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ise of Medical Tourism

Introduction

Medical Tourism is an upcoming type in the tourism industry. It could be for different reasons and different treatments in all kind of different places. Tourism for medical purposes is a well known phenomenon that has changed over the years, decades and ages.  Some of the earliest forms of tourism were used to improve health or were just good for the body and mind. The Greeks already had their kind of health tourism, such as the spas and meditations. This is an old phenomenon that still exists. People have different reasons to travel, explore or go on a holiday. But the main reason is usually for some kind of relaxation or break from everyday life and their stressful moments.  Trips may also include sports, walking, cycling or mountaineering, which can be seen as healthy However, this is not what medical tourism is actually about. Medical tourism can be defined as the process of traveling outside the country of residence for the purpose of receiving medical care. Medical tourists choose to travel across international borders to receive some form of medical treatment. The following paper will be about the rise of medical tourism in the last years. The rise of medical tourism is a consequence of medical, political, social, economical and technological developments over time. This paper will start by discussing the beginning of medical tourism and then move on to medical tourism nowadays. Where the different aspects of medical tourism will be discussed. The most important topics will be about the development over time that brought us to today's medical tourism.

Medical tourism over time

The first recorded kind of medical tourism dates back to more than 2000 years ago, when people travelled from around the Mediterranean to Epidaurus in the Peloponnese. The supposed birthplace and sanctuary of the god of healing: Asklepios, the son of Apollo. (Connell, 2010) The most well known types of medical tourism are wellness and spas. These types of medical treatment exist for centuries already. It started with the rise and fall of spas. Around 1700 BCE water was recognized with having healing abilities. The spas where used in Europe but also in many other places. For example, in Asia it was a well known phenomenon too. The spas and hot springs flourished from the end of the 19th century. It became a common use for the so called high society. Doctors even started to recommend these places. (Connell, 2010)

The motives for pilgrimage varied from concern for the afterlife to the desire for benefits in the present life, such as fertility, healing or simply good luck. (Connell, 2010) Hills and mountains became some kind of health tourism later on without any real spiritual or ritual relevance. “Sanitoria were constructed in countries like Switzerland, as people with tuberculosis were encouraged to go to mountain areas, while those with bronchitis or rheumatism went to the seaside''. (Connell, 2010) People started thinking that seawater has healing capacities and climate therapy as a whole became more popular. Because of the industrialisation the cities were seen as dirty and not very fresh places. So people visited places outside their usual environment with ‘cleaner' air and water.

In the old days the use of natural elements was important for medical tourism, but nowadays we see a different process. New developments in the world and healthcare caused a lot of changes in the medical tourism. As it gets easier to travel around the world, there is a rise in the medical treatment people seek. People have more opportunities to get medical care. Nowadays a lot of people travel from place to place to undergo surgery or other treatments. Medical tourism, where patients travel abroad for operations, has grown rapidly in the past decade. The rise of medical tourism emphasises the privatisation of health care, the growing dependence on technology, uneven access to health resources and the accelerated globalisation of both health care and tourism. During the 20th century people travelled from the less developed countries to other places in the world for better medical treatment and better educated/trained medics. However, at the end of the 20th century this reversed. Now people travel from ‘developed' countries to ‘less developed countries' for medical treatment.

Developments

The concept of traveling for health care is certainly not new. In the seventeenth century, the wealthy of Europe travelled to spas and specialized hospitals on the Nile. However, it has been only recently that travelling across the globe has been safe, fast and inexpensive enough to support the resort hospitals that cover the the medical tourism service industry. An aspect that drives people to do this kind of medical treatments is because of the globalisation and decline of time-space compression. Think about the declining costs and travel time of air transport or the access to the internet. The uprising of air transport is of course of huge importance for the tourism industry. These days it gets easier to travel to other places around the world for affordable prices. When travelling gets easier, every tourism niche will increase. This is also the case for medical tourism.

