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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 commodification

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 influence medical tourism behaviour.

a r t i c l e i n f o

Article history:Received 3 February 2012Accepted 21 May 2012

Keywords:Medical tourismMedical travelProceduresTypologyDiasporaTourist numbersMarketingMultinationalsThailand

* Tel.: þ61 (0)2 9351 2327.E-mail addresses: john.connell@sydney.edu.au, jco

0261-5177/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.tourman.2012.05.009

a b s t r a c t

An overview is given of the short history and rapid rise of medical tourism, its documentation, andcurrent knowledge and analysis of the industry. Definitions of medical tourism are limited hence whomedical tourists are and how many exist are both indeterminate and inflated. Definitions often conflatemedical tourism, health tourism and medical travel, and are further complicated by the variablesignificance of motivation, procedures and tourism. While media coverage suggests long-distance travelfor surgical procedures, and the dominance of middle class European patients, much medical tourism isacross nearby borders and from diasporas, and of limited medical gravity, conflicting with popularassumptions. Numbers are usually substantially less than industry and media estimates. Data mustremain subject to critical scrutiny. Medical travel may be a better form of overall categorisation withmedical tourism a sub-category where ‘patient-tourists’ move through their own volition. Much medicaltourism 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 newsignificance. Opportunities are diffused by word of mouth with the internet of secondary value. Qualityand availability of care are key influences on medical tourism behaviour, alongside economic and culturalfactors. More analysis is needed of the rationale for travel, the behaviour of medical tourists, theeconomic and social impact of medical tourism, the role of intermediaries, the place of medical tourismwithin tourism (linkages with hotels, airlines, travel agents), ethical concerns and global healthrestructuring.

� 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Medical tourism (MT), primarily a late twentieth centuryphenomenon, is said to have recently and rapidly boomed. Thispaper assesses the parallel boom in academic analysis. Numericaldata on MT are inadequate and unreliable (e.g. Hopkins, Labonté,Runnels, & Packer, 2010; Johnston, Crooks, Snyder, & Kingsbury,2010) being based on industry optimism and boosterism ratherthan rigorous analysis. Significant cross border movements forhealth care (including diasporas and institutional transfers) are

nnell@mail.usyd.edu.au.

All rights reserved.

conflated with ‘accidental’ and expatriate health care, yet devel-oping a rigorous definition of MT poses problems. This paper seeksto fill this analytical gap and draw attention to those that remain.The second part analyses recent trends in MT, and the implicationsof contemporary change, and argues for greater analysis to be givento decision-making, the role of intermediaries (medical tourismcompanies) and the place of MT within both tourism (linkages withhotels, airlines and travel agents and tourist performativity) andglobal health restructuring.

Travel for medical care (and wellbeing) has long existed.Destinations, such as Harley Street in London, are famous asinternational centres of medical care. Yet in the last two decadesa form of ‘reverse globalisation’ has occurred with patients from

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more developed countries travelling for medical care to lessdeveloped countries, for a combination of reasons involving cost,access, service and quality, overturning implicit notions of theterritoriality 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 flow is usually seen to be thebasis of MT, though international mobility for medical care is morediverse and complicated, notably in its cross-border and diasporiccomponent.

MT is said to have grown explosively since the late 1990s withthousands of patients moving to countries such as India, Thailandand Mexico, in search of medical care usually deemed too expen-sive, inadequate or unavailable at home. Ironically the first accountof what has become a phenomenon imbued with capitalism,entitlement, individualism and self-fulfilment was of Cuba(Goodrich & Goodrich, 1987). Multiple studies have subsequentlydocumented the rise of Asian, European and Latin Americandestinations, as their economies have diversified and built onexisting tourism industries and health care systems (e.g. Bookman& Bookman, 2007; Connell, 2006, 2008; Reisman, 2010). Increasingnumbers of countries have enthusiastically marketed themselves asMT destinations, hundreds of medical tourism companies (MTCs)have become travel agents, brokering and facilitating medicaltravel, and extraordinary claims have been made for numericalgrowth, especially by industry participants and destination coun-tries (Connell, 2011a). However no national data or definitions ofMT exist, hence there has long been scope for exaggeration andjournalistic hyperbole. At least four basic issues remain unresolved:what is MT, who are the medical tourists (MTS), howmany of themare there and what impact do they have? This paper seeks tocontribute to some resolution of these questions, review recentanalyses of trends inmedical 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 andnational estimates are unquestioned. Consequently estimates ofmarket shares and revenue are equally problematic (e.g. Heung,Kucukusta, & Song, 2011). ‘By definition almost every officialfigure is flawed. They are often badly collected, imperfectly collatedand spun to infinity. Some hospitals inflate figures by counting thenumber of patient visits rather than the number of patients’(Youngman, 2009; see also Pollard, 2010). One overview ‘founda lack of hard data on the magnitude of medical tourism, withanecdotes, brokerage claims, and theoretical conjecturessubstituting for more deliberative study’ (Hopkins et al., 2010: 194;see also Glinos, Baeten, Helble, & Maarse, 2010). Some nationaldata, like that of the UAE, are so inflated that even industry analystsdisregard it: ‘the claimed medical tourism figures are so exagger-ated as to be pure fantasy’ (Youngman, 2010a). Without arrival anddeparture cards there are no reliable and comparable internationaldata on cross-border medical travel. Most data that are touted asmeasures of numbers, growth and economic impact are anecdotal,yet such data have largely eluded detailed analysis since MT iscompetitive and partly clandestine.

2. Medical tourism

Most accounts of ‘medical tourism’ use it as an umbrella termwhere improved health is a key component of travel overseas, andinvolves invasive procedures (and also medical check-ups), ratherthan the more passive processes of health and wellness tourism.Many accounts assume a definition, others are minimalist andundeveloped, such as that of Bookman and Bookman (2007: 1)

‘international ‘travel with the aim of improving one’s health’,Wikipedia’s current ‘travelling across international borders toobtain health care’ (2012) or, more elaborately, ‘the organized traveloutside one’s local environment for themaintenance, enhancementor restoration of an individual’s wellbeing in mind and body’(Carrera & Bridges, 2006: 447). One industry perspective is simi-larly brief: ‘patients travelling to another country for more afford-able care, or care that is higher quality or more accessible’ (Edelheit,2008: 10). Others, such as Reisman (2010: 1), circumvent anydefinition preferring the less emotive ‘global medical care’. Stillothers have chosen bland formulations such as ‘the act of travellingabroad to obtain medical care’ (Cormany & Baloglu, 2011). Anotherclaim has been for international travel ‘deliberately linked to directmedical intervention, and [where] outcomes are expected to besubstantial and long-term’ (Connell, 2006: 1094). Most definitionshave sought to distinguish ‘medical tourism’ from ‘health tourism’

e seen to be primarily concerned with low-key, therapeuticand non-invasive ‘procedures’ e while allowing the inclusion ofdentistry and check-ups, since that might lead to medicalintervention.

Some definitions emphasise intent. Johnston et al. (2010: 1)refer to ‘patients leaving their country of residence outside ofestablished cross-border care arrangements made with the intentof accessing medical care, often surgery, abroad’. Lunt and Carreralikewise restrict the definition of medical tourist to ‘patients whoare mobile through their own volition’ (2010: 27). Thompson(2008, 2011) distinguishes ‘medical tourists’ as ‘empoweredbiosocial citizens’ in contrast to ‘medical migrants’, who are diverse,but regulated through institutions, rather than making personaldecisions. MTS may therefore be seen as ‘patient-consumers’:a more medical term. All these definitions exclude those who areeffectively sent abroad for ‘necessary’ care by health agencies (suchas hospitals, insurance companies and government referrals)perhaps as an outcome of long waiting lists, a lack of availablespecialists or unavailable skills and facilities. MT is then both nar-rowed towhat is elective and discretionary, and thus primarily self-funded, unlike formal cross-border institutional transfers such asthose within the EU, but expanded into ‘a wider, more diverse andmore nuanced phenomenon’ (Glinos et al., 2010: 1146). Howeverthe diversity of patient motivations for overseas treatment withinEurope e availability, affordability, familiarity and perceivedqualitye are also those that influence this broader spectrum ofMTS(Connell, 2011a; Laugesen & Vargas-Bustamante, 2010).

