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Tourism Management 34 (2013) 1e13

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Tourism Management
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Current Issue in Tourism

Contemporary medical tourism: Conceptualisation, culture and commodication


John Connell*
School of Geosciences, University of Sydney, NSW 2006, Australia

h i g h l i g h t s
< Medical tourism is now seen as relatively short distance, cross border and diasporic.
< Medical tourism is of limited gravity despite cosmetic surgery dominating media discussions.
< Numbers are usually substantially less than industry and media estimates.
< Medical tourism companies integrated into the wider tourism industry.
< Culture, quality and availability of care inuence medical tourism behaviour.

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 3 February 2012
Accepted 21 May 2012

An overview is given of the short history and rapid rise of medical tourism, its documentation, and
current knowledge and analysis of the industry. Denitions of medical tourism are limited hence who
medical tourists are and how many exist are both indeterminate and inated. Denitions often conate
medical tourism, health tourism and medical travel, and are further complicated by the variable
signicance of motivation, procedures and tourism. While media coverage suggests long-distance travel
for surgical procedures, and the dominance of middle class European patients, much medical tourism is
across nearby borders and from diasporas, and of limited medical gravity, conicting with popular
assumptions. Numbers are usually substantially less than industry and media estimates. Data must
remain subject to critical scrutiny. Medical travel may be a better form of overall categorisation with
medical tourism a sub-category where patient-tourists move through their own volition. Much medical
tourism is short distance and diasporic, despite being part of an increasingly global medical industry,
linked to and parallel with the tourism industry. Intermediaries (medical tourism companies) are of new
signicance. Opportunities are diffused by word of mouth with the internet of secondary value. Quality
and availability of care are key inuences on medical tourism behaviour, alongside economic and cultural
factors. More analysis is needed of the rationale for travel, the behaviour of medical tourists, the
economic and social impact of medical tourism, the role of intermediaries, the place of medical tourism
within tourism (linkages with hotels, airlines, travel agents), ethical concerns and global health
restructuring.
2012 Elsevier Ltd. All rights reserved.

Keywords:
Medical tourism
Medical travel
Procedures
Typology
Diaspora
Tourist numbers
Marketing
Multinationals
Thailand

1. Introduction
Medical tourism (MT), primarily a late twentieth century
phenomenon, is said to have recently and rapidly boomed. This
paper assesses the parallel boom in academic analysis. Numerical
data on MT are inadequate and unreliable (e.g. Hopkins, Labont,
Runnels, & Packer, 2010; Johnston, Crooks, Snyder, & Kingsbury,
2010) being based on industry optimism and boosterism rather
than rigorous analysis. Signicant cross border movements for
health care (including diasporas and institutional transfers) are
* Tel.: 61 (0)2 9351 2327.
E-mail addresses: john.connell@sydney.edu.au, jconnell@mail.usyd.edu.au.
0261-5177/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tourman.2012.05.009

conated with accidental and expatriate health care, yet developing a rigorous denition of MT poses problems. This paper seeks
to ll this analytical gap and draw attention to those that remain.
The second part analyses recent trends in MT, and the implications
of contemporary change, and argues for greater analysis to be given
to decision-making, the role of intermediaries (medical tourism
companies) and the place of MT within both tourism (linkages with
hotels, airlines and travel agents and tourist performativity) and
global health restructuring.
Travel for medical care (and wellbeing) has long existed.
Destinations, such as Harley Street in London, are famous as
international centres of medical care. Yet in the last two decades
a form of reverse globalisation has occurred with patients from

J. Connell / Tourism Management 34 (2013) 1e13

more developed countries travelling for medical care to less


developed countries, for a combination of reasons involving cost,
access, service and quality, overturning implicit notions of the
territoriality of health care. Jenner (2008) emphasises distant
locations, which is the assumption of most popular media coverage,
however Ormond (2008) recognised most MT destinations as
backyards, close to source countries, but with some more distant
playgrounds. This reverse global ow is usually seen to be the
basis of MT, though international mobility for medical care is more
diverse and complicated, notably in its cross-border and diasporic
component.
MT is said to have grown explosively since the late 1990s with
thousands of patients moving to countries such as India, Thailand
and Mexico, in search of medical care usually deemed too expensive, inadequate or unavailable at home. Ironically the rst account
of what has become a phenomenon imbued with capitalism,
entitlement, individualism and self-fullment was of Cuba
(Goodrich & Goodrich, 1987). Multiple studies have subsequently
documented the rise of Asian, European and Latin American
destinations, as their economies have diversied and built on
existing tourism industries and health care systems (e.g. Bookman
& Bookman, 2007; Connell, 2006, 2008; Reisman, 2010). Increasing
numbers of countries have enthusiastically marketed themselves as
MT destinations, hundreds of medical tourism companies (MTCs)
have become travel agents, brokering and facilitating medical
travel, and extraordinary claims have been made for numerical
growth, especially by industry participants and destination countries (Connell, 2011a). However no national data or denitions of
MT exist, hence there has long been scope for exaggeration and
journalistic hyperbole. At least four basic issues remain unresolved:
what is MT, who are the medical tourists (MTS), how many of them
are there and what impact do they have? This paper seeks to
contribute to some resolution of these questions, review recent
analyses of trends in medical tourism and point to future directions.
What might be regarded as medical tourism is far from obvious,
and exaggerated statistics blend into marketing strategies and
success stories, notably in journalistic contexts where hospital and
national estimates are unquestioned. Consequently estimates of
market shares and revenue are equally problematic (e.g. Heung,
Kucukusta, & Song, 2011). By denition almost every ofcial
gure is awed. They are often badly collected, imperfectly collated
and spun to innity. Some hospitals inate gures by counting the
number of patient visits rather than the number of patients
(Youngman, 2009; see also Pollard, 2010). One overview found
a lack of hard data on the magnitude of medical tourism, with
anecdotes, brokerage claims, and theoretical conjectures
substituting for more deliberative study (Hopkins et al., 2010: 194;
see also Glinos, Baeten, Helble, & Maarse, 2010). Some national
data, like that of the UAE, are so inated that even industry analysts
disregard it: the claimed medical tourism gures are so exaggerated as to be pure fantasy (Youngman, 2010a). Without arrival and
departure cards there are no reliable and comparable international
data on cross-border medical travel. Most data that are touted as
measures of numbers, growth and economic impact are anecdotal,
yet such data have largely eluded detailed analysis since MT is
competitive and partly clandestine.
2. Medical tourism
Most accounts of medical tourism use it as an umbrella term
where improved health is a key component of travel overseas, and
involves invasive procedures (and also medical check-ups), rather
than the more passive processes of health and wellness tourism.
Many accounts assume a denition, others are minimalist and
undeveloped, such as that of Bookman and Bookman (2007: 1)