The most recent growth of medical tourism has been in the middle-income countries of Asia, Latin America, Eastern Europe and the Mediterranean. These countries have been able to develop high quality medical services (in some places), they have reasonable infrastructure and hotel facilities and have often some connections with the tourism industry. Besides medical tourism, many also have other tourist highlights. (Connell, 2010) In these destinations the development of medical technology and surgical skills are important to increase the trust of the costumers. The emergence of a middle class with new needs, privatization and restructuring after economic problems encouraged supply. Furthermore, prior to the last 15 years, surgical procedures, hospital stays, and other health care options offered at medical tourism destinations were either not competitively priced or not of competitive quality compared with care offered in the United States or Western Europe. (Connell, 2010) In many developing countries a growing elite with capital and contempt for local medical care enhanced demand. The rise of high quality medical care in ‘developing' countries is of course of big importance. People are more willing to travel for medical purposes, when they know or ‘think' that the services are of high quality.

Several improvements in healthcare and curing diseases is an important factor for the increasing medical sector. 1955 was assumed the year of the first polio vaccine that was safe and effective. (Tansey, 2015) At the moment it is well known, that we can achieve a lot with medical treatments. The first medical simulators, an example of the medical developments, were simple models fashioned from sheep lungs and liver, used by temple priests in ancient Mesopotamia for instructing disciples and predicting the course of future events. With the ongoing advances in computer and medical graphics, software design and hardware manufacture, medical simulators were refined to offer virtual, life-like replication of medical and surgical procedures. With that said, the sooner simulation training can be used to support developing technologies and procedures. (Kunkler, 2006) There are now even future science fiction stories that could be possible to reach. A lot of medical advances were predicted before. Inventions like the MRI and CT-scan are some developments with huge importance and examples of medical improved technologies. (Boulos, Hetherington and Wheeler, 2007) The medical developments are still going on in the medical industry. A good example that is more recent, is the potential of 3-D-virtual worlds in medical and health education. Of course when more medical treatments are available, more diseases or medical problems can be treated. Of course there will be more medical treatment in general. The different improvements and changes in the world of healthcare contribute to the rise of medial tourism.

Stem cell tourism has similarly become a new phenomenon, with companies marketing injections of stem cells as life-changing treatments. Embryonic stem cells are much valued for their ability to grow into any other kind of tissue, but their use is controversial and the basis of ethical debates because a human embryo must be created to obtain the cells.

The most extreme forms of travel, where the word tourism fits least easily, are those of patients beyond cure who are seeking euthanasia. In recent years this has brought a stream of people and so called ‘death tourists' over the world.

Medical tourists must be convinced to travel, promoting and marketing medical tourism is a considerable challenge. Virtually no standard travel agencies market medical tourism. More than in any other form of tourism, the internet plays a critical role, it is helpful for all kinds of tourism. (Connell, 2010) There are big changes in the advertising strategies, where of course the invention of internet is helpful. Most commercial intermediaries, doctors, and clinics heavily rely on the Internet to advertise their products, recruit potential clients, and win new markets for their services (Lunt, Hardey, & Mannion, 2010). Promoting your product is an old tool to recruit customers. However, with the invention of internet and the world wide web it has become much easier to get in touch with the consumer. It does not only make it easier, but it increases the reach for possible patients. An example for promotion is Facebook as a heavy tool of marketing, which patients use as a forum for discussion. It is an easy tool to use, and the costs are low. (Holliday, Bell, Cheung, Jones and Probyn, 2014)


Economic

The main reason for people to travel for medical purposes outside their own countries is because of economical situations. Where before the wealthier people of poorer countries travelled to undergo surgeries or other medical treatment, the other way around is now much more common. People from wealthy countries who are travelling for medical purposes are often the poorer elite of the society. Although both directions of travelling are still happening and counts as medial tourism. (Holliday, Bell, Cheung, Jones and Probyn, 2014) Cost can be a primary reason to travel abroad. The reason why people now travel from the wealthier countries to the poorer ones for medical purposes, has different reasons and depends on the point of view of individuals. Like always economical reasons are very important. The rising cost of health care and insurance in developed countries, lack of access to health care at reasonable cost and insufficient insurance and income to pay for local health care are a few examples. Where it would be hard or much more expensive in the home country, the decrease in cost for medical tourism abroad gets more attractive. Costs are higher in developed countries for a number of reasons. The wages and salaries of medics are high, doctors in middle-income countries earn less than half the salaries of those in developed countries, nurses and allied workers earn perhaps a third of comparable salaries and unskilled workers earn very low incomes. Reduced labour costs can be very important and can be a critical point to keep the prices low. (Connell, 2010) This shift in global economics, medical tourism was an activity of the wealthy, not the bargain shopper. Harde bewijs, niet zomaar een verwijzing van Connell, moet ik nog eventjes opzoeken.)