Other than in nomenclature ‘tourism’ has largely been absentfrom formal discussions of international medical travel. HoweverJagyasi prefers ‘the set of activities in which a person travels oftenlong distance or across the border, to avail medical services withdirect or indirect engagement in leisure, business or otherpurposes’ (2008: 10). Similar perspectives include: ‘a vacation thatinvolves travelling across international borders to obtain a broadrange of medical services. It usually includes leisure, fun andrelaxation activities, as well as wellness and health-care service’(Heung, Kucukusta, & Song, 2010: 236) and ‘the blending of tourismand medical treatment for both elective and necessary surgical andmedical procedures as well as for dental procedures’ (Jenner, 2008:236). Hopkins et al. take a broadly similar perspective on blendingmedicine and tourism: ‘cross-border health care motivated bylower cost, avoidance of long wait times, or services not available inone’s own country. Such care is increasingly linked with touristactivities to ease foreign patients into a new cultural environmentand to occupy them during the pre- and post- operative periods’(2010: 185).

A continuum exists from health (or wellness) tourism involvingrelaxation exercise and massage, cosmetic surgery (ranging fromdentistry to substantial interventions), operations (such as hip

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replacements and transplants), to reproductive procedures andeven ‘death tourism’. Health and wellness tourism are usuallydifferentiated as being too ‘soft’ and trivial to be MT, and are thesubject 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 cellprocedures, not all of which require procedures. Are there thendistinct (medical) tourism procedures? Is there a pain thresholdthat differentiates medical procedures from health and wellness,and where any notion of tourism as pleasure is implausible? Thaimassage may be scarcely less painful or invasive than teeth whit-ening; by contrast ‘transplant tourism’ is far removed from whatmay immediately be pleasurable. Tattooing, never regarded asa medical procedure, despite its cosmetic undertones, is morepainful and invasive than many forms of treatment usuallysubsumed under MT (and is often undertaken overseas). Dentaltourism has sometimes been excluded from definitions of MT(Pollard, 2011) or distinguished as a separate category (Turner,2008). Vast numbers of media accounts have depicted medicaltourism as centred on cosmetic surgery.

3. Pain and procedures

Procedures are often implicitly linked to durations. Proceduresthat take less than a daye such as audiology and dentistry, that arenot ‘medical’ and do not involve hospitalisation e tend to beexcluded as ‘drop-in’ procedures (which is how many are adver-tised in tourist publications) though may be the primary intent ofthe international travel. Pain and outcome are implicit in someapproaches. Certain conditions exist where any sense of tourism(associated with pleasure, frivolity, relaxation or education) isnonsense, with patients so weak or incapacitated afterwards thatany semblance of tourism is impossible and the notion would beregarded as demeaning.

The concept of ‘tourism’ complicates analysis, implying some-thing deliberately chosen as pleasurable (though it might also bechallenging and educational) but MT literature usually excludes‘tourist’ behaviour and expectations. Certainly broad notions oftourism fit poorly, and arewidely rejected, in procedures associatedwith desperation, last resort and heavy financial liability. Whereinsurance cover is limited or local services unavailable, so that ‘themost vulnerable individuals, rather than more affluent individuals’travel overseas, but ‘not because it is a luxury or choice’ (Kangas,2007; Laugesen & Vargas-Bustamante, 2010: 1) or where patientstravel for such ‘extreme’ interventions as transplants and stem celltreatments, tourism seems absent or inappropriate. A rapidlygrowing body of literature (e.g. Song, 2010; Turner, 2007b) hasfocused on international travel for such challenging procedures,which also raise ethical issues and where the word ‘tourism’ is usedwholly ironically. Whittaker similarly sees ‘medical tourism asa misnomer, carrying connotations of pleasure not always associ-ated with this travel, and blurs distinctions between desperately illpeople [and] more discretionary travel’ (2008: 272). Song regards itas implying a frivolity that ‘renders it a problematic term [for]patients who often feel enforced to travel in order to seek themedical care they desire or need’ (2010: 386). There is little tour-istic intent in institutional mobility and desperation, howeverbeneficial the outcome.

Value judgements are implicit. Milstein and Smith (2006),describing the plight of ‘seriously ill Americans’ who receivetreatment at overseas hospitals because they cannot afforddomestic 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 impoverishedYemeni 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 thatpatients experience’, so trivialising the experience. So-called‘maternity tourism’ or ‘citizenship tourism’ where expectantmothers cross borders (for example from China to Hong Kong andNigeria to the United States) to have ‘anchor babies’ in moredeveloped countries (e.g. Erbe, 2011; Gilmartin &White, 2010) havefew touristic characteristics. Long-staying ‘reproductive tourists’and those in search of stem cell cures see their travels as more akinto 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 toThailand, are particularly problematic (Connell, 2011a) withpatient-consumers effectively outsourcing themselves, again withno obvious resemblance to tourism. From this general perspectiveKangas (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 peopleengage in somewhat similar travels and experiences.

Some components of the medical industry also regard MT as toofrivolous a term. In the words of one plastic surgeon: ‘While weappreciate the involvement of the travel and hotel industries wemust never lose sight of the fact that travelling abroad for a medicalprocedure is not a vacation, it is surgery’ (Nahai, 2009: 106).Destination hospitals focus on high-quality care, reliability andcompetence, although other institutions, including the facilitatingMTCs and destination countries, seek to emphasise ‘normal’ tour-istic elements, such as shopping, dining and hotel facilities, to stressthat the experience will be pleasurable. Some recuperation isusually possible, and a journey with a serious purpose can havea frivolous, pleasurable and celebratory ending. Tourism offersadded value. One industry analyst has argued that ‘the industryshould be working to get medical tourism counted as a nichetourism sector’ (Youngman, 2010b). However it is extremely diffi-cult to differentiate MT according to the procedures involved, theirmorality and necessity and the social and economic characteristicsassociated with them in different national contexts.

4. A detour around diaspora

From a primarily Thai perspective, it has been argued, that eventhe idea of ‘medical tourism’ creates assumptions about ‘race nationand class, with the emblematic medical tourist a wealthy whitewestern or East Asian tourist who combines cosmetic surgery witha beach holiday’ (Whittaker, 2009: 323). Such assumptions areenhanced in the generally available statistical data, and muchpromotional material (especially websites) within marketingstrategies. Countries and institutions seek affluent patients ofEuropean origin, hence there is a focus on ‘whiteness’ wherepatients appear to be of European origin and, in some destinationssuch as Argentina, Mexico and the Philippines, staff too aredepicted as white. However growing recognition of the significanceof diasporic tourism challenges assumptions about whiteness,long-distance travel and the meaning of MT. Diasporic tourism isa 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 ofreasons.

Much international medical travel is of overseas diasporicpopulations, notably Mexicans in the United States and a moreglobal Indian and Middle Eastern diaspora. In some countriesreturn migration for medical care contributed to the genesis ofa wider MT. Patients return ‘home’ because they are likely to becomfortable and familiar with the health system, the language and

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broader cultural context, and costs may be significantly cheaper, asin Mexico (Horton & Cole, 2011; Macias & Morales, 2001; Wallace,Mendez-Luck, & Castaneda, 2009). In some cases, as in the returnmobility of Koreans from New Zealand and British migrants fromSpain (La Parra & Mateo, 2008; Lee, Kearns, & Friesen, 2010),cultural factors are particularly significant since no economicrationale exists. Similarly second generation overseas migrants,including Arabs and Indians, move for medical care into an‘appropriate’ cultural context. (Only in India does that apparentlyinclude significant ‘alternative’ medical procedures.) MTS alsotravel to destinations with comparable cultures, so that thepredominantly Islamic state of Malaysia has become a destinationfor medical tourists from Indonesia and the Gulf.

