International Journal of Tourism Sciences, Volume 7, Number 1, pp. 129-140, 2007 Tourism Sciences Society of Korea.

All rights reserved.

Medical Tourism: A New Global Niche

William Cannon Hunter Cheju National University

Abstract: Medical tourism is a new global niche market. This market has a significant economic scope, but little research exists regarding the actual effects that medical tourism has on a destination. This paper provides a survey of the history, economic scope and traveler motivations associated with medical tourism. In addition, a discursive analysis explores the implications for the larger medical industry and tourism industry of a destination. A grounded theory is provided that can serve as a foundation for future research, and directions for this research, in collaboration with managers and policy makers are suggested.

Keywords: Destination, Discursive Analysis, Health Tourism, Medical Tourism, Motivations, Niche Market, Representations

Cheju National University, Department of Tourism Management, 66 Jejudaehakn o, Jeju City, Jeju Special Self-Governing Province, Korea 690-756, Email: primala merica@yahoo.com or hunter@cheju.ac.kr, Telephone: 010-4699-4199 or 064-754-3 148 Fax: 064-725-2074

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INTRODUCTION
Medical tourism is a new global niche market that is of growing interest to researchers and policy makers in both the medical industry and the tourism industry. Medical tourism has its roots in health tourism, an ancient social practice where people travel to seek cures or certain health benefits available only at certain places. Along with everything else today, specialization has transformed health tourism (the pursuit of general well being available at certain destinations) into an emerging niche market. Medical tourism is a form of tourism that involves medical interventions that are substantial and have long-term effects (Connell, 2006). Medical tourism also involves recuperation and the enjoyment of certain activities available at the destination. Although there are no comprehensive descriptions or figures at the global level, the effects of medical tourism at the national level are available from a variety of sources. This information is sufficient enough to demonstrate the economic and social significance of medical tourism. This new global niche is currently under-researched and it is the purpose of this paper to first describe the general contours of medical tourism in terms of economic scope, medical services and traveler motivations. In addition, the wider scope of influence is examined through a discursive analysis. A discursive analysis presents the potential effects of medical tourism on destinations in terms of the medical industry and the tourism industry. However, little research has been performed regarding the effects of medical tourism, and the question regarding its real impacts on a destination and its resources are in question. The main point of this lecture is to examine medical tourisms potential for sustainability.

HISTORY: ROOTS IN HEALTH TOURISM

Medical tourism is a contemporary form of an ancient practice, health tourism. People for thousands of years have traveled for the sake of health, or to seek cures available only in certain locations. Considered a sacred pilgrimage for many, this journey took people to bathe at the Shrine of Bath in what is Britain today, 2000 years ago during the ancient days of the Roman Empire. Sacred sites in India, Greece and Persia have existed for millennia, even before Hippocrates (460-370 BC), the father of medicine declared the important therapeutic values of certain environments. In India, Ayurvedic treatments have long existed, offering a mixture of therapeutic and spiritual solutions not available elsewhere until the last century. For at least 200 years, Europeans have visited spas as far as the Nile. The importance of spas in Europe as a motive for travel is apparent even today, as

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many still remain in use. By the 1800s, during the peak of the European colonial movement, remote colonies such as the French Pacific territory of New Caledonia was widely recognized as a health tourism destination. There, and in other exotic tropical locales, hill stations appeared therapeutic centers offering certain curative properties and procedures (Smyth, 2005). The Philippines has historically been a destination for faith healing (Adams, 2005), made especially notorious in the 1970s with Andy Kaufmans famous journey to escape death by lung cancer after all other treatments had failed. Health tourism has always been around, offering certain types of massage, bathing, exercise and diets, including fasting, and a general retreat from daily life. Health tourism features various therapeutic, healing and curative effects specific to a particular destination and its natural and cultural resources. This type of travel, once inclusive of any pursuit associated with overall well being (including leisure sports and mountaineering) has become more specialized, to include specific medical interventions.