international travel with the aim of improving ones health,


Wikipedias current travelling across international borders to
obtain health care (2012) or, more elaborately, the organized travel
outside ones local environment for the maintenance, enhancement
or restoration of an individuals wellbeing in mind and body
(Carrera & Bridges, 2006: 447). One industry perspective is similarly brief: patients travelling to another country for more affordable care, or care that is higher quality or more accessible (Edelheit,
2008: 10). Others, such as Reisman (2010: 1), circumvent any
denition preferring the less emotive global medical care. Still
others have chosen bland formulations such as the act of travelling
abroad to obtain medical care (Cormany & Baloglu, 2011). Another
claim has been for international travel deliberately linked to direct
medical intervention, and [where] outcomes are expected to be
substantial and long-term (Connell, 2006: 1094). Most denitions
have sought to distinguish medical tourism from health tourism
e seen to be primarily concerned with low-key, therapeutic
and non-invasive procedures e while allowing the inclusion of
dentistry and check-ups, since that might lead to medical
intervention.
Some denitions emphasise intent. Johnston et al. (2010: 1)
refer to patients leaving their country of residence outside of
established cross-border care arrangements made with the intent
of accessing medical care, often surgery, abroad. Lunt and Carrera
likewise restrict the denition of medical tourist to patients who
are mobile through their own volition (2010: 27). Thompson
(2008, 2011) distinguishes medical tourists as empowered
biosocial citizens in contrast to medical migrants, who are diverse,
but regulated through institutions, rather than making personal
decisions. MTS may therefore be seen as patient-consumers:
a more medical term. All these denitions exclude those who are
effectively sent abroad for necessary care by health agencies (such
as hospitals, insurance companies and government referrals)
perhaps as an outcome of long waiting lists, a lack of available
specialists or unavailable skills and facilities. MT is then both narrowed to what is elective and discretionary, and thus primarily selffunded, unlike formal cross-border institutional transfers such as
those within the EU, but expanded into a wider, more diverse and
more nuanced phenomenon (Glinos et al., 2010: 1146). However
the diversity of patient motivations for overseas treatment within
Europe e availability, affordability, familiarity and perceived
quality e are also those that inuence this broader spectrum of MTS
(Connell, 2011a; Laugesen & Vargas-Bustamante, 2010).
Other than in nomenclature tourism has largely been absent
from formal discussions of international medical travel. However
Jagyasi prefers the set of activities in which a person travels often
long distance or across the border, to avail medical services with
direct or indirect engagement in leisure, business or other
purposes (2008: 10). Similar perspectives include: a vacation that
involves travelling across international borders to obtain a broad
range of medical services. It usually includes leisure, fun and
relaxation activities, as well as wellness and health-care service
(Heung, Kucukusta, & Song, 2010: 236) and the blending of tourism
and medical treatment for both elective and necessary surgical and
medical procedures as well as for dental procedures (Jenner, 2008:
236). Hopkins et al. take a broadly similar perspective on blending
medicine and tourism: cross-border health care motivated by
lower cost, avoidance of long wait times, or services not available in
ones own country. Such care is increasingly linked with tourist
activities to ease foreign patients into a new cultural environment
and to occupy them during the pre- and post- operative periods
(2010: 185).
A continuum exists from health (or wellness) tourism involving
relaxation exercise and massage, cosmetic surgery (ranging from
dentistry to substantial interventions), operations (such as hip

J. Connell / Tourism Management 34 (2013) 1e13

replacements and transplants), to reproductive procedures and


even death tourism. Health and wellness tourism are usually
differentiated as being too soft and trivial to be MT, and are the
subject of a distinct literature (Smith, & Puczko, 2009). The word
medical is said to mean illness, disorder or injuries (Jagyasi, 2008)
but this covers multiple possibilities, from psychiatry to stem cell
procedures, not all of which require procedures. Are there then
distinct (medical) tourism procedures? Is there a pain threshold
that differentiates medical procedures from health and wellness,
and where any notion of tourism as pleasure is implausible? Thai
massage may be scarcely less painful or invasive than teeth whitening; by contrast transplant tourism is far removed from what
may immediately be pleasurable. Tattooing, never regarded as
a medical procedure, despite its cosmetic undertones, is more
painful and invasive than many forms of treatment usually
subsumed under MT (and is often undertaken overseas). Dental
tourism has sometimes been excluded from denitions of MT
(Pollard, 2011) or distinguished as a separate category (Turner,
2008). Vast numbers of media accounts have depicted medical
tourism as centred on cosmetic surgery.
3. Pain and procedures
Procedures are often implicitly linked to durations. Procedures
that take less than a day e such as audiology and dentistry, that are
not medical and do not involve hospitalisation e tend to be
excluded as drop-in procedures (which is how many are advertised in tourist publications) though may be the primary intent of
the international travel. Pain and outcome are implicit in some
approaches. Certain conditions exist where any sense of tourism
(associated with pleasure, frivolity, relaxation or education) is
nonsense, with patients so weak or incapacitated afterwards that
any semblance of tourism is impossible and the notion would be
regarded as demeaning.
The concept of tourism complicates analysis, implying something deliberately chosen as pleasurable (though it might also be
challenging and educational) but MT literature usually excludes
tourist behaviour and expectations. Certainly broad notions of
tourism t poorly, and are widely rejected, in procedures associated
with desperation, last resort and heavy nancial liability. Where
insurance cover is limited or local services unavailable, so that the
most vulnerable individuals, rather than more afuent individuals
travel overseas, but not because it is a luxury or choice (Kangas,
2007; Laugesen & Vargas-Bustamante, 2010: 1) or where patients
travel for such extreme interventions as transplants and stem cell
treatments, tourism seems absent or inappropriate. A rapidly
growing body of literature (e.g. Song, 2010; Turner, 2007b) has
focused on international travel for such challenging procedures,
which also raise ethical issues and where the word tourism is used
wholly ironically. Whittaker similarly sees medical tourism as
a misnomer, carrying connotations of pleasure not always associated with this travel, and blurs distinctions between desperately ill
people [and] more discretionary travel (2008: 272). Song regards it
as implying a frivolity that renders it a problematic term [for]
patients who often feel enforced to travel in order to seek the
medical care they desire or need (2010: 386). There is little touristic intent in institutional mobility and desperation, however
benecial the outcome.
Value judgements are implicit. Milstein and Smith (2006),
describing the plight of seriously ill Americans who receive
treatment at overseas hospitals because they cannot afford
domestic care, even deride medical tourists as those who seek
low-cost aesthetic advancement. Likewise Kangas (2010: 350;
2011) rejects outright any designation of tourism for impoverished
Yemeni travellers similarly desperately seeking care, as Yemenis

themselves do, since the term suggests leisure and frivolity [and]
promotes a marketplace model that disregards the suffering that
patients experience, so trivialising the experience. So-called
maternity tourism or citizenship tourism where expectant
mothers cross borders (for example from China to Hong Kong and
Nigeria to the United States) to have anchor babies in more
developed countries (e.g. Erbe, 2011; Gilmartin & White, 2010) have
few touristic characteristics. Long-staying reproductive tourists
and those in search of stem cell cures see their travels as more akin
to exile or pilgrimage, or at least holiday-exile (Inhorn, 2011a,
2011b; Inhorn & Patrizio, 2009; Matorras, 2005; Song, 2010).
Clandestine cross-border and refugee movements for health care,
such as from Papua New Guinea to Australia, and from Burma to
Thailand, are particularly problematic (Connell, 2011a) with
patient-consumers effectively outsourcing themselves, again with
no obvious resemblance to tourism. From this general perspective
Kangas (2010) opts for either medical travel, medical care abroad
or treatment abroad. Yet, though not conventionally seen as MTS,
and sometimes with little individual volition, many such people
engage in somewhat similar travels and experiences.
Some components of the medical industry also regard MT as too
frivolous a term. In the words of one plastic surgeon: 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 (Nahai, 2009: 106).
Destination hospitals focus on high-quality care, reliability and
competence, although other institutions, including the facilitating
MTCs and destination countries, seek to emphasise normal touristic elements, such as shopping, dining and hotel facilities, to stress
that the experience will be pleasurable. Some recuperation is
usually possible, and a journey with a serious purpose can have
a frivolous, pleasurable and celebratory ending. Tourism offers
added value. One industry analyst has argued that the industry
should be working to get medical tourism counted as a niche
tourism sector (Youngman, 2010b). However it is extremely difcult to differentiate MT according to the procedures involved, their
morality and necessity and the social and economic characteristics
associated with them in different national contexts.
4. A detour around diaspora
From a primarily Thai perspective, it has been argued, that even
the idea of medical tourism creates assumptions about race nation
and class, with the emblematic medical tourist a wealthy white
western or East Asian tourist who combines cosmetic surgery with
a beach holiday (Whittaker, 2009: 323). Such assumptions are
enhanced in the generally available statistical data, and much
promotional material (especially websites) within marketing
strategies. Countries and institutions seek afuent patients of
European origin, hence there is a focus on whiteness where
patients appear to be of European origin and, in some destinations
such as Argentina, Mexico and the Philippines, staff too are
depicted as white. However growing recognition of the signicance
of diasporic tourism challenges assumptions about whiteness,
long-distance travel and the meaning of MT. Diasporic tourism is
a widely recognised phenomenon (e.g. Basu, 2004; Coles &
Timothy, 2004) and it has become a distinct component of MT,
although most such returnees probably travel for a multiplicity of
reasons.
Much international medical travel is of overseas diasporic
populations, notably Mexicans in the United States and a more
global Indian and Middle Eastern diaspora. In some countries
return migration for medical care contributed to the genesis of
a wider MT. Patients return home because they are likely to be
comfortable and familiar with the health system, the language and