Diasporic tourists may not be travelling to ‘distant’ places. Someof the largest flows of cross-border travellers are diasporic, to‘backyard’ rather than ‘tourist’ destinations (Ormond, 2008). InIndia, Jordan, Mexico, Turkey and the Philippines, overseasnationals are a significant proportion, perhaps a majority, of MTSand that may also be true in Colombia, Taiwan, Iran, Lebanon, Maltaand elsewhere (Connell, 2011a; Glinos et al., 2010). At least 22% ofmedical tourists in India are Non-Resident Indians (NRIs), frommany countries, alongside second-generation overseas Indianswho are not classified as NRIs. A further 19% came from neigh-bouring countries, Bangladesh, Nepal and Sri Lanka, where culturesare 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 andelsewhere, is across nearby borders, to neighbouring countries withsimilar (or complementary) facilities and cultures, andwhere travelcosts are minimised. International medical travel is thus moreregional than global, with the relatively poor likely to travel shorterdistances (Connell, 2011a). Kangas (2010) thus distinguishes‘transnational’ or ‘international’ for journeys to destinationsbeyond neighbouring countries, and reserves ‘cross-border’ fortravel to adjoining countries, arguing that ‘selecting a transnationaltreatment destination involves more than a cross-border one’(2010: 353). In practice there may be little difference betweenthem.

5. Medical tourism or medical travel?

Definitional problems, the significance of the diaspora (and thedesire to market MT), have made attempts to differentiate MTSfrom other tourists or patients rare, partly because of the problemsoutlined above, but also because practitioners have no need orinterest in doing so. Based on Thailand, Cohen has suggesteda fourfold classification: ‘medicated tourists’ (who receive treat-ment for accidents or health problems that occur during an over-seas holiday), ‘medical tourists proper’ (who visit a country forsome medical treatment, or who may decide on a procedure oncein a country), ‘vacationing patients’ (who visit mainly for medicaltreatment, but make incidental use of holiday opportunities,usually during the convalescence period) and ‘mere patients’ (whovisit solely for medical treatment, and make no use of holidayopportunities). There are also ‘mere tourists’who have no overseasmedical treatment of any kind (Cohen, 2008: 227). Cohen arguesthat most of the literature covers ‘vacationing patients’ and ‘merepatients’, where the medical component dominates, and henceprefers the term ‘medical travel’ arguing that the recreationalcomponent is slight for these two categories. In practice ‘merepatients’ probably refers only to very short duration travel, such asfor some dentistry, and no literature discusses this. The two cate-gories said to be covered by most of the literature here become‘medical travel’ whereas ‘medical tourism’ occurs where treatmentis only decided upon belatedly and procedures are low-key.

Balancing tourism, medical care and also intent is difficult. Mostother definitions have started from the notion of deliberatemovement for medical care across international borders, and thussimilarly exclude both ‘medicated tourists’ and resident expatriates(including retirees). Intent rather than procedures or duration arethe defining characteristics. Pollard (2010) thus defines a medicaltourist as ‘someone whose specific reason for travelling to anothercountry is medical treatment’, thus paralleling the criteria used inthe influential McKinsey Report on the MT industry. The McKinseyreport suggested that the number of medical tourists in 2007 wasbetween 60,000 and 85,000. That excluded ‘medicated tourists’,expatriates and ‘wellness tourists’ travelling for massages oracupuncture, and also excluded ‘patients who travel in largelycontiguous geographies to the closest available care’ so excludingsubstantial cross-border mobility. Omitting such groups revealedthat the largest single segment, with 40% of MTS, were patientsseeking high quality care in destinations like the United States andwho mainly came from the Middle East and Latin America. Thesecond largest segment (with 32% of MTS) were those seekingbetter care than they could receive in their less developed homecountries. Three remaining segments included those avoiding longwaiting times, and those seeking lower costs for necessary ordiscretionary procedures (Ehrbeck, Guevara, & Mango, 2008). Itthus challenged basic assumptions about the main MT categories,and that destinations were mainly in developing countries, thoughthe McKinsey report did not explain how their numbers werederived and segmented.

Industry commentators criticised the assumptions and defini-tions of the McKinsey report, and its exclusion of non-JCI (JointCommission International) accredited providers, patients whowere not in-patients (including many dental and cosmetic surgerypatients) and cross-border migrants, and argued that MTS numberswere more likely to be a ‘conservative estimate’ of over 5 million(Youngman, 2009). However this total included an unspecifiednumber of ‘wellness tourists’, on the grounds that their objectiveswere no different from those of other medical tourists, andaccepted largely uncritically various country estimates. DeloitteConsulting estimated that 750,000 Americans alone had goneoverseas 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 muchwelcomed in the industry. A subsequent study of United StatesMTCs concluded that industry estimates were invariably inflatedand numbers were more likely to be in accord with the McKinseyreport, although they excluded dental tourism (Alleman et al.,2011).

Combining notions of intent, procedure, and duration suggestsa more complex, somewhat hierarchical structure and typology ofmedical tourism with five overlapping but necessarily crude cate-gories. Firstly, elite patients travel frommany regions, including theGulf, to places like London, New York and Berlin for exclusive andcostly medical treatment, continuing a century long tradition.Secondly, rising numbers of patients, many part of the emergingglobal middle class that Bookman and Bookman (2007: 54) calleda ‘second tier of wealthy patients’, travel for cosmetic procedures,and have contributed to the emergence of Latin America and Asia asdestinations. Others move for cheaper and necessary services, forexample when their insurance is inadequate. These are the subjectof most of the literature, the targets of MTguidebooks and websitesand the popular conception of MTS. Indeed cosmetic surgery is thepopular image of MT (often non-essential, from entitlement ratherthan necessity). Those who are referred by national governments,usually not travelling for cosmetic procedures, may also be includedhere. Thirdly, there are diasporic patients, of diverse socio-economic status, from relatively affluent Maltese and Koreans to

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less affluent Mexicans, returning to their home countries fordifferent combinations of political, economic, cultural and healthreasons. Their numbers are much greater than, by omission, mostliterature implies. Fourthly, there are cross-border patients (whoinclude many diasporic patients), a long-established group inEurope (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 bynational health services. Fifthly, there are reluctant and evendesperate ‘medical tourists’, such as those from Burma or Yemen,moving at considerable personal cost, and those from developedcountries seeking ‘last resort’ or nationally unavailable health care.Like all other categories they would have preferred cost-effectivelocal treatment.

‘Medicated tourists’ and resident expatriates have beenexcluded from each of these categories. This typology is arbitraryand not homogeneous, especially without reliable data. Geographycomplicates classification; all other categories of MTS may also becross-border travellers. Flows are multidirectional; in middleincome countries elites may leave as others move in, while in highincome countries low and middle income earners may leave asother elites move in. A ‘geography of the body’, income, culture andlanguage influence choice of destination for different procedures.Preferred destination hierarchies exist in most countries, influ-enced by costs and procedures, hence flows frequently change (e.g.Kangas, 2002). Some procedures are trivial and others life-saving,relationships with ‘standard’ tourism differ, and rights in destina-tions vary, but this differentiation is both suggestive of realdistinctions between MTS, while indicative of the definitionalproblems.