THE MEDICAL TOURISM INDUSTRY: A HIDDEN GIANT

Medical tourism is emerging as a unique and readily identifiable form of tourism that is deliberately linked to direct medical intervention, and the outcomes are expected to be substantial and long term (Connell, 2006). It can also be identified as a unique tourism niche, satisfying the needs of a growing number of people, mainly in developed countries, benefiting both themselves and a growing number of destinations, principally in developing countries (Connell, 2006; Gupta, 2004). Still referred to by some as health tourism, or health tourism services (Garcia-Altes, 2005), it is a niche that is identified as medical tourism when travel involves specific medical treatments (CBC, 2004). Medical tourism can be further clarified as a balanced mixture of a particular destinations natural and cultural environment with the medical treatments available there. For the patient, or medical tourist, it involves the procedures for a particular medical treatment along with recuperation and the concurrent enjoyment of certain activities associated with nature, culture and leisure sports, all unique to a particular destination. In other words, medical tourism incorporates central features of the medical industry and the tourism industry at a destination.

Destinations
The contours of medical tourism as a niche have not been clearly defined, although it is easily recognized. People are generally aware of it, and there is

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evidence of its economic and social significance. Tourism researchers and policy makers can only gain a partial view of the impacts of medical tourism and since comprehensive descriptions and figures have not yet been developed, the only recourse is to examine specific cases selected destinations and their features. Notable destinations for medical tourism are scattered all across the globe. Figure 1 (Map source: Altis Website) indicates some key locations. They each cater to distinct markets and they each offer very different products. In the Americas, Cuba offers plastic surgery (specializing in skin diseases) and dentistry for American and emphasizes the quality of its professionals (www.cubanhealth.com), with Costa Rica a close competitor for the same market. Other areas in the Caribbean find it more difficult to enter the medical tourism race, as prices are not competitive with Latin America (Huff-Rousselle, Shepherd, Cushman, Imrie, & Lalta, 1995). In Europe, medical tourism is a new opportunity for destinations previously under visited. Latvia and Lithuania are gaining recognition as destinations offering dental care and plastic surgery. Hungary declared 2003 as the Year of Health Tourism (Connell, 2006). In the Middle East, Dubai a fast-growing world-class travel destination will complete the Dubai Healthcare City by 2010. Situated on the Red Sea, this will be the largest international medical center from Europe to Southeast Asia, and will include a branch of the Harvard Medical School. Perhaps they hope to lure the market away from Singapore, currently the largest provider (along with India) of medical services for travelers from Middle Eastern nations. Thailand caters to American travelers and foreign nationals residing in Asia who are generally professionals who work for international companies and enjoy flexible, worldwide insurance plans. Bangkoks International Medical Center offers services in 26 languages and recognizes cultural and religious dietary restrictions. It has a special wing exclusively for Japanese patients (CBC, 2004). Eye surgery, kidney dialysis and organ transplantation are among the most common procedures sought by medical vacationers in Thailand. Of course, the Bangkok Phuket Hospital is the world leader for sex-change surgery, one of the top 10 procedures for patients visiting Thailand. South Africa has grown in prominence, offering cosmetic surgery and safari packages. Vigorous promotion specifically for medical tourism destinations exists. India is promoted in Germany and Air Mauritius in-flight magazines feature one of the five most advanced clinics in the world (Connell, 2006). Websites like ArabMedicare.com (http://www.arabmedicare.com/medicaltourism.htm) offer direct access to information on the top 25 hospitals in the Arab world as

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well as medical tourism topics and news geared directly to the medical tourist. Surgeon and Safari for South Africa and Antigua Smiles lure tourists while Gorgeous Getaways in Australia send clients to Thailand and Malaysia for cosmetic surgery (Connell, 2006).

Economic Scope
The economic scope of the medical tourism industry should not be underestimated. For Malaysia, health tourism, implemented in 1998 by the government has become the second largest income earner for the national economy (Chaynee, 2003). In India, medical tourism will become a US1$ billion dollar industry by 2012 (CBC, 2004) or it could become as much as a $2.2 billion dollar per year industry (DeMicco & Cetron, 2005). There are already a number of corporations in place there, such as Apollo Hospital Enterprises (CBC, 2004). This group treated an estimated 60,000 patients between 2001 and 2004. Some say 150,000 medical tourists visited India last year, mostly from Middle East and South Asian countries (Gupta, 2004). Others say more than 500,000 medical tourists will visit next year to receive some kind of treatment, usually in the form of package deals that include flights, transfers, hotel accommodations, treatment and a post-operative vacation. India offers open-heart surgery, pediatric heart surgery, dentistry, bone marrow transplants and cancer therapy along with the technological sophistication and infrastructure to maintain its market (DeMicco & Cetron, 2005). Nigerians spend about US$1 billion dollars per year abroad (Gupta, 2004). The American Baby Boom generation, about 220 million people, are increasingly seeking health care outside their nations borders. 50,000 people from the UK traveled for medical reasons in 2003 (Connell, 2006). In Thailand during 2004, 247,238 Japanese, 118,701 Americans, 95,941 British, and 35,092 Australians sought medical care (Connell, 2006).