J. Connell / Tourism Management 34 (2013) 1e13

broader cultural context, and costs may be signicantly cheaper, as


in Mexico (Horton & Cole, 2011; Macias & Morales, 2001; Wallace,
Mendez-Luck, & Castaneda, 2009). In some cases, as in the return
mobility of Koreans from New Zealand and British migrants from
Spain (La Parra & Mateo, 2008; Lee, Kearns, & Friesen, 2010),
cultural factors are particularly signicant since no economic
rationale exists. Similarly second generation overseas migrants,
including Arabs and Indians, move for medical care into an
appropriate cultural context. (Only in India does that apparently
include signicant alternative medical procedures.) MTS also
travel to destinations with comparable cultures, so that the
predominantly Islamic state of Malaysia has become a destination
for medical tourists from Indonesia and the Gulf.
Diasporic tourists may not be travelling to distant places. Some
of the largest ows of cross-border travellers are diasporic, to
backyard rather than tourist destinations (Ormond, 2008). In
India, Jordan, Mexico, Turkey and the Philippines, overseas
nationals are a signicant proportion, perhaps a majority, of MTS
and that may also be true in Colombia, Taiwan, Iran, Lebanon, Malta
and elsewhere (Connell, 2011a; Glinos et al., 2010). At least 22% of
medical tourists in India are Non-Resident Indians (NRIs), from
many countries, alongside second-generation overseas Indians
who are not classied as NRIs. A further 19% came from neighbouring countries, Bangladesh, Nepal and Sri Lanka, where cultures
are similar, and 43% from Afghanistan and the Middle East. Just 10%
were of United States and European ancestry (IWHTA, 2010).
Much medical travel, in Europe, Thailand, India, Singapore and
elsewhere, is across nearby borders, to neighbouring countries with
similar (or complementary) facilities and cultures, and where travel
costs are minimised. International medical travel is thus more
regional than global, with the relatively poor likely to travel shorter
distances (Connell, 2011a). Kangas (2010) thus distinguishes
transnational or international for journeys to destinations
beyond neighbouring countries, and reserves cross-border for
travel to adjoining countries, arguing that selecting a transnational
treatment destination involves more than a cross-border one
(2010: 353). In practice there may be little difference between
them.
5. Medical tourism or medical travel?
Denitional problems, the signicance of the diaspora (and the
desire to market MT), have made attempts to differentiate MTS
from other tourists or patients rare, partly because of the problems
outlined above, but also because practitioners have no need or
interest in doing so. Based on Thailand, Cohen has suggested
a fourfold classication: medicated tourists (who receive treatment for accidents or health problems that occur during an overseas holiday), medical tourists proper (who visit a country for
some medical treatment, or who may decide on a procedure once
in a country), vacationing patients (who visit mainly for medical
treatment, but make incidental use of holiday opportunities,
usually during the convalescence period) and mere patients (who
visit solely for medical treatment, and make no use of holiday
opportunities). There are also mere tourists who have no overseas
medical treatment of any kind (Cohen, 2008: 227). Cohen argues
that most of the literature covers vacationing patients and mere
patients, where the medical component dominates, and hence
prefers the term medical travel arguing that the recreational
component is slight for these two categories. In practice mere
patients probably refers only to very short duration travel, such as
for some dentistry, and no literature discusses this. The two categories said to be covered by most of the literature here become
medical travel whereas medical tourism occurs where treatment
is only decided upon belatedly and procedures are low-key.

Balancing tourism, medical care and also intent is difcult. Most


other denitions have started from the notion of deliberate
movement for medical care across international borders, and thus
similarly exclude both medicated tourists and resident expatriates
(including retirees). Intent rather than procedures or duration are
the dening characteristics. Pollard (2010) thus denes a medical
tourist as someone whose specic reason for travelling to another
country is medical treatment, thus paralleling the criteria used in
the inuential McKinsey Report on the MT industry. The McKinsey
report suggested that the number of medical tourists in 2007 was
between 60,000 and 85,000. That excluded medicated tourists,
expatriates and wellness tourists travelling for massages or
acupuncture, and also excluded patients who travel in largely
contiguous geographies to the closest available care so excluding
substantial cross-border mobility. Omitting such groups revealed
that the largest single segment, with 40% of MTS, were patients
seeking high quality care in destinations like the United States and
who mainly came from the Middle East and Latin America. The
second largest segment (with 32% of MTS) were those seeking
better care than they could receive in their less developed home
countries. Three remaining segments included those avoiding long
waiting times, and those seeking lower costs for necessary or
discretionary procedures (Ehrbeck, Guevara, & Mango, 2008). It
thus challenged basic assumptions about the main MT categories,
and that destinations were mainly in developing countries, though
the McKinsey report did not explain how their numbers were
derived and segmented.
Industry commentators criticised the assumptions and denitions of the McKinsey report, and its exclusion of non-JCI (Joint
Commission International) accredited providers, patients who
were not in-patients (including many dental and cosmetic surgery
patients) and cross-border migrants, and argued that MTS numbers
were more likely to be a conservative estimate of over 5 million
(Youngman, 2009). However this total included an unspecied
number of wellness tourists, on the grounds that their objectives
were no different from those of other medical tourists, and
accepted largely uncritically various country estimates. 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). No methodology was stated but the report was much
welcomed in the industry. A subsequent study of United States
MTCs concluded that industry estimates were invariably inated
and numbers were more likely to be in accord with the McKinsey
report, although they excluded dental tourism (Alleman et al.,
2011).
Combining notions of intent, procedure, and duration suggests
a more complex, somewhat hierarchical structure and typology of
medical tourism with ve overlapping but necessarily crude categories. Firstly, elite patients travel from many regions, including the
Gulf, to places like London, New York and Berlin for exclusive and
costly medical treatment, continuing a century long tradition.
Secondly, rising numbers of patients, many part of the emerging
global middle class that Bookman and Bookman (2007: 54) called
a second tier of wealthy patients, travel for cosmetic procedures,
and have contributed to the emergence of Latin America and Asia as
destinations. Others move for cheaper and necessary services, for
example when their insurance is inadequate. These are the subject
of most of the literature, the targets of MT guidebooks and websites
and the popular conception of MTS. Indeed cosmetic surgery is the
popular image of MT (often non-essential, from entitlement rather
than necessity). Those who are referred by national governments,
usually not travelling for cosmetic procedures, may also be included
here. Thirdly, there are diasporic patients, of diverse socioeconomic status, from relatively afuent Maltese and Koreans to