No agreed definition of MT therefore exists and no looseumbrella term is wholly adequate. Agreed definitions are unlikelybecause 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 theamount of time and resources allocated to particular activities. Incircumstances where international travel for broadly medicalreasons is apparently increasing, but estimated numbers fluctuatewildly, a standard definition would be valuable. Objections to theterm ‘tourism’ rather than ‘travel’ centre on intentionality andprocedure, yet even where travel overseas is for crucial medicalcare, significant financial resources are required, and the experi-ence is scarcely pleasurable, medical travel is not simply ‘businesstravel’, being less purely functional because of the need for somerecuperation (and with most MTS being accompanied). Many MTSintend to and do engage in some ‘standard’ tourist activities withassociated expenditure (and, more so, those who accompanythem), 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 umbrellaterm that avoids value judgements over intentionality or the gravityand necessity of procedures. ‘Medical tourists proper’ and‘vacationing patients’ are the core of medical tourism, where someprior intentionality exists. Health and wellness tourists can beexcluded because of the absence of ‘medical’ procedures, but thereis no valid reason to exclude dentistry, audiology, cosmetic surgeryor check-ups, even where procedures are limited. Ultimately thereis a very diverse market ‘segmented by purpose, complexity andtype of care, and cost’ (Ramirez de Arellano, 2011: 290), wheredifferentiation is difficult, and adequate data are absent. Any defi-nition, however valid in particular circumstances, is unlikely to beuniversally useful, given the diversity and ambiguity of cross-bordermedicalmobility, but that is unimportant as long as distinctions anddefinitions are clarified. Unresolved conceptualisations of MT

intersect with parallel debates over tourism, where tourism is notnecessarily trivial and frivolous (Bell, Holliday, Jones, Probyn, &Taylor, 2011). Thus MT parallels tourism itself where this is seenas ‘a hybrid economic formation blending different industries, thestate, ‘nature’, the informal sector, the capitalist and non-capitalisteconomies, and all manner of technologies, commodities andinfrastructures’ (Gibson, 2010: 529). Yet, ultimately, and crucially,rigorous application of any definition is unlikely to result innumbers comparable with those touted by the industry.

6. Notes on numbers: dilemmas of quantification

Without definitions most of the numbers attached to MT,whether on flows, growth rates or income generated, are specula-tive, based on estimates, remarkably rounded (upwards) andoptimistic. Numbers are complicated by diaspora patients, expa-triates within countries, short term drop-ins, spa visitors,purchasers of pharmaceuticals and friends and relatives accom-panying patients (Connell, 2011a; Youngman, 2010a). No countriesproduce official data on medical tourism, since they have no meansof collecting them, and no hospitals release data verified by anindependent body. The numbers stated by some countries andhospitals are substantial exaggerations, but inflated figures implygrowth and success, and encourage private sector investment andnational support.

Focussing on one country e Thailand e a leading player in MT(and where diasporic MT is unimportant, since relatively few Thaisreside overseas), and one key hospital, indicates how numericaldiscrepancies exist and how some data correction is possible. MT inThailand covers many procedures from dentistry to cardiac surgeryand transplants to gender reassignment. Medical procedures arelinked in advertising to standard forms of tourism. By 1997 Bum-rungrad International Hospital in Bangkok was the largest privatehospital in south-east Asia, and the first JCI accredited hospital inThailand, with a staff of 950 full or part-time doctors. After theAsian financial crisis it aggressively targeted overseas clients,placing advertisements in in-flight magazines, encouraging trav-ellers on the national airline Thai Airways to use frequent flyermiles for executive physical examinations and offering variousdiscount packages. The hospital was redesigned, with executivesuites, to be more like a luxury hotel.

By the late 2000s Bumrungrad claimed to serve more than 3000patients a day, ‘to outperform other hospitals in the region’ and be‘perhaps the world’s first truly international hospital’ (BumrungradInternational Hospital, 2009: 1). It was said to have treated 360,000foreigners in 2005, as the hospital for the first time had overa million patients in a calendar year. Since then Bumrungrad hasbeen reported many times as having about 400,000 overseaspatients a year (Connell, 2011a). That claim was made in 2008,when Thailand itself claimed some 1.4 million foreigners visitingfor medical treatment. By 2009 it claimed just over 1 millionpatients, of whom 400,000 were ‘international’ patients, thereduction in numbers being attributed to the GFC and local politicalconflict. Dominating the front of its home web page, Bumrungradclaims to annually serve patients ‘from over 190 countries’, virtuallyall the 192 members of the United Nations.

Bumrungrad’s public data are based on outpatient visits (inwhich most procedures are completed within a day, hence double-counting is limited) and admissions (recorded once however longa patient may stay). Most patients come from South East Asia,mainly Thailand itself which accounts for about 600,000 of allpatient visits, few of whom are diasporic. Otherwise by far the mostimportant source region is the Gulf. Of the approximately 407,000patients who are not Thais, about 100,000 are local expatriates andaround 100e120,000 are ‘medicated tourists’ from in and near

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Thailand. Some of these (especially expatriates) visit more thanonce a year hence the absolute number of such patients is less than100,000. The remainder, around 200,000, constitute what Bum-rungrad distinguish as ‘fly-in’ medical tourists. Almost all thosefrom the Gulf (almost half this total) are ‘genuine’ medical tourists,arriving specifically for some procedure, as are the smaller numbersfrom China and Japan, whereas American, European and Austral-asian patients are more likely to be ‘medicated tourists’ than long-distance travellers. Bumrungrad states that the three ‘highestrevenue contributors by country continue to be the United ArabEmirates, the United States and Oman’ (Bumrungrad HospitalLimited, 2010: 59; my italics). A significant number of patientscross 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 inEurope, North America and Australasia. Comparable data from theBangkok Phuket Hospital have a similar structure (Connell, 2011a).This procedure could equally be applied elsewhere, were dataavailable and accessible. It reveals that the actual number of‘genuine’ intentional MTS specifically travelling to Thailand (andprobably also elsewhere) for medical treatment is lower thansuggested in most existing estimates, including those of Thailand.The closest examinations of MT data consistently reveal thatnumbers are fewer than usually publicised, accord with recentanalysis of American source numbers (Alleman et al., 2011) andoffer further support for the smaller numbers of the McKinseyreport.

7. Neo-liberalism, entrepreneurialism and tourism

Contemporary MT is a function of the growing privatisation andcommodification of health care, where the ability to pay hasbecome the key to obtaining medical care, discontent with publiccare (waiting time, efficiency and outcome), ageing populationsand greater demand for health care (especially cosmetic proce-dures), more disposable income, greater familiarity with distantcultures and regions, international accreditation of facilities, anddiversification of economies in middle income economies in Asia,Europe, the Middle East and Latin America (in the Asian case in thewake of the late 1990s financial crisis). As technology has improvedand diffused, and ethical boundaries stretched, the range ofprocedures has increased and diversity ensued. Some countries,like Singapore (and the US and the UK), have become both MTsources and destinations, and some hospitals have diverse func-tions: ‘modern well-equipped hospitals in some areas of the worldserve the dual role of regional referral centers for patients frompoor neighboring countries and, concurrently, function as low costmedical tourism destinations for patients from highly developednations’ (Horowitz & Rosensweig, 2008: 8). In a neo-liberal era ofgreater competition, free markets and deregulation MT is seen,especially in India, as a form of ‘medical outsourcing’, analogous tothe IT industry.