Medical Tourist Motivations: Push Factors

One key reason that medical tourism exists today is because of problems endemic to the global medical paradigm, as it exists in industrialized countries. The rise of this medical paradigm, dominated by the United States has brought with the problems of high costs and differential access to treatment (Borman, 2004). There are two types of medical tourists. The ones described in this paper are residents of industrialized nations who travel to less developed destinations to receive treatment for certain conditions that may be too expensive or inaccessible at home. The other type of medical tourists are people who travel from less developed places to industrialized nations for the purpose of obtaining advanced care unavailable at home. These include pregnant women arriving in the UK on a holiday visa, knowing they will get free treatment, or business travelers bringing their partners or children with them and then

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suddenly discovering there is something wrong with them (BBC, 2003). This paper concerns the first type of medical tourist, those from industrialized countries. The other type is largely excluded in current research and reports concerning medical tourism as it carries a totally different set of implications. The major push factor for medical tourism is that rising health needs of an ageing population is generating demand for medical care outside the borders of industrialized nations. By 2015 the American Baby Boom Generations health demands will rise as 220 million people in North America, Europe, Australia and New Zealand seek medical treatment outside the boundaries of their own countries (Ross, 2001). In the United States, medical care is prohibitively expensive, and the health care industry is very complex and the same medical treatments can be received in other countries for a fourth to a tenth of the cost. Some claim that up to 80% of American health costs are associated with the paperwork necessary to support the complex bureaucracies of Medicare and Medicaid (Adams, 2005) and another big part of the expense is liability in terms of malpractice litigation. In addition to the high cost of medical care, it is estimated that in the United States, 43,000,000 people do not have medical insurance and 120,000,000 people have no dental coverage. Waiting lists for certain treatments are also getting longer and longer. In Canada and Britain, the waiting list for a hip replacement can be a year or more, but available immediately on demand in Bangkok (DeMicco & Cetron, 2005). The bottom line is that while the US might have the best health care in the world, most Americans get less of it per dollars spent. For dollars spent, the United States ranks very near the bottom of the list of all industrialized nations (Adams, 2005). The wildly escalating costs of medical care and exclusionary medical care systems in the United States and other industrialized nations are pushing people to travel elsewhere to seek treatment, in combination with a vacation. And this is becoming easier to do, as international travel becomes cheaper and more convenient while currency exchange rates remain favorable. Travel agencies are specializing in medical tourism for individuals and companies are arranging medical tours for their employees, including the scheduling of surgeries and the booking of flights, tours and activities as well as accommodations. Rapidly improving technology and standards of care are the results of the globalization that has produced a consumerist culture and the ability to buy any service, such as medical care, at any destination (Handszuh & Waters, 1997).

Motivations: Pull Factors

The major pull factors for medical tourism are cost-effectiveness and availability of services on demand in combination with the unique features offered at a destination. Open-heart surgery might cost $70,000 in Britain and up to $150,000 in the United States, but only $3,000 to $10,000 at one of Indias best hospitals. Knee surgery, both knees is about $17,000 in Great

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Britain but only about $7,700 in India (Gupta, 2004). Knee replacement with 6 days physical therapy runs one-fifth the cost of a similar treatment in the United States. Dental, eye and cosmetic surgeries are about one-fourth the cost in India compared with the West. A $5,500 dental bridge in the US is about $500 in India. A full face lift costs $20,000 in the US but is available for about $1,250 in South Africa (http://en.wikipedia.org/wiki/Medical_tourism). Eye surgery that costs about $20,000 in the US is available in many countries for about $730. Breast augmentation in Thailand costs about $2,000 including accommodation. In addition to low cost, medical tourists enjoy high quality care. Personalized care, favorable environments for recuperation and cultural sensitivity have made destinations like Thailand very popular for Japanese patients (CBC, 2004). For others, recovering after cosmetic surgery or other medical interventions, the privacy available at a remote location is valued. Destinations offering medical tourism services take measures to stress the quality of its professionals and facilities, including levels of hygiene.