J. Connell / Tourism Management 34 (2013) 1e13

less afuent Mexicans, returning to their home countries for


different combinations of political, economic, cultural and health
reasons. Their numbers are much greater than, by omission, most
literature implies. Fourthly, there are cross-border patients (who
include many diasporic patients), a long-established group in
Europe (e.g. Guerrieri, 1985) who may be seeking cheaper, quicker,
more culturally sensitive or reliable care across a nearby border.
Some such travellers are clandestine; others are regulated by
national health services. Fifthly, there are reluctant and even
desperate medical tourists, such as those from Burma or Yemen,
moving at considerable personal cost, and those from developed
countries seeking last resort or nationally unavailable health care.
Like all other categories they would have preferred cost-effective
local treatment.
Medicated tourists and resident expatriates have been
excluded from each of these categories. This typology is arbitrary
and not homogeneous, especially without reliable data. Geography
complicates classication; all other categories of MTS may also be
cross-border travellers. Flows are multidirectional; in middle
income countries elites may leave as others move in, while in high
income countries low and middle income earners may leave as
other elites move in. A geography of the body, income, culture and
language inuence choice of destination for different procedures.
Preferred destination hierarchies exist in most countries, inuenced by costs and procedures, hence ows frequently change (e.g.
Kangas, 2002). Some procedures are trivial and others life-saving,
relationships with standard tourism differ, and rights in destinations vary, but this differentiation is both suggestive of real
distinctions between MTS, while indicative of the denitional
problems.
No agreed denition of MT therefore exists and no loose
umbrella term is wholly adequate. Agreed denitions are unlikely
because of problems in combining intent, procedure and duration,
the diverse socio-economic and institutional structures of mobility,
disagreements over the nature of tourism and leisure, and the
amount of time and resources allocated to particular activities. In
circumstances where international travel for broadly medical
reasons is apparently increasing, but estimated numbers uctuate
wildly, a standard denition would be valuable. Objections to the
term tourism rather than travel centre on intentionality and
procedure, yet even where travel overseas is for crucial medical
care, signicant nancial resources are required, and the experience is scarcely pleasurable, medical travel is not simply business
travel, being less purely functional because of the need for some
recuperation (and with most MTS being accompanied). Many MTS
intend to and do engage in some standard tourist activities with
associated expenditure (and, more so, those who accompany
them), hence MT is sometimes welcomed (but less often perceived)
as a niche in the tourism industry.
Conceptualising all cross border mobility for medical care as
medical travel rather than medical tourism provides an umbrella
term that avoids value judgements over intentionality or the gravity
and necessity of procedures. Medical tourists proper and
vacationing patients are the core of medical tourism, where some
prior intentionality exists. Health and wellness tourists can be
excluded because of the absence of medical procedures, but there
is no valid reason to exclude dentistry, audiology, cosmetic surgery
or check-ups, even where procedures are limited. Ultimately there
is a very diverse market segmented by purpose, complexity and
type of care, and cost (Ramirez de Arellano, 2011: 290), where
differentiation is difcult, and adequate data are absent. Any denition, however valid in particular circumstances, is unlikely to be
universally useful, given the diversity and ambiguity of cross-border
medical mobility, but that is unimportant as long as distinctions and
denitions are claried. Unresolved conceptualisations of MT

intersect with parallel debates over tourism, where tourism is not


necessarily trivial and frivolous (Bell, Holliday, Jones, Probyn, &
Taylor, 2011). Thus MT parallels tourism itself where this is seen
as a hybrid economic formation blending different industries, the
state, nature, the informal sector, the capitalist and non-capitalist
economies, and all manner of technologies, commodities and
infrastructures (Gibson, 2010: 529). Yet, ultimately, and crucially,
rigorous application of any denition is unlikely to result in
numbers comparable with those touted by the industry.
6. Notes on numbers: dilemmas of quantication
Without denitions most of the numbers attached to MT,
whether on ows, growth rates or income generated, are speculative, based on estimates, remarkably rounded (upwards) and
optimistic. Numbers are complicated by diaspora patients, expatriates within countries, short term drop-ins, spa visitors,
purchasers of pharmaceuticals and friends and relatives accompanying patients (Connell, 2011a; Youngman, 2010a). No countries
produce ofcial data on medical tourism, since they have no means
of collecting them, and no hospitals release data veried by an
independent body. The numbers stated by some countries and
hospitals are substantial exaggerations, but inated gures imply
growth and success, and encourage private sector investment and
national support.
Focussing on one country e Thailand e a leading player in MT
(and where diasporic MT is unimportant, since relatively few Thais
reside overseas), and one key hospital, indicates how numerical
discrepancies exist and how some data correction is possible. MT in
Thailand covers many procedures from dentistry to cardiac surgery
and transplants to gender reassignment. Medical procedures are
linked in advertising to standard forms of tourism. By 1997 Bumrungrad International Hospital in Bangkok was the largest private
hospital in south-east Asia, and the rst JCI accredited hospital in
Thailand, with a staff of 950 full or part-time doctors. After the
Asian nancial crisis it aggressively targeted overseas clients,
placing advertisements in in-ight magazines, encouraging travellers on the national airline Thai Airways to use frequent yer
miles for executive physical examinations and offering various
discount packages. The hospital was redesigned, with executive
suites, to be more like a luxury hotel.
By the late 2000s Bumrungrad claimed to serve more than 3000
patients a day, to outperform other hospitals in the region and be
perhaps the worlds rst truly international hospital (Bumrungrad
International Hospital, 2009: 1). It was said to have treated 360,000
foreigners in 2005, as the hospital for the rst time had over
a million patients in a calendar year. Since then Bumrungrad has
been reported many times as having about 400,000 overseas
patients a year (Connell, 2011a). That claim was made in 2008,
when Thailand itself claimed some 1.4 million foreigners visiting
for medical treatment. By 2009 it claimed just over 1 million
patients, of whom 400,000 were international patients, the
reduction in numbers being attributed to the GFC and local political
conict. Dominating the front of its home web page, Bumrungrad
claims to annually serve patients from over 190 countries, virtually
all the 192 members of the United Nations.
Bumrungrads public data are based on outpatient visits (in
which most procedures are completed within a day, hence doublecounting is limited) and admissions (recorded once however long
a patient may stay). Most patients come from South East Asia,
mainly Thailand itself which accounts for about 600,000 of all
patient visits, few of whom are diasporic. Otherwise by far the most
important source region is the Gulf. Of the approximately 407,000
patients who are not Thais, about 100,000 are local expatriates and
around 100e120,000 are medicated tourists from in and near

J. Connell / Tourism Management 34 (2013) 1e13

Thailand. Some of these (especially expatriates) visit more than


once a year hence the absolute number of such patients is less than
100,000. The remainder, around 200,000, constitute what Bumrungrad distinguish as y-in medical tourists. Almost all those
from the Gulf (almost half this total) are genuine medical tourists,
arriving specically for some procedure, as are the smaller numbers
from China and Japan, whereas American, European and Australasian patients are more likely to be medicated tourists than longdistance travellers. Bumrungrad states that the three highest
revenue contributors by country continue to be the United Arab
Emirates, the United States and Oman (Bumrungrad Hospital
Limited, 2010: 59; my italics). A signicant number of patients
cross regional international borders, notably from Vietnam,
Cambodia, Burma and Bangladesh, while the remainder of the MTS,
about 50,000, are from distant, more developed countries in
Europe, North America and Australasia. Comparable data from the
Bangkok Phuket Hospital have a similar structure (Connell, 2011a).
This procedure could equally be applied elsewhere, were data
available and accessible. It reveals that the actual number of
genuine intentional MTS specically travelling to Thailand (and
probably also elsewhere) for medical treatment is lower than
suggested in most existing estimates, including those of Thailand.
The closest examinations of MT data consistently reveal that
numbers are fewer than usually publicised, accord with recent
analysis of American source numbers (Alleman et al., 2011) and
offer further support for the smaller numbers of the McKinsey
report.
7. Neo-liberalism, entrepreneurialism and tourism
Contemporary MT is a function of the growing privatisation and
commodication of health care, where the ability to pay has
become the key to obtaining medical care, discontent with public
care (waiting time, efciency and outcome), ageing populations
and greater demand for health care (especially cosmetic procedures), more disposable income, greater familiarity with distant
cultures and regions, international accreditation of facilities, and
diversication of economies in middle income economies in Asia,
Europe, the Middle East and Latin America (in the Asian case in the
wake of the late 1990s nancial crisis). As technology has improved
and diffused, and ethical boundaries stretched, the range of
procedures has increased and diversity ensued. Some countries,
like Singapore (and the US and the UK), have become both MT
sources and destinations, 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 & Rosensweig, 2008: 8). In a neo-liberal era of
greater competition, free markets and deregulation MT is seen,
especially in India, as a form of medical outsourcing, analogous to
the IT industry.
The greatest beneciaries of the global restructuring of medical
treatment have been a few countries, which have experienced
economic growth, technological change, return migration of skilled
health workers, the growth of a middle class (who have demanded
superior health care) and are major international airline hubs.
Increased numbers of expatriates and the new middle class
provided markets for private sector hospital growth and subsequent MT. While such factors were broadly positive the rise of MT
was also a response to the Asian nancial crisis of the late 1990s.
Subsequent years, as Asian countries sought alternative sources of
economic growth, coincided with the expansion of MT and the
privatisation and business orientation of the medical industry. The
crisis destroyed the savings of much of the emerging Asian middle