The greatest beneficiaries of the global restructuring of medicaltreatment have been a few countries, which have experiencedeconomic growth, technological change, return migration of skilledhealth workers, the growth of a middle class (who have demandedsuperior health care) and are major international airline hubs.Increased numbers of expatriates and the new middle classprovided markets for private sector hospital growth and subse-quent MT. While such factors were broadly positive the rise of MTwas also a response to the Asian financial crisis of the late 1990s.Subsequent years, as Asian countries sought alternative sources ofeconomic growth, coincided with the expansion of MT and theprivatisation and business orientation of the medical industry. Thecrisis destroyed the savings of much of the emerging Asian middle

class, who could no longer pay for private health care, hence privatehospitals lost their customer base and revised their marketingstrategies to target overseas patients, for whom devaluation meantthat prices effectively halved (Turner, 2007b). Malaysia andThailand both became involved after 1998. India entered the MTmarket rather later than south-east Asia but developed rapidlywithshifts in technology and the development of sophisticated hospitalchains. Entrepreneurial governments have become supporters andpromoters, through national development planning and tourismcampaigns. In India, Malaysia and Thailand, tax concessions weregiven to MT providers and tourism office campaigns for MT,alongside subsidies for land purchases and infrastructure (Alsharif,Labonté, & Zuxun, 2010; Chee, 2010; Gupta, 2008; Wilson, 2011).Asian successes have prompted growing global interest andcompetition, with optimism both unbounded and often unfounded.Difficult political situations, high costs, poor infrastructure,language differences, unfamiliarity and overstretched medical caresystems are constraints in several countries (Heung et al., 2011).While MTS flows 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, nationaltourism 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 goodluck, depending on the gravity of the procedure. Most MT guide-books were published in the mid and late 2000s and have not beenupdated, as the internet has taken over. Although the internet hasbecome crucial to marketing it only dominates in surveys of groupsof people who are not necessarily intending to be MTS (e.g. Gill &Singh, 2011) or where a medical tourism industry is being estab-lished (Ye, Qiu, & Yuen, 2011). A 2009 survey of an unknownnumber of international patients at Bumrungrad revealed thatmost learned about medical tourism through friends, and very fewthrough books and the media, with a quarter of Bumrungradpatients using the internet for information on country destinationsand hospitals (Anon, 2010). Further studies have shown that themain influence on the majority of MTS at Bumrungrad and 60% ofthose in Kuala Lumpur hospitals was advice and referrals fromfriends and family (Musa, Thirumoorthi, & Doshi, in press;Veerasoontorn, Beise-Zee, & Sivayathorn, 2011). In a general surveyof MTS, with no information on methodology or sample size, 49%found out about MT through the internet and 73% sought specificinformation on the internet, as opposed to through friends, booksor MTCs (Anon, 2009). In Oman more than 70% of medical touristsgot their information from friends and a further 19% from family(Al-Hinai, Al-Busaidi, & Al-Busaidi, 2011). Asians (or at leastChinese, Japanese and Koreans) preferred recommendations fromfriends rather than the Internet (Yu & Ko, 2012), and in a largesample 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 MTevolves word of mouth appears to be becoming more important,with the internet simply a means of checking, corroborating andbooking. How people use the internet, which websites they visit(whether of MTCs, hospitals or countries) and how they assess theinformation is largely unknown. Whether a ‘digital divide’discriminates against potential users in some places is similarlyunknown (Lunt & Carrera, 2010).

The growth of MT has been accompanied and reciprocated bythe 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 dealer-ships of the global health-services industry’ (2007a: 127), beyondthe bounds of ethics or fiduciary duty, but they are little different

J. Connell / Tourism Management 34 (2013) 1e13 7

from most travel agents. Indeed MTCs work ‘like specialized travelagents’ (Herrick, 2007: 6), some with branches in different coun-tries andwith affiliations to hospitals, hotels and airlines. Almost allwere established in this century, but most are reticent about theirhistory, and many have been short lived (Cormany & Baloglu, 2011;Turner, 2011). Hundreds of MTCs exist in both source and desti-nation countries; Reisman suggests ‘almost 1000 niche facilitators’(2010: 70) while Treatment Abroad has a directory of 820 regis-tered companies.

Most MTCs are small. In the United States MTCs had a mean of9.8 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 surgeryrecipients themselves, hence had personal links with the industry,promoting their work as a service rather than an industry, and withfew if any employees (Ackerman, 2010; Bell et al., 2011; Jones,2011). Several larger MTCs have operations spanning the sourcecountry and sometimes multiple destinations. Some MTCs takea more or less global perspective on the provision of medicaltourism, but most MTCs limit themselves or are limited to partic-ular markets, destinations and procedures e usually about fourdestinations e where they claim specialist knowledge, and canclaim to vouch for reputation and experience (Peters & Sauer, 2011).MTC websites have multiple linkages to countries, hospitals andclinics, patient stories and testimonials (sometimes in videos),press reports, virtual tours of particular facilities and interactivesections for obtaining quotations. All are commercial sites,complete with advertisements and linkages, for insurance, hotels,travel companies, sources of finance and related MTCs. Such sitesraise awareness, create a perceived need, offer multiple possibili-ties, stress benefits, emphasise normality, refer to pleasant tourismcomponents and encourage potential patients to enquire further.

The MTC websites emphasise hospital accreditation and thepragmatics of international travel, with United States sitesproviding more detail on what is likely to be an exceptional expe-rience; all stress affordable, timely, high-quality, reliable care withthe latest technology (Cormany & Baloglu, 2011; Lunt & Carrera,2011; Sobo et al., 2011; Turner, 2011). Few mention any actualrisks of treatment, although Canadian MTCs were more likely to doso (Connell, 2011a; Penney, Snyder, Crooks, & Johnston, 2011), butemphasised patient agency and savvy consumerism. They refer to‘medical tourism’, perhaps as a purposive strategy to reduce patientfears (Sobo et al., 2011), so promoting the benefits of overseastreatment while playing down the risks (Mason & Wright, 2011).Procedures are advertised and promoted in ways that make themacceptable and not challenging. Gorgeous Getaways in Australia haspackages described as Yummy Mummy, Fabulous Facelift and evenDesigner Vagina (Weaver, 2008). Some MTCs encourage contactbetween aspiring and former patients, sometimes at forums. Asurvey of MTS at Bumrungrad revealed that over half (52%) hadacquired their knowledge of country destinations and hospitalsthrough 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 domi-nance of MTCs within MT. All MTCs stress safety and reliability, byreferring to accreditation, staff credentials and testimonials ofrecent patients.

Beyond the ubiquitous focus on price and reliability, the thirdfocus of MTCs is tourism, often linked into a package. The merits ofparticular countries (and their people) as tourist destinations areusually covered. Thus MedRetreat states: ‘Imagine travelling toexotic locations like Thailand, Malaysia, India, Argentina and SouthAfrica in perfect anonymity with a personal assistant at your side’(www.medtretreat.com). As one Indianweb site advertisement hassuggested ‘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 possibil-ities much more than the actual health providers.

Health providers also advertise on the web, and most intendingpatients refer to the websites of potential hospitals and clinics.Their primary focus is on available procedures, reliability, qualityand cost, but the last is somewhat downplayed, except in Asia(where prices are lower), on the assumption that most potentialpatients have already discovered that element. Images of moder-nity, via technology, cleanliness and apparent efficiency are domi-nant. Mainly English language sites feature the range of possibleprocedures, costs, accreditation and affiliations, smart and qualifiedstaff, lavish wards and accommodation, patient testimonials anddiverse language competence. Technological prowess is rarelyignored 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 itsfacilities, such as internet connections), and links to hotels andother tourism providers. Websites stress the hotel-like quality andamenities of the hospitals, like restaurants, and related servicessuch as airport transfers and visa extensions.

The hospitals at the core of medical tourism have transformedthemselves from the functional and clinical public hospitals thatpreceded them, taking on elements of elite hotels, IT offices andshopping malls, with an architecture projecting ‘the corporatehospital as anything but a hospital’ (Lefebvre, 2008: 102). Foyersresemble hotels rather than hospitals. In elite hospitalse ‘hospitels’e five-star rooms have personal VCRs, restaurants provide respitefrom ‘hospital food’ and at Bumrungrad Japanese and Italianrestaurants, McDonald’s and Starbucks are all on the first floor. Inform and function the key hospitals in themedical tourism industryhave come close to luxury hotels, in a transition where consump-tion and consumerism have been added to cure and care. Ratherlike such hotels, they too have become ‘non-places’: placeless andlargely indistinguishable (Augé, 1995), and thus more like the basicelements, the hotel chains, of the international tourism industry.