DISCURSIVE ANALYSIS
The current understanding of medical tourism has been summarized in section three. Existing research and reports related to medical tourism detail specific destinations and markets, and focus on medical interventions available as well as cost comparisons. They also point out medical tourism travel motivations. However, medical tourism is not an autonomous industry it is a niche market. And as such, its position in terms of the medical industry and the tourism industry should be carefully evaluated. The following discursive analysis is a first step to developing a grounded theory for medical tourism, to provide a foundation for future empirical studies. Medical tourisms wider scope of influence in terms of the destination is provided, outlining major critical issues.

The Medical Industry

Most of the limited existing research on medical tourism, is concerned with the effects of tourism on destinations medical industries. This research also focuses on the conditions of the global medical industry in general. As previously described, the medical industry in industrialized countries is costly, complex and does not offer universal health care. Therefore, the industry itself is being exported, along with its patients. In this sense, the standards of accreditation and professionalism, quality of care and infrastructure find their way to developing medical destinations, improving the general consciousness of what quality medical care is all about (Tan, 2004). But even with an

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improved medical industry, travelers worry about malpractice, insurance coverage, and access to follow-up care. A rapidly improving medical industry combined with competitive prices draws ever-larger numbers of travelers to destinations. On the surface this appears to be good news for local economies. However, there are some potentially negative effects for the industry. Medical tourism reinforces a medicalised view of health care (Gupta, 2004). With business going to the provider who offers competitive prices with quality care, local and national comprehensive healthcare policies and the interests of local residents and citizens can be compromised (CBC, 2004). A local medical industry cannot adopt a strictly commercial approach to health care, nor cater exclusively to the medical tourist. The social problems of public hygiene, communicable diseases and the general health and life expectancy of the population are national concerns. Medical tourism can potentially have negative effects on the public health care system by drawing attention away from local concerns. In addition to the problem of public health care provision is the problem of the distribution of earnings from medical tourism to the local economy. Medical tourism is the exclusive domain of large specialist hospitals run by corporate entities, and profits earned seldom filter back down to the local level. These catering to the medical tourist hospitals should be responsible for treating a certain proportion of patients from the local population free of cost in return for receiving certain government subsidies. And a portion of earnings from medical tourism should be contributed to the local economy by means of taxes or contributions. Some also worry about the bandwagon effect, of every hospital trying to get access to the medical tourism market (Adams, 2005). Not all facilities are equipped to deal with the unique cultural expectations of patients, or even the language barrier. It requires a complex infrastructure of facilities and an educated staff to handle medical tourism.

The Tourism Industry

Less attention has been paid to the effects of medical tourism on the tourism industry, as it exists in certain destinations. In terms of spending and numbers of medical tourists, previous research describes the economic scope of this niche market, but the actual effects of medical tourism on the tourism industry is overlooked. It is unclear whether medical tourism has a direct effect on annual visitation numbers or average length of stay. It is also unclear exactly how much money is spent on accommodation, attractions, tours and other sectors of the local tourism industry. There is also little evidence of medical tourism having an effect on tourists existing destination image perception. However, some efforts are being made to market medical services in connection with local attractions: One Bombay hospital has considered the slogan, open your new eyes on the beach at Juha (Connell, 2006). South

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Africa has also maintained a seamless packaging of cosmetic surgery and safaris. Connell (2006) offers several examples of how hotels and hospitals have become horizontally integrated. It is yet to be seen if the medical tourism market niche will be able to contribute to the sustainability of a destinations cultural and environmental resources. The current resurgence of popularity concerning aboriginal, or world cultures along with the increasingly packaged eco-tourism and leisure sports experiences available at destinations have brought with them various positive and negative effects. Positive effects are mainly related to economic gains, but are also closely tied to raised awareness among policy makers regarding the value of their countrys or destinations cultural and natural resources. In the best of cases, income from tourism and other sources has filtered back to the resource, providing money for conservation, restoration, preservation and even education. It has also provided employment for local residents. In the worst of cases, it has led to conflict, overuse and misrepresentations largely associated with rampant commodification. A large concern regarding medical tourism should be its potential effect on destination image. In tourism, representations are used extensively in the form of brochures, guidebooks and postcards as well as travel narratives and descriptions that inform the tourist on how to enjoy a destination what to see, what to buy and what to eat. These representations convey the arrestive presentation of the culture, the ethnicity, and the race of Other (Hollinshead 1998: 149). Places and spaces are heterosexualized and racialized (Pritchard & Morgan 2001: 168) and even the landscape becomes a form of representation and not an empirical object (Rose 1993: 89). They reveal sites, attractions, landmarks, destinations and landscapes as spaces where a particular form of socio-cultural dynamics is negotiated (Pritchard & Morgan, 2000:167). At the same time they combine together to form an impenetrable discourse that directs expectations, influences perceptions and thereby provides a preconceived landscape for the tourist to discover (Weightman 1987: 230), commodifying destinations. Classic examples exist, such as The Kodak Hula Show (Buck 1993: 1) that positioned Hawaii as an exotic spectacle and how the Tasaday were created, made into a sign by the media, by science and by politics, to represent the permanent performance of a living and eternal Filipino folklore (Dumont 1988: 265). And it seems that medical tourism has already contributed some new representations, with Antigua Smiles and Gorgeous Getaways, making the medical tourist into a vain and self-indulgent type. This discursive analysis introduces the major implications of medical tourism for a destination in terms of its medical industry and its tourism industry. The major challenge for future research is to maintain a balanced perspective of medical tourism as a niche market, with implications for the larger issues related to the two industries between which it is positioned. Further horizontal integration between hotels and hospitals should be the key focus of future destination policy. In terms of the medical industry, medical

