with the potential consequence of a loss of skills and local services, similar to the deindustrialisation observed in a number of countries after activities are outsourced. This phenomenon therefore raises many social and ethical issues.

Sébastien Fleuret

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