Some hospitals and hospital chains have become functionallyintegrated into the tourist industry. Bumrungrad owns 74 servicedapartments. The principal hospital group in Singapore, Raffles,arranges airport transfers, books relatives into hotels and arrangeslocal tours. Hospitals have also become linked to airlines. BangkokHospital is linked with AirAsia, Bumrungrad has an agreement withFlight Centre for North American patients. Turkish Airlinesannounced that they were working with the major nationalmedical tourism providers to provide discounted fares for MTSfrom the United States and various European countries. Keyhospitals have become more like MTCs, and multinational ‘multi-product firms’, part of integrated systems where, if not owningcomponents of the travel industry, they are closely integrated intoit, with preferential arrangements with particular hotels, airlinesand related companies. Numerous countries and their touristindustries, from Jamaica to China (Heung & Kucukusta, in press;Pearcy, Gorodnia, & Lester, 2012), remain anxious to participate inevery facet of the industry.

No health care sector is as competitive and consumer-orientedas MT, since some procedures do not need be undertaken, andmost are possible in many countries, usually including homecountries. Beyond obvious information about price differentials andquality of care, the discourses of marketing MT have taken ondiverse themes that emphasise the ambience and even opulence ofcare. Marketing has had the considerable task of convincingpatients to abandon uncertainty and fear, even xenophobia, trustoverseas hospitals and health workers in different cultural contexts(even though diasporic tourism led the way), at a time of personaluncertainty and even crisis.

J. Connell / Tourism Management 34 (2013) 1e138

8. Engaging in medical tourism

Few studies assess who are the majority of MTS, where theyhave come from and gone to, and why they are where they are.While much literature assumes or implies that most are relativelywell-off visitors from developed countries (from the north and theGulf) to poorer countries, mostMT is across nearby borders, and notnecessarily to poorer countries. Geography and culture influencemobility. Language barriers, financial constraints and lack ofinformation limit willingness to travel; older people, women andunskilled workers are least willing to travel, evenwhere substantialcost savings are involved, so perhaps forgoing medical care.

The basic rationale for MT has been widely addressed andcentres on reduced costs overseas, the lack of certain treatmentsand long waiting times at home, partly related to greater demandfor services: primarily an economic basis frequently summarised as‘first world health care at third world prices’ (Ormond, 2008;Turner, 2007b). That basic rationale is modified by cultural andgeographical factors; MTS generally choose to go to countries in thesame language area, or where English is spoken, and in similarcultural contexts (a circumstance that includes religious similarity).Geography influences mobility and most MT is over short distancestypified by border crossings from the United States intoMexico (notonly of Mexicans) and from southern China into Hong Kong, butwhere even language and other cultural similarities do not preventsome discrimination (Ye et al., 2011). Facility in English hascontributed to South African success (Mazzaschi, 2011).

Mexican migrants in the United States, especially when close tothe border and uninsured, tend to return toMexico for medical care(Brown, 2008; Horton & Cole, 2011). ManyMTS are diasporic wherethe cultural context enables ease of communication and compre-hension of complex procedures while enabling patients and theirfamilies to visit friends and relatives (Inhorn, 2011b; Lee et al.,2010). Both Korea and Taiwan, neither of which are low costdestinations, have sought to develop larger MT industries from thisfamilial starting point.

Various destinations have responded to MTS cultural require-ments through language training for staff, distinctive food prepa-ration, prayer rooms and separate wards and floors (Connell,2011a). Religious variations may be important within a broadercultural context; Sunni and Shi’a branches of Islam have differentperspectives on assisted reproductive technology so that Shi’aMuslims in countries where Sunni Islam dominates may travel toIran, where the converse is true, for fertility treatments(Moghimehfar & Nasr-Esfahani, 2011). MTS may also escapegovernment regulations, usually restricting particular medical andcultural practices, but also including China’s one child policy (Yeet al., 2011). Loose notions of ‘cultural’ preference, often invokedby return migrants, that might include rapid service, personalattention, effective medication, privacy and clinical discretion, mayactually be phenomena associated with private hospitals (Horton &Cole, 2011). While tourist attractions are rarely considered to beimportant (cf. Moghimehfar & Nasr-Esfahani, 2011) minimalaccessibility to basic tourism infrastructure is significant (Connell,2011a). Moreover when MT is extended to cover ‘medical touristsproper’ and MTS are accompanied, as most are, tourism and touristfacilities become highly important (Yu & Ko, 2012).

Within this broad economic and cultural rationale medical skillsand facilities are crucial in destination choice. ChineseMTS in Koreavalued medical skills far above other factors in choice of destina-tion, and were more focused on the medical experience thanJapanese who also valued the tourist experience (Yu & Ko, 2012).International MTS at Bumrungrad similarly emphasised the qualityof medical care (Veerasoontorn et al., 2011). But care is set againstcost. In Jordan, the leading destination in the Middle East, MTS

mainly come from low- income Arabic speaking countries such asYemen, Sudan and also Libya, where the doctor: population ratio islower, and the skills of doctors perceived to be weaker (Smith et al.,2009: 163). However half of all Omani medical tourists went toThailand and a third to India e since they were cheaper destina-tions e rather than remain in the cultural region (Al-Hinai et al.,2011). Elite Gulf MTS usually go to Europe. Malaysia has experi-enced a rise in MT from Indonesia because of rising costs inSingapore. Cost may result in more distant moves.

Attempts have been made to model decision-making proce-dures but most have made sweeping assumptions about causality,or excluded key variables. Smith and Forgione’s (2007) two stage-model argues that MTS first select a destination and subsequentlyconsider the medical and tourism facilities at that destination, yetfew data support these stages or that order (Heung et al., 2010,2011; Lee, Han, & Lockyer, 2012; Ye et al., 2011). More studies haveconcluded that the cost, availability and reputation of health carefacilities are of primary importance with destination of lessersignificance (e.g. Musa et al., in press) other than for diasporic MTS.

Most studies of MT have been undertaken in developed countrysources and hence have tended to imply that most MTS come fromthese countries, or from the Gulf. In Asia numbers of MTS from theGulf were boosted after 9/11 in 2001 and it remains a major Asiansource. As studies have increasingly been undertaken in destina-tions the significance of regional movements has become moreevident. More than 80% of overseas patients in Tunisia, Singaporeand Jordan come from neighbouring countries (Lautier, 2008). In2005 those who came to Singapore for medical treatment camemostly fromneighbouring countries, especially Indonesia (52%) andMalaysia (11%) (Khalik, 2006). Singapore has however seen a shift ofits market from Indonesia to the Gulf, alongside greater numbers ofethnic Chinese from a diversity of sources. In Malaysia a survey ofMTS at five Kuala Lumpur hospitals revealed that almost half (48%)were from Indonesia, with less than 10% from Australia, New Zea-land, the Philippines and India (Musa et al., in press). Further nichesare significant within regions. In Asia perceptions of body images,and the broader context of Korean popular culture, have resulted inKorea becoming a cosmetic surgery destination for several parts ofeast and south-east Asia (Connell, 2011a; Yu & Ko, 2012).

Even fewer studies provide data on the economic impacts of MTand country estimates are rarely based on fact or analysis. Most failto differentiate health expenditure from travel and tourismexpenditure, consider the duration of stay of MTS in destinationsand may or may not include patients’ relatives and friends. Witha lengthy period of recuperation, the rewards to the touristindustry, and especially the hotel sector, may be greater than withstandard tourism. Cosmetic tourists stay longer than other MTS butdo little more than stay in the hotel, eat and shop (Ackerman, 2010).Diasporic medical tourists who are visiting friends and relativesmay stay even longer.

In Tunisia the direct expenditure of MTS on health alone (cliniccosts, doctors’ fees and pharmaceuticals) was estimated at $55million in 2004, about a quarter of the total earnings of all privateclinics, and thus a substantial input to the health sector (entirely tothe private sector, in the two largest cities). Adding to that the totalexpenditure of patients and relatives in the hotel, food and trans-port sectors (based on an average length of hospital stay of threedays and outside stay of two days, and about 1.5 relatives perpatient) brought the overall expenditure figure to $107 million(Lautier, 2008). Almost exactly half of all expenditure was thereforeoutside the health sector, and half the jobs created were alsooutside, but broadlywithin tourism-related service sector activities.