class, who could no longer pay for private health care, hence private
hospitals lost their customer base and revised their marketing
strategies to target overseas patients, for whom devaluation meant
that prices effectively halved (Turner, 2007b). Malaysia and
Thailand both became involved after 1998. India entered the MT
market rather later than south-east Asia but developed rapidly with
shifts in technology and the development of sophisticated hospital
chains. Entrepreneurial governments have become supporters and
promoters, through national development planning and tourism
campaigns. In India, Malaysia and Thailand, tax concessions were
given to MT providers and tourism ofce campaigns for MT,
alongside subsidies for land purchases and infrastructure (Alsharif,
Labont, & Zuxun, 2010; Chee, 2010; Gupta, 2008; Wilson, 2011).
Asian successes have prompted growing global interest and
competition, with optimism both unbounded and often unfounded.
Difcult political situations, high costs, poor infrastructure,
language differences, unfamiliarity and overstretched medical care
systems are constraints in several countries (Heung et al., 2011).
While MTS ows have become more complex and multidirectional,
Asia is likely to continue to dominate the industry.
MT has parallels with and links to the wider tourism industry.
Marketing is undertaken through websites (of hospitals, national
tourism organisations and MTCs) and distinctive MT guidebooks.
Diaspora tourists are loosely familiar with what is available at
home and many rely almost entirely on word of mouth or good
luck, depending on the gravity of the procedure. Most MT guidebooks were published in the mid and late 2000s and have not been
updated, as the internet has taken over. Although the internet has
become crucial to marketing it only dominates in surveys of groups
of people who are not necessarily intending to be MTS (e.g. Gill &
Singh, 2011) or where a medical tourism industry is being established (Ye, Qiu, & Yuen, 2011). A 2009 survey of an unknown
number of international patients at Bumrungrad revealed that
most learned about medical tourism through friends, and very few
through books and the media, with a quarter of Bumrungrad
patients using the internet for information on country destinations
and hospitals (Anon, 2010). Further studies have shown that the
main inuence on the majority of MTS at Bumrungrad and 60% of
those in Kuala Lumpur hospitals was advice and referrals from
friends and family (Musa, Thirumoorthi, & Doshi, in press;
Veerasoontorn, Beise-Zee, & Sivayathorn, 2011). In a general survey
of MTS, with no information on methodology or sample size, 49%
found out about MT through the internet and 73% sought specic
information on the internet, as opposed to through friends, books
or MTCs (Anon, 2009). In Oman more than 70% of medical tourists
got their information from friends and a further 19% from family
(Al-Hinai, Al-Busaidi, & Al-Busaidi, 2011). Asians (or at least
Chinese, Japanese and Koreans) preferred recommendations from
friends rather than the Internet (Yu & Ko, 2012), and in a large
sample of MTS in four different destinations almost half (45%)
learned of opportunities through friends, relatives and colleagues,
followed by internet advertising (Alsharif et al., 2010). As MT
evolves word of mouth appears to be becoming more important,
with the internet simply a means of checking, corroborating and
booking. How people use the internet, which websites they visit
(whether of MTCs, hospitals or countries) and how they assess the
information is largely unknown. Whether a digital divide
discriminates against potential users in some places is similarly
unknown (Lunt & Carrera, 2010).
The growth of MT has been accompanied and reciprocated by
the rise of medical tourism companies: medical travel agencies
(Sobo, Herlihy, & Bicker, 2011) or virtual brokers (Solomon, 2011).
Rather more scathingly, Turner described them as the car dealerships of the global health-services industry (2007a: 127), beyond
the bounds of ethics or duciary duty, but they are little different

J. Connell / Tourism Management 34 (2013) 1e13

from most travel agents. Indeed MTCs work like specialized travel
agents (Herrick, 2007: 6), some with branches in different countries and with afliations to hospitals, hotels and airlines. Almost all
were established in this century, but most are reticent about their
history, and many have been short lived (Cormany & Baloglu, 2011;
Turner, 2011). Hundreds of MTCs exist in both source and destination countries; Reisman suggests almost 1000 niche facilitators
(2010: 70) while Treatment Abroad has a directory of 820 registered companies.
Most MTCs are small. In the United States MTCs had a mean of
9.8 employers, substantially larger than elsewhere (Alleman et al.,
2011), whereas in Australia, MTCs focused on cosmetic surgery,
were mainly owned by women who had been cosmetic surgery
recipients themselves, hence had personal links with the industry,
promoting their work as a service rather than an industry, and with
few if any employees (Ackerman, 2010; Bell et al., 2011; Jones,
2011). Several larger MTCs have operations spanning the source
country and sometimes multiple destinations. Some MTCs take
a more or less global perspective on the provision of medical
tourism, but most MTCs limit themselves or are limited to particular markets, destinations and procedures e usually about four
destinations e where they claim specialist knowledge, and can
claim to vouch for reputation and experience (Peters & Sauer, 2011).
MTC websites have multiple linkages to countries, hospitals and
clinics, patient stories and testimonials (sometimes in videos),
press reports, virtual tours of particular facilities and interactive
sections for obtaining quotations. All are commercial sites,
complete with advertisements and linkages, for insurance, hotels,
travel companies, sources of nance and related MTCs. Such sites
raise awareness, create a perceived need, offer multiple possibilities, stress benets, emphasise normality, refer to pleasant tourism
components and encourage potential patients to enquire further.
The MTC websites emphasise hospital accreditation and the
pragmatics of international travel, with United States sites
providing more detail on what is likely to be an exceptional experience; all stress affordable, timely, high-quality, reliable care with
the latest technology (Cormany & Baloglu, 2011; Lunt & Carrera,
2011; Sobo et al., 2011; Turner, 2011). Few mention any actual
risks of treatment, although Canadian MTCs were more likely to do
so (Connell, 2011a; Penney, Snyder, Crooks, & Johnston, 2011), but
emphasised patient agency and savvy consumerism. They refer to
medical tourism, perhaps as a purposive strategy to reduce patient
fears (Sobo et al., 2011), so promoting the benets of overseas
treatment while playing down the risks (Mason & Wright, 2011).
Procedures are advertised and promoted in ways that make them
acceptable and not challenging. Gorgeous Getaways in Australia has
packages described as Yummy Mummy, Fabulous Facelift and even
Designer Vagina (Weaver, 2008). Some MTCs encourage contact
between aspiring and former patients, sometimes at forums. A
survey of MTS 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, 2010). While that proportion is likely to be particularly high
(since diasporic MT is limited) it emphasises the growing dominance of MTCs within MT. All MTCs stress safety and reliability, by
referring to accreditation, staff credentials and testimonials of
recent patients.
Beyond the ubiquitous focus on price and reliability, the third
focus of MTCs is tourism, often linked into a package. The merits of
particular countries (and their people) as tourist destinations are
usually covered. Thus MedRetreat states: Imagine travelling to
exotic locations like Thailand, Malaysia, India, Argentina and South
Africa in perfect anonymity with a personal assistant at your side
(www.medtretreat.com). As one Indian web site advertisement has
suggested many patients are pleased at the prospect of combining