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tourism exports the industry, including standards of accreditation and professionalism, quality of care and infrastructure. Medical tourism contributes to an improved medical industry in developing countries. But with this comes the concern that hospitals will neglect the healthcare needs of local residents in favor of the medical tourist. In addition, there is the concern that earnings from medical tourism are not benefiting the local economy. In terms of the tourism industry, the social and economic effects of medical tourism are less clear. General figures are not yet available concerning visitation, length of stay or spending directly related to medical tourism. Also of great interest should be the effects of medical tourism on a destinations tourist image.

CONCLUSION
Medical tourism is a rapidly emerging global niche market. There is evidence that it has significant social economic effects and is both reinforcing and changing the medical and tourism industries at various destinations. However, the exact effects of medical tourism are largely unknown. In terms of sustainability, medical tourism can potentially be an important niche for any destination that is competitive in terms of price and services. Supervised, supplemental packages can lessen the load on valuable cultural resources while potentially generating more income for development and preservation purposes. Medical tourism can contribute to longer stays, more spending and more constructive interactions between hosts and guests (Hunter, 2000). Medical tourism can also contribute to loosening the stiff definitions of a destination by breaking down stereotypes and other representations. However, evidence from the discursive analysis (section four) suggests that there are a number of detrimental effects that medical tourism may produce for a destination, both in terms of its medical industry as well as its tourism industry. Medical tourism appears to be an economically significant niche market but at this point in time it is unclear just how much it will contribute to a destination. This papers major limitation is a lack of grounded theory regarding medical tourism. That limitation is addressed by a discursive analysis that defines the conceptual parameters of the research on medical tourisms effects, and suggests directions for future empirical research. With the scope of the medical tourism niche market described in terms of its history, economic scope and traveler motivations, and its potential benefits and drawbacks identified, researchers and policymakers can move forward with more focused and destination-based investigations. Implications for management and policy makers include the need for closer attention regarding the actual effects of medical tourism on the resources of a destination. Without proper intelligence, medical tourism can lead to an even

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more serious dehumanization between hosts and guests, exacerbating economic disparity and uneven distribution of wealth among those who reside at a destination. It can also contribute to maintaining cultural stereotypes and rigid representations through improper promotion and packaging. Medical tourism can also negatively affect the public healthcare system by re-channeling medical resources to the tourist. Implications for research suggest that medical tourism should not be regarded as a distinct market independent of other interests. Rather, researchers need to implement studies that evaluate the effects of medical tourism on a destination, especially in terms of economic distribution of benefits as well as potential contributions to social and environmental resources and the general sustainability of tourism. Research should be performed with the vision of a comprehensive information system to examine the effects of medical tourism on destinations cultural, natural and economic resources. The most important finding suggested in this paper is that there is a need for collaboration between managers and policymakers, and tourism researchers. Methods for horizontal integration between the medical industry and the tourism industry need to be developed that can ensure that the maximum benefits for destinations and travelers alike are realized through medical tourism. Destinations can implement action plans that detail systematic and comprehensive steps to implement policy that can develop its attractions in new ways, tying natural and cultural resources together with medical services.

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Submitted March 7th, 2006 Accepted May 27th, 2007 Referred anonymously