Every estimate suggests that MTS spend more that standardtourists, usually about twice as much, because of the high costs ofmedical services. An Indian MTS apparently spends $7000

J. Connell / Tourism Management 34 (2013) 1e13 9

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 medicaltreatment ($3742), followed by international airfares ($1187),accommodation ($1038), food and drink ($468) and domestictransport ($159). Expenditure on evidently tourism-related activi-ties 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 (Musaet al., in press), whose expenditure was not estimated. Had thatbeen included already substantial expenditures would have beenmuch greater. Those accompanying MTS in Thailand spend abouttwice as much as the MTS themselves on hotels and tourismactivities (NaRanong & NaRanong, 2011). The whole infrastructureof the tourist industry (travel agents, airlines, hotels, restaurants,taxis) benefits considerably from the new niche. This partlyexplains why some hospitals have sought to diversify into tourism,why growing numbers of MTCs have played integrative roles andhow offshore medical care has stimulated tourism for some whohad never hitherto been overseas.

What proportion of MTS engages in ‘standard’ tourism is largelyunknown. Few studies have been undertaken. Most MTS in China,India and Jordan engage in some form of tourism such as sight-seeing, shopping and enjoying local culture (Alsharif et al., 2010). Atleast half the MTS in Kuala Lumpur engaged in shopping, organisedtouring or other recreational activities, including visiting relatives(Musa et al., in press). Some 85% of Bumrungrad patients stated thatthey and/or their companions had done some tourist activities suchas sightseeing, shopping, eating out or ‘enjoying the local culture’(Anon, 2010). While most Australian cosmetic tourists in Bangkokstressed such touristic phenomena as the comfort and value of theirhotels, the food and the intent to take part in tours e which theysubsequently did (Jones, 2011)e very few of a group ofMTS in Indiawere intent on vacationing after treatment, though accompanyingrelatives and friends did engage in tourism (Solomon, 2011). Atleast passively MTS make some contribution to the local economy,like other tourists, through expenditure on hotels, transport andfood, even if not necessarily anxious to do more.

MT has become an unusual but valuable niche in the increas-ingly competitive travel industry. While many painful activities,such as transplant surgery, have no relationship to the pleasure andeven frivolity usually associated with tourism, most MT has paral-lels in other forms of tourism, and obvious impacts on the tourismindustry. ‘Bikinis and bandages’ (Bell et al., 2011), analogous to ‘sea,sun, sand ...and surgery’ (Connell, 2006), symbolise perhapsimperfect and flawed vacations. Ironically, the more dramaticsurgical procedures that may seem to define MT, are the leastamenable to linkages with tourism. Other kinds of niche tourismmay be uncomfortable, unpleasant and even dangerous or life-threatening: 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 latterwhere tourists often travel independent of other family members,and spend most of their time engaged in activities that otherswould find dull, or bereft of pleasure and relaxation. All suchactivities at least minimally benefit the infrastructure of tourism. IfMT may sometimes seem devoid of hedonistic pleasures e equallytrue of other tourism niches e the long term outcomes may still beexceptionally pleasurable.

9. Ethics

MT has raised ethical questions centred on issues of accredita-tion and quality of care (and after-care), the validity of particular

‘extreme’ procedures (often not undertaken in the patients’ homecountries) and its impact on the health care of nationals in desti-nation countries. Most recently concern has mounted over possiblebiosecurity risks from the spread of infections and pandemics byreturning MTS (Hall & James, 2011). The ethics of media depictionsof body shapes, involving the pathologising of (usually) women’sbodies and invocations to change have also been questioned (Buote,Wilson, Strahan, Gazzola, & Papps, 2011; Sarwer & Crerand, 2004).Inherent inequality has posed complex bioethical questions, espe-cially for new and experimental procedures where a variety ofdifferentiated and geographically distinct practices are subordi-nated to the ‘logic of the market’ (Parry, 2008) in contexts whereregulation is weak.

The most distinctive feature of MT is that it takes patients acrossinternational borders, beyond the perhaps comfortable and familiarcultural relationships sometimes built up over years betweenhealth care providers, doctors and patients, to places that may beculturally, climatically and linguistically distinct and unfamiliar. Fordecades health systems, in countries such as India, have beenconventionally regarded in the west as inadequate. Cautionarynotes have come from professional bodies in source countries,whose members may have to remedy botched procedures andcomplications (e.g. Connell, 2011b; Dalstrom, 2012). Both thehospitals (and MTCs), who publish positive testimonials, and theprofessional bodies, who recordmisadventure, have obvious vestedinterests. Real rates of success and failure are immeasurable: thereis no means of recording this, and no guidelines against which tomeasure success rates, especially in such areas as cosmetic surgerywhere disappointments and failures may be more frequent.

Complex procedures that have attracted ethical concerns haveincluded stem cell therapy, surrogacy and even ‘death tourism’ oreuthanasia (e.g. Higginbotham, 2011; Inhorn, 2011a) some of whichhave been described as ‘rogue medical tourism’ through concernsover safety, inadequate evidence of effectiveness of the proceduresand moral acceptability (Hunter & Oultram, 2010). On thesegrounds some procedures, such as ‘transplant tourism’, have beendistinguished from the wider body of MT (Bagheri, 2010). In thecontext of reproductive tourism, although travellers are consumingtourism products (e.g. transport, accommodation, food), regardingthis as ‘tourism’ is to devalue the journey by implying that it isprimarily a novel cultural experience (Pennings, 2002) yet not alltourism is merely a novel cultural experience. Transplantationbrings together patients on long waiting lists, the ‘parsimoniouspayers of their expensive dialysis (states, insurers and providers)’,travel and tourism industries and ‘the impoverished men andwomen who can sell nothing but their body parts’ in an extremeform of ‘neoliberal globalization’ (Epstein, 2009: 134) or ‘neo-colonialism’ (Buzinde & Yarnal, 2012). Few of the limited benefitshave trickled down to impoverished vendors, the poor have lesschance of receiving organs and transplantation success is limited indifficult medical and social circumstances where medical care isprobably substandard (Turner, 2007b, 2010). Transplant tourism isalso problematic since failure rates are high, and patients may alsocontract transmissible infections.

More than most forms of human behaviour, reproductionappears a private and intimate affair, yet it is bound up in nationalpolicies (for example towards abortion, provision of contraception,family sizes and one-child families). Partly in response, reproduc-tion has ‘gone global’ through transnational adoption (recentlyinvolving prominent film and popular music stars), fertility treat-ment and reproductive tourism, in what has been described asa ‘global market of commercial fertility’ (Prasad, 2008: 37).Reproductive tourism occurs where people travel to access suchreproductive technologies and services as in vitro fertilisation (IVF),sperm and egg donation, sex selection and embryonic diagnosis,

J. Connell / Tourism Management 34 (2013) 1e1310

and surrogate parenthood (Martin, 2009; Whittaker, 2010) and, theconverse, abortion, contraception and vasectomies. Unlike mostother contexts where biomedical ethical principles occur (Connell,2011a, 2011b) some standard tourist potential is apparent and it haseven been termed a ‘procreation vacation’. New reproductivetechnologies nonetheless raise diverse ethical questions aroundindividual and state responses to liberty, rights and autonomy.