their tummy tucks with a trip to the Taj Mahal (quoted in Connell,
2008: 232). MTCs, anxious to gain clients, stress tourism possibilities much more than the actual health providers.
Health providers also advertise on the web, and most intending
patients refer to the websites of potential hospitals and clinics.
Their primary focus is on available procedures, reliability, quality
and cost, but the last is somewhat downplayed, except in Asia
(where prices are lower), on the assumption that most potential
patients have already discovered that element. Images of modernity, via technology, cleanliness and apparent efciency are dominant. Mainly English language sites feature the range of possible
procedures, costs, accreditation and afliations, smart and qualied
staff, lavish wards and accommodation, patient testimonials and
diverse language competence. Technological prowess is rarely
ignored in any form of marketing (Crooks, Turner, Snyder, Johnston,
& Kingsbury, 2011). Tourism is less common in hospital websites,
though they often stress comfortable accommodation (and its
facilities, such as internet connections), and links to hotels and
other tourism providers. Websites stress the hotel-like quality and
amenities of the hospitals, like restaurants, and related services
such as airport transfers and visa extensions.
The hospitals at the core of medical tourism have transformed
themselves from the functional and clinical public hospitals that
preceded them, taking on elements of elite hotels, IT ofces and
shopping malls, with an architecture projecting the corporate
hospital as anything but a hospital (Lefebvre, 2008: 102). Foyers
resemble hotels rather than hospitals. In elite hospitals e hospitels
e ve-star rooms have personal VCRs, restaurants provide respite
from hospital food and at Bumrungrad Japanese and Italian
restaurants, McDonalds and Starbucks are all on the rst oor. 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 (Aug, 1995), and thus more like the basic
elements, the hotel chains, of the international tourism industry.
Some hospitals and hospital chains have become functionally
integrated into the tourist industry. Bumrungrad owns 74 serviced
apartments. The principal hospital group in Singapore, Rafes,
arranges airport transfers, books relatives into hotels and arranges
local tours. Hospitals have also become linked to airlines. Bangkok
Hospital is linked with AirAsia, Bumrungrad has an agreement with
Flight Centre for North American patients. Turkish Airlines
announced that they were working with the major national
medical tourism providers to provide discounted fares for MTS
from the United States and various European countries. Key
hospitals have become more like MTCs, and multinational multiproduct rms, part of integrated systems where, if not owning
components of the travel industry, they are closely integrated into
it, with preferential arrangements with particular hotels, airlines
and related companies. Numerous countries and their tourist
industries, from Jamaica to China (Heung & Kucukusta, in press;
Pearcy, Gorodnia, & Lester, 2012), remain anxious to participate in
every facet of the industry.
No health care sector is as competitive and consumer-oriented
as MT, since some procedures do not need be undertaken, and
most are possible in many countries, usually including home
countries. Beyond obvious information about price differentials and
quality of care, the discourses of marketing MT have taken on
diverse themes that emphasise the ambience and even opulence of
care. Marketing has had the considerable task of convincing
patients to abandon uncertainty and fear, even xenophobia, trust
overseas hospitals and health workers in different cultural contexts
(even though diasporic tourism led the way), at a time of personal
uncertainty and even crisis.

J. Connell / Tourism Management 34 (2013) 1e13

8. Engaging in medical tourism


Few studies assess who are the majority of MTS, where they
have come from and gone to, and why they are where they are.
While much literature assumes or implies that most are relatively
well-off visitors from developed countries (from the north and the
Gulf) to poorer countries, most MT is across nearby borders, and not
necessarily to poorer countries. Geography and culture inuence
mobility. Language barriers, nancial constraints and lack of
information limit willingness to travel; older people, women and
unskilled workers are least willing to travel, even where substantial
cost savings are involved, so perhaps forgoing medical care.
The basic rationale for MT has been widely addressed and
centres on reduced costs overseas, the lack of certain treatments
and long waiting times at home, partly related to greater demand
for services: primarily an economic basis frequently summarised as
rst world health care at third world prices (Ormond, 2008;
Turner, 2007b). That basic rationale is modied by cultural and
geographical factors; MTS generally choose to go to countries in the
same language area, or where English is spoken, and in similar
cultural contexts (a circumstance that includes religious similarity).
Geography inuences mobility and most MT is over short distances
typied by border crossings from the United States into Mexico (not
only of Mexicans) and from southern China into Hong Kong, but
where even language and other cultural similarities do not prevent
some discrimination (Ye et al., 2011). Facility in English has
contributed to South African success (Mazzaschi, 2011).
Mexican migrants in the United States, especially when close to
the border and uninsured, tend to return to Mexico for medical care
(Brown, 2008; Horton & Cole, 2011). Many MTS are diasporic where
the cultural context enables ease of communication and comprehension of complex procedures while enabling patients and their
families to visit friends and relatives (Inhorn, 2011b; Lee et al.,
2010). Both Korea and Taiwan, neither of which are low cost
destinations, have sought to develop larger MT industries from this
familial starting point.
Various destinations have responded to MTS cultural requirements through language training for staff, distinctive food preparation, prayer rooms and separate wards and oors (Connell,
2011a). Religious variations may be important within a broader
cultural context; Sunni and Shia branches of Islam have different
perspectives on assisted reproductive technology so that Shia
Muslims in countries where Sunni Islam dominates may travel to
Iran, where the converse is true, for fertility treatments
(Moghimehfar & Nasr-Esfahani, 2011). MTS may also escape
government regulations, usually restricting particular medical and
cultural practices, but also including Chinas one child policy (Ye
et al., 2011). Loose notions of cultural preference, often invoked
by return migrants, that might include rapid service, personal
attention, effective medication, privacy and clinical discretion, may
actually be phenomena associated with private hospitals (Horton &
Cole, 2011). While tourist attractions are rarely considered to be
important (cf. Moghimehfar & Nasr-Esfahani, 2011) minimal
accessibility to basic tourism infrastructure is signicant (Connell,
2011a). Moreover when MT is extended to cover medical tourists
proper and MTS are accompanied, as most are, tourism and tourist
facilities become highly important (Yu & Ko, 2012).
Within this broad economic and cultural rationale medical skills
and facilities are crucial in destination choice. Chinese MTS in Korea
valued medical skills far above other factors in choice of destination, and were more focused on the medical experience than
Japanese who also valued the tourist experience (Yu & Ko, 2012).
International MTS at Bumrungrad similarly emphasised the quality
of medical care (Veerasoontorn et al., 2011). But care is set against
cost. In Jordan, the leading destination in the Middle East, MTS

mainly come from low- income Arabic speaking countries such as


Yemen, Sudan and also Libya, where the doctor: population ratio is
lower, and the skills of doctors perceived to be weaker (Smith et al.,
2009: 163). However half of all Omani medical tourists went to
Thailand and a third to India e since they were cheaper destinations e rather than remain in the cultural region (Al-Hinai et al.,
2011). Elite Gulf MTS usually go to Europe. Malaysia has experienced a rise in MT from Indonesia because of rising costs in
Singapore. Cost may result in more distant moves.
Attempts have been made to model decision-making procedures but most have made sweeping assumptions about causality,
or excluded key variables. Smith and Forgiones (2007) two stagemodel argues that MTS rst select a destination and subsequently
consider the medical and tourism facilities at that destination, yet
few data support these stages or that order (Heung et al., 2010,
2011; Lee, Han, & Lockyer, 2012; Ye et al., 2011). More studies have
concluded that the cost, availability and reputation of health care
facilities are of primary importance with destination of lesser
signicance (e.g. Musa et al., in press) other than for diasporic MTS.
Most studies of MT have been undertaken in developed country
sources and hence have tended to imply that most MTS come from
these countries, or from the Gulf. In Asia numbers of MTS from the
Gulf were boosted after 9/11 in 2001 and it remains a major Asian
source. As studies have increasingly been undertaken in destinations the signicance of regional movements has become more
evident. More than 80% of overseas patients in Tunisia, Singapore
and Jordan come from neighbouring countries (Lautier, 2008). In
2005 those who came to Singapore for medical treatment came
mostly from neighbouring countries, especially Indonesia (52%) and
Malaysia (11%) (Khalik, 2006). Singapore has however seen a shift of
its market from Indonesia to the Gulf, alongside greater numbers of
ethnic Chinese from a diversity of sources. In Malaysia a survey of
MTS at ve Kuala Lumpur hospitals revealed that almost half (48%)
were from Indonesia, with less than 10% from Australia, New Zealand, the Philippines and India (Musa et al., in press). Further niches
are signicant within regions. In Asia perceptions of body images,
and the broader context of Korean popular culture, have resulted in
Korea becoming a cosmetic surgery destination for several parts of
east and south-east Asia (Connell, 2011a; Yu & Ko, 2012).
Even fewer studies provide data on the economic impacts of MT
and country estimates are rarely based on fact or analysis. Most fail
to differentiate health expenditure from travel and tourism
expenditure, consider the duration of stay of MTS in destinations
and may or may not include patients relatives and friends. With
a lengthy period of recuperation, the rewards to the tourist
industry, and especially the hotel sector, may be greater than with
standard tourism. Cosmetic tourists stay longer than other MTS but
do little more than stay in the hotel, eat and shop (Ackerman, 2010).
Diasporic medical tourists who are visiting friends and relatives
may stay even longer.
In Tunisia the direct expenditure of MTS on health alone (clinic
costs, doctors fees and pharmaceuticals) was estimated at $55
million in 2004, about a quarter of the total earnings of all private
clinics, and thus a substantial input to the health sector (entirely to
the private sector, in the two largest cities). 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 three
days and outside stay of two days, and about 1.5 relatives per
patient) brought the overall expenditure gure to $107 million
(Lautier, 2008). Almost exactly half of all expenditure was therefore
outside the health sector, and half the jobs created were also
outside, but broadly within tourism-related service sector activities.
Every estimate suggests that MTS spend more that standard
tourists, usually about twice as much, because of the high costs of
medical services. An Indian MTS apparently spends $7000

J. Connell / Tourism Management 34 (2013) 1e13

compared with other tourists who spend $3000 (Reisman, 2010:


102). A large sample of MTS in Malaysia spent an average of $8720,
of which the single largest component was the cost of medical
treatment ($3742), followed by international airfares ($1187),
accommodation ($1038), food and drink ($468) and domestic
transport ($159). Expenditure on evidently tourism-related activities included $678 for shopping, alongside entertainment ($180)
and organised tours ($489). Almost all the MTS (108 out of 121)
travelled with at least one other person, usually a relative (Musa
et al., in press), whose expenditure was not estimated. Had that
been included already substantial expenditures would have been
much greater. Those accompanying MTS in Thailand spend about
twice as much as the MTS themselves on hotels and tourism
activities (NaRanong & NaRanong, 2011). The whole infrastructure
of the tourist industry (travel agents, airlines, hotels, restaurants,
taxis) benets considerably from the new niche. This partly
explains why some hospitals have sought to diversify into tourism,
why growing numbers of MTCs have played integrative roles and
how offshore medical care has stimulated tourism for some who
had never hitherto been overseas.
What proportion of MTS engages in standard tourism is largely
unknown. Few studies have been undertaken. Most MTS in China,
India and Jordan engage in some form of tourism such as sightseeing, shopping and enjoying local culture (Alsharif et al., 2010). At
least half the MTS in Kuala Lumpur engaged in shopping, organised
touring or other recreational activities, including visiting relatives
(Musa et al., in press). Some 85% of Bumrungrad patients stated that
they and/or their companions had done some tourist activities such
as sightseeing, shopping, eating out or enjoying the local culture
(Anon, 2010). While most Australian cosmetic tourists in Bangkok
stressed such touristic phenomena as the comfort and value of their
hotels, the food and the intent to take part in tours e which they
subsequently did (Jones, 2011) e very few of a group of MTS in India
were intent on vacationing after treatment, though accompanying
relatives and friends did engage in tourism (Solomon, 2011). At
least passively MTS make some contribution to the local economy,
like other tourists, through expenditure on hotels, transport and
food, even if not necessarily anxious to do more.
MT has become an unusual but valuable niche in the increasingly competitive travel industry. While many painful activities,
such as transplant surgery, have no relationship to the pleasure and
even frivolity usually associated with tourism, most MT has parallels in other forms of tourism, and obvious impacts on the tourism
industry. Bikinis and bandages (Bell et al., 2011), analogous to sea,
sun, sand ...and surgery (Connell, 2006), symbolise perhaps
imperfect and awed vacations. Ironically, the more dramatic
surgical procedures that may seem to dene MT, are the least
amenable to linkages with tourism. Other kinds of niche tourism
may be uncomfortable, unpleasant and even dangerous or lifethreatening: potholing, rock climbing or thanatourism (e.g.
Knudsen, 2011). Equally MT has much in common with VFR
(Visiting Friends and Relatives) and MICE (Meetings, Incentives,
Conventions/Conferences and Exhibitions) tourism, the latter
where tourists often travel independent of other family members,
and spend most of their time engaged in activities that others
would nd dull, or bereft of pleasure and relaxation. All such
activities at least minimally benet the infrastructure of tourism. If
MT may sometimes seem devoid of hedonistic pleasures e equally
true of other tourism niches e the long term outcomes may still be
exceptionally pleasurable.
9. Ethics
MT has raised ethical questions centred on issues of accreditation and quality of care (and after-care), the validity of particular

extreme procedures (often not undertaken in the patients home


countries) and its impact on the health care of nationals in destination countries. Most recently concern has mounted over possible
biosecurity risks from the spread of infections and pandemics by
returning MTS (Hall & James, 2011). The ethics of media depictions
of body shapes, involving the pathologising of (usually) womens
bodies and invocations to change have also been questioned (Buote,
Wilson, Strahan, Gazzola, & Papps, 2011; Sarwer & Crerand, 2004).
Inherent inequality has posed complex bioethical questions, especially for new and experimental procedures where a variety of
differentiated and geographically distinct practices are subordinated to the logic of the market (Parry, 2008) in contexts where
regulation is weak.
The most distinctive feature of MT is that it takes patients across
international borders, beyond the perhaps comfortable and familiar
cultural relationships sometimes built up over years between
health care providers, doctors and patients, to places that may be
culturally, climatically and linguistically distinct and unfamiliar. For
decades health systems, in countries such as India, have been
conventionally regarded in the west as inadequate. Cautionary
notes have come from professional bodies in source countries,
whose members may have to remedy botched procedures and
complications (e.g. Connell, 2011b; Dalstrom, 2012). Both the
hospitals (and MTCs), who publish positive testimonials, and the
professional bodies, who record misadventure, have obvious vested
interests. Real rates of success and failure are immeasurable: there
is no means of recording this, and no guidelines against which to
measure success rates, especially in such areas as cosmetic surgery
where disappointments and failures may be more frequent.
Complex procedures that have attracted ethical concerns have
included stem cell therapy, surrogacy and even death tourism or
euthanasia (e.g. Higginbotham, 2011; Inhorn, 2011a) some of which
have been described as rogue medical tourism through concerns
over safety, inadequate evidence of effectiveness of the procedures
and moral acceptability (Hunter & Oultram, 2010). On these
grounds some procedures, such as transplant tourism, have been
distinguished from the wider body of MT (Bagheri, 2010). In the
context of reproductive tourism, although travellers are consuming
tourism products (e.g. transport, accommodation, food), regarding
this as tourism is to devalue the journey by implying that it is
primarily a novel cultural experience (Pennings, 2002) yet not all
tourism is merely a novel cultural experience. Transplantation
brings together patients on long waiting lists, the parsimonious
payers of their expensive dialysis (states, insurers and providers),
travel and tourism industries and the impoverished men and
women who can sell nothing but their body parts in an extreme
form of neoliberal globalization (Epstein, 2009: 134) or neocolonialism (Buzinde & Yarnal, 2012). Few of the limited benets
have trickled down to impoverished vendors, the poor have less
chance of receiving organs and transplantation success is limited in
difcult medical and social circumstances where medical care is
probably substandard (Turner, 2007b, 2010). Transplant tourism is
also problematic since failure rates are high, and patients may also
contract transmissible infections.
More than most forms of human behaviour, reproduction
appears a private and intimate affair, yet it is bound up in national
policies (for example towards abortion, provision of contraception,
family sizes and one-child families). Partly in response, reproduction has gone global through transnational adoption (recently
involving prominent lm 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 in vitro fertilisation (IVF),
sperm and egg donation, sex selection and embryonic diagnosis,