Health care systems in developing countries, some of the maindestinations of MTS, are notoriously uneven, and often becomingmore so, in circumstances where both urban bias and the decay ofremote and regional facilities have long occurred. Such central-isation has been hastened by privatisation, stagnant budgets forhealth expenditure and, possibly, by MT. Yet, despite considerableconcern, most of the literature on the broad socio-economic impactof MT ‘is “data free” and based on theory, assumption and conjec-ture’ (Lautier, 2008: 102). Detailed analysis of the national impactsof MT is yet to occur and evaluations of its social and economicimpact on local populations are scarcely even fragmentary(Connell, 2011b). However in some contexts ‘a dual medical systemhas emerged in which specialization in cardiology, opthalmologyand plastic surgery serves the foreign and wealthy domesticpatients while the [majority of the] local populations lack basicssuch as sanitation, clean water and regular deworming’ (Bookman& Bookman, 2007: 7). Such situations characterize India andoccur less dramatically in Thailand, Malaysia and elsewhere(NaRanong & NaRanong, 2011) and may be accentuated by themigration of skilled health workers from rural and regional areasand from the public sector into the private sector, that includes MT.MT has thus been described as an ‘elite private space ... inextricablylinked to a beleaguered national medical program’ and a ‘reversesubsidy for the elite’ (Ackerman, 2010: 403; Sengupta, 2011: 312).In South Africa it also emphasises the ‘racialized inequality inhealth care’ (Mazzaschi, 2011). In rare contexts, such as Hong Kong(Heung et al., 2011), local interests have consequently opposed MTon ethical grounds. More frequently uneven development atmultiple scales typifies the globalisation of health care.

10. Conclusions and directions for research

Medical tourism is difficult to define, the effort is usuallyunproductive (since diversity is considerable) and more detailedstudies of most categories of MTS are required. It is neverthelessone niche within tourism, even if parts of the industry prefer thegravity, responsibility and trustworthiness associatedwith ‘medicaltravel’ or ‘medical migration’ (Helble, 2011; Thompson, 2011).However it makes sense to subsume all cross-border movementsfor medical care under the term ‘medical travel’, but recognise that‘medical tourism’ will continue to be used for many components ofthat mobility. In the absence of agreed definitions and rigorousdetailed studies, caution will continue to be required in assessingnational and industry estimates. Even with agreement on defini-tions, the significance of clandestine and diaspora movementsalongside inaccessible medical data make imprecise statisticsalmost inevitable.

It is increasingly evident that MT remains largely regional, crossborder and diasporic, but with the potential to becomemore global.A preference for rich-world medical tourists, and media fixation oncosmetic surgery, have distorted some accounts (and numbers) andconfused preferred markets with actual markets (Connell, 2011a;Ormond, 2011). Numbers of ‘western’ medical tourists are fewerthan usually intimated, while diaspora and intra-regional numbersare considerable. With rare exceptions, notably Thailand, ironicallyone of the most successful, MT is concentrated in ‘backyards’ not‘playgrounds’. Of the major southern destinations only those insouth-east Asia have medical tourism markets where diaspora play

a limited role. Active government support, flexibility, moderntechnology, effective marketing and an existing infrastructure withevolving links to hospitality, tourism and transport industries havebeen invaluable there. In some Asian countries MT is marketed aspart of the tourist industry, and generally facilitated by new MTCs,that function like travel agents.

Market mechanisms have become increasingly important. Thegrowingprivatisationof health care, its shift from traditional notionsof ‘family doctors’ and neighbourhood care, and consequentlygrowing international competition for markets, has meant thatmedical care is increasingly global rather than local, and to be tradedrather than perceived as a right. The outsourcing of medical care,through MT, shows that even the most seemingly location-specificactivity is mobile. Tensions between national policies of promotionof health care within states and international strategies to generateincome through promoting mobility between states have emerged(Pocock & Phua, 2011), alongside various ethical issues.

In this emerging nexus of complex privatisations, links withcomponents of the tourism industry provide institutional evidencethat medical procedures overseas are not merely of clinical interest.MT is niche tourism, a form of tourism that may bemore sustainableand sophisticated, with segmented marketing mechanisms andmedia, and where tourists engage in only a fraction of the activitiespossible at a particular destination (Connell, 2009; Robinson &Novelli, 2005). With its significant diasporic element MT is alsoa formofVFR tourism.Mostpatients have some time for conventionaltourism. That may not be strenuous or energetic, but shopping,sightseeing anddining are relaxing, recuperative andenduring forms.

MT has transformed the geography of international health care,but much of what has beenwritten of this transformation has beenspeculative, optimistic and distanced from detailed documentationand analysis of MTS mobility. Websites have been examined indetail but the users of the sites and the eventual MTS remain moreshadowy presences. Little is yet known of how medical touristschoose destinations, how choice processes differ from those ofother tourists (Cormany & Baloglu, 2011), which factors are mostinfluential and what medical procedures are most likely to result inMT. Consequently the age, gender and ethnic composition of MTSflows is largely unknown, as are themedical and touristic outcomes.A consensus exists on the need for better surveys of decision-making and the balancing of ‘hard data’ (performance measures)and ‘soft intelligence’ (website and personal recommendations)(Lunt, Mannion, & Exworthy, in press) though the former are rarelyparticularly ‘hard’ or accessible. That will eventually enable moresophisticated analysis and modelling of MTS behaviour.

Few branches of tourism and even fewer of medicine appear soreliant on the web as a source of information, yet key sources ofinformation and familiarity are shifting from the internet to friendsand relatives. Many MTS learn of destinations and opportunitiesfrommedia stories and through the recommendations, experiencesand advice of friends and acquaintances and, as interest increases,through internet websites, but how such diverse influences shape(or discourage) mobility is largely unknown. Whether that variesaccording to region or procedures is similarly unknown, as is therelationship between ‘need’ and destination, and how certainprocedures (including cosmetic surgery) align to notions of self-help and entitlement overseas rather than more traditional,locally-based patientedoctor relationships. Equally what sourcesprove the most reliable and acceptable are likewise uncertain. Therole 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 betterunderstood, and is likely to be highly variable.

A better understanding of howMTCs (and their websites) shapeand steer choice of destination will provide more clarity on how an

J. Connell / Tourism Management 34 (2013) 1e13 11

increasingly global market place works e for a distinct form ofmobility and tourism where technology, cost and place are inter-related e and thus on how some therapeutic places have becomeparticularly successful e for therapy or place eand what are themost effective and attractive combinations. Aspiring destinations,and there aremany of these, have engaged inmarketing from a verylimited evidence base.

Remarkably little is known about the behaviour of MTS (andtheir ‘supporters’) in terms of duration of stay, economic expendi-ture and activities, and the extent to which medical and touristexpectations were accomplished. The performative and embodiedexperience ofMTandmedical care has rarely been examined (Cook,2010; Jones, 2011; Solomon, 2011). Little is known about whetherMTS expect to engage in ‘an encounter with a particular culture’(Bell et al., 2011) or whether the encounter is intendedly entirelyfunctional. Once again experiences are likely to be variable and bevery different for diaspora MTS or those ‘whose tourist experiencemay be limited to a few painful days in a cheap hotel room’ (Bellet al., 2011: 14) How the experience of MT is different from otherforms of niche tourism remains to be explored. What then are themedical and social experiences of MTS especially where they enterother cultural contexts and when they return home (where after-care may be lacking), and do MTS see themselves as patients,travellers or tourists e or some fluid combination of these e and dosuch distinctions vary or matter?

Ultimately surprisingly little is known about cross-bordermobility, even in Europe, despite its considerable and regulatedsignificance (Glinos, Doering, & Maarse, 2012). Medical mobility indeveloping countries is even more poorly understood. Much moreneeds 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 filter through medical tourism’s broaderdiscursive formation’ (Solomon, 2011: 109). Both groups aresignificantly different in a range of ways from other MTS but havebeen largely ignored in the literature (and media). Here and else-where cultural and ethical perspectives, including how MT maydistort the structure of health care and health equity in destinationsare only beginning to become apparent. The emerging and evolvinglinks between MT, national governments (in regulation, promotionand branding of MT), insurance companies and the tourismindustry e within a parallel globalization and corporatization ofhealth care, travel and tourisme have attracted some attention, butmuch more must be learned from and about this diverse, dynamicand multi-faceted industry.

Acknowledgements

I am indebted to Kenneth Mays for helping to unravel theBumrungrad admissions data.

I am indebted to Meghann Ormond and Nicola Pocock forcomments on a much earlier version.

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John Connell is Professor of Geography, School of Geosciences, University of Sydney.