10

J. Connell / Tourism Management 34 (2013) 1e13

and surrogate parenthood (Martin, 2009; Whittaker, 2010) and, the


converse, abortion, contraception and vasectomies. Unlike most
other contexts where biomedical ethical principles occur (Connell,
2011a, 2011b) some standard tourist potential is apparent and it has
even been termed a procreation vacation. New reproductive
technologies nonetheless raise diverse ethical questions around
individual and state responses to liberty, rights and autonomy.
Health care systems in developing countries, some of the main
destinations of MTS, 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 centralisation has been hastened by privatisation, stagnant budgets for
health expenditure and, possibly, by MT. Yet, despite considerable
concern, most of the literature on the broad socio-economic impact
of MT is data free and based on theory, assumption and conjecture (Lautier, 2008: 102). Detailed analysis of the national impacts
of MT is yet to occur and evaluations of its social and economic
impact on local populations are scarcely even fragmentary
(Connell, 2011b). However in some contexts a dual medical system
has emerged in which specialization in cardiology, opthalmology
and plastic surgery serves the foreign and wealthy domestic
patients while the [majority of the] local populations lack basics
such as sanitation, clean water and regular deworming (Bookman
& Bookman, 2007: 7). Such situations characterize India and
occur less dramatically in Thailand, Malaysia and elsewhere
(NaRanong & NaRanong, 2011) and may be accentuated by the
migration of skilled health workers from rural and regional areas
and from the public sector into the private sector, that includes MT.
MT has thus been described as an elite private space ... inextricably
linked to a beleaguered national medical program and a reverse
subsidy for the elite (Ackerman, 2010: 403; Sengupta, 2011: 312).
In South Africa it also emphasises the racialized inequality in
health care (Mazzaschi, 2011). In rare contexts, such as Hong Kong
(Heung et al., 2011), local interests have consequently opposed MT
on ethical grounds. More frequently uneven development at
multiple scales typies the globalisation of health care.
10. Conclusions and directions for research
Medical tourism is difcult to dene, the effort is usually
unproductive (since diversity is considerable) and more detailed
studies of most categories of MTS are required. It is nevertheless
one niche within tourism, even if parts of the industry prefer the
gravity, responsibility and trustworthiness associated with medical
travel or medical migration (Helble, 2011; Thompson, 2011).
However it makes sense to subsume all cross-border movements
for medical care under the term medical travel, but recognise that
medical tourism will continue to be used for many components of
that mobility. In the absence of agreed denitions and rigorous
detailed studies, caution will continue to be required in assessing
national and industry estimates. Even with agreement on denitions, the signicance of clandestine and diaspora movements
alongside inaccessible medical data make imprecise statistics
almost inevitable.
It is increasingly evident that MT remains largely regional, cross
border and diasporic, but with the potential to become more global.
A preference for rich-world medical tourists, and media xation on
cosmetic surgery, have distorted some accounts (and numbers) and
confused preferred markets with actual markets (Connell, 2011a;
Ormond, 2011). Numbers of western medical tourists are fewer
than usually intimated, while diaspora and intra-regional numbers
are considerable. With rare exceptions, notably Thailand, ironically
one of the most successful, MT is concentrated in backyards not
playgrounds. Of the major southern destinations only those in
south-east Asia have medical tourism markets where diaspora play

a limited role. Active government support, exibility, modern


technology, effective marketing and an existing infrastructure with
evolving links to hospitality, tourism and transport industries have
been invaluable there. In some Asian countries MT is marketed as
part of the tourist industry, and generally facilitated by new MTCs,
that function like travel agents.
Market mechanisms have become increasingly important. The
growing privatisation of health care, its shift from traditional notions
of family doctors and neighbourhood care, and consequently
growing international competition for markets, has meant that
medical care is increasingly global rather than local, and to be traded
rather than perceived as a right. The outsourcing of medical care,
through MT, shows that even the most seemingly location-specic
activity is mobile. Tensions between national policies of promotion
of health care within states and international strategies to generate
income through promoting mobility between states have emerged
(Pocock & Phua, 2011), alongside various ethical issues.
In this emerging nexus of complex privatisations, links with
components of the tourism industry provide institutional evidence
that medical procedures overseas are not merely of clinical interest.
MT is niche tourism, a form of tourism that may be more sustainable
and sophisticated, with segmented marketing mechanisms and
media, and where tourists engage in only a fraction of the activities
possible at a particular destination (Connell, 2009; Robinson &
Novelli, 2005). With its signicant diasporic element MT is also
a form of VFR tourism. Most patients have some time for conventional
tourism. That may not be strenuous or energetic, but shopping,
sightseeing and dining are relaxing, recuperative and enduring forms.
MT has transformed the geography of international health care,
but much of what has been written of this transformation has been
speculative, optimistic and distanced from detailed documentation
and analysis of MTS mobility. Websites have been examined in
detail but the users of the sites and the eventual MTS remain more
shadowy presences. Little is yet known of how medical tourists
choose destinations, how choice processes differ from those of
other tourists (Cormany & Baloglu, 2011), which factors are most
inuential and what medical procedures are most likely to result in
MT. Consequently the age, gender and ethnic composition of MTS
ows is largely unknown, as are the medical and touristic outcomes.
A consensus exists on the need for better surveys of decisionmaking and the balancing of hard data (performance measures)
and soft intelligence (website and personal recommendations)
(Lunt, Mannion, & Exworthy, in press) though the former are rarely
particularly hard or accessible. That will eventually enable more
sophisticated analysis and modelling of MTS behaviour.
Few branches of tourism and even fewer of medicine appear so
reliant on the web as a source of information, yet key sources of
information and familiarity are shifting from the internet to friends
and relatives. Many MTS learn of destinations and opportunities
from media stories and through the recommendations, experiences
and advice of friends and acquaintances and, as interest increases,
through internet websites, but how such diverse inuences shape
(or discourage) mobility is largely unknown. Whether that varies
according to region or procedures is similarly unknown, as is the
relationship between need and destination, and how certain
procedures (including cosmetic surgery) align to notions of selfhelp and entitlement overseas rather than more traditional,
locally-based patientedoctor relationships. Equally what sources
prove the most reliable and acceptable are likewise uncertain. The
role of wider perceptions of countries, and the possibility of
standard tourism, in terms of both information gathering,
decision-making (and eventual practice) needs to be much better
understood, and is likely to be highly variable.
A better understanding of how MTCs (and their websites) shape
and steer choice of destination will provide more clarity on how an

J. Connell / Tourism Management 34 (2013) 1e13

increasingly global market place works e for a distinct form of


mobility and tourism where technology, cost and place are interrelated e and thus on how some therapeutic places have become
particularly successful e for therapy or place eand what are the
most effective and attractive combinations. Aspiring destinations,
and there are many of these, have engaged in marketing from a very
limited evidence base.
Remarkably little is known about the behaviour of MTS (and
their supporters) in terms of duration of stay, economic expenditure and activities, and the extent to which medical and tourist
expectations were accomplished. The performative and embodied
experience of MT and medical care has rarely been examined (Cook,
2010; Jones, 2011; Solomon, 2011). Little is known about whether
MTS expect to engage in an encounter with a particular culture
(Bell et al., 2011) or whether the encounter is intendedly entirely
functional. Once again experiences are likely to be variable and be
very different for diaspora MTS or those whose tourist experience
may be limited to a few painful days in a cheap hotel room (Bell
et al., 2011: 14) How the experience of MT is different from other
forms of niche tourism remains to be explored. What then are the
medical and social experiences of MTS especially where they enter
other cultural contexts and when they return home (where aftercare may be lacking), and do MTS see themselves as patients,
travellers or tourists e or some uid combination of these e and do
such distinctions vary or matter?
Ultimately surprisingly little is known about cross-border
mobility, even in Europe, despite its considerable and regulated
signicance (Glinos, Doering, & Maarse, 2012). Medical mobility in
developing countries is even more poorly understood. Much more
needs to be known about cross-border and diaspora tourists e
beyond a handful of studies of Yemenis and Mexicans e whose
experiences rarely if ever lter through medical tourisms broader
discursive formation (Solomon, 2011: 109). Both groups are
signicantly different in a range of ways from other MTS but have
been largely ignored in the literature (and media). Here and elsewhere cultural and ethical perspectives, including how MT may
distort the structure of health care and health equity in destinations
are only beginning to become apparent. The emerging and evolving
links between MT, national governments (in regulation, promotion
and branding of MT), insurance companies and the tourism
industry e within a parallel globalization and corporatization of
health care, travel and tourism e have attracted some attention, but
much more must be learned from and about this diverse, dynamic
and multi-faceted industry.
Acknowledgements
I am indebted to Kenneth Mays for helping to unravel the
Bumrungrad admissions data.
I am indebted to Meghann Ormond and Nicola Pocock for
comments on a much earlier version.
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John Connell is Professor of Geography, School of Geosciences, University of Sydney.

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