A particular combination of development circumstances like economy, cultural and political has meant that medical tourism has recently developed in a number of middle income and undeveloped countries. These countries have medical care linked to tourism encouraging the attractions of hospitals and nearby resorts. The medical tourism takes a stronger place in the national development strategy. (Connell, 2010) The rise of Asian medical tourism has been exceptional since it has developed at some distance from Western markets. Rich-world countries cannot compete on price. Poor countries, especially could have insufficient high level skills, infrastructure and capacity to develop a medical tourism industry, or market effectively. The rise of these undeveloped countries are changing this image where for example China has one of the best high level skills on technology. The countries in Asia for example have had a tremendous economical growth the last years. Development policies in many countries support and encourage medical tourism, as a valuable means of economic shift and growth. In some countries it is linked to promotion of business and commerce but, just as frequently, it is directly linked to tourism and seen as one component of a tourism development strategy. Where in India, it has become part of a strategy that links different stands of tourism together. Medical tourism has become more successful and its promotion has intensified. In countries where tourism promotion was unheard of in the 1980s, it has grown and intensified, marking the shift from agriculture and industry to the service sector. Not only therefore is medical tourism promoted but, like other aspects in the tourism industry, it has drawn government investment and subsidy. (Connell, 2010)

One of the reasons why Medical tourism has grown so much over the last years is because of the rising costs of medical treatment. (Chuang,  John,  Liu,  Louis, Lu and Lee, 2014) Where for a lot of Americans, the medical tourism is a great option.  For more than 40 million Americans who lack health insurance, there's no doubt that lower cost is the main driving factor. (Larocco, 2011) Medical tourism is a market that offers less emergency medical procedures for relatively low cost. Where for the locals these prices are sometime enormous, for the wealthier elite or ‘travellers' this is pretty cheap. Where they will pay much more in their own countries. That is to say that as long as health costs continue to rise, overseas hospitals will continue to add new services to cover the demand for lower cost alternatives. (Burkett, 2007) The dental care, a part of the medical tourism, has an important contribution tot he medical tourism industry. It could be very expensive in some countries. Where in other countries it is much cheaper. For example, Thailand has a lot to offer when it comes to dental care. They can take care of your teeth for a much cheaper price. (Horowitz and Rosensweig 2007) In figure 1. You can see differences in prices for a view healthcare treatment in the USA, Singapore, Thailand and India.

  Fig 1.

Where planning a medical tourism trip is a little bit similar to planning a normal vacation, it is also depending on travel agencies. Where they work in good combination with the places that offers treatments abroad. It will be easier to get in contact with customers due the fact of all kind of the new technologies mentioned before. The travel agencies are growing and developing more to the medical tourism industry to.

Social        The single most crucial challenge that medical tourism faces is the need to convince people, who have never been to the possible destinations. Medical care in relatively poor countries is nowadays comparable with that available at home, in outcomes, safety, ‘after-care service', value for money and perhaps even convenience. For a long time, health care and medical treatments in less developed countries has been seen as inadequate in the West. But as we can see this image is changing. Not everybody will think the same about it, but more and more people are willing to try it oar trust it even more than in the West.

While we see a large amount of medical tourist from the ‘developed countries' as the USA, Australia and European countries. There is an amount of people who are not originally from these countries. You can think about the Hispanics migrants in the USA or the Moroccan people in Europe. There are a lot of these people who go back tot their home country for medical treatments. This can have several explanations like cultural barriers to health care, discrimination, a preference for health care in a familiar place or to the opportunity to catch up with friends and relatives. Such people have been making these journeys for several decades with numbers increasing over time. (Connell, 2010)

Medical tourism functions as a moral safety value for ‘extreme medical tourists', yet also takes some patients beyond regulatory systems usually designed to protect them, in circumstances where desperate people with severe conditions are willing and eager to spend substantial sums for a ‘last chance to survive. Even despite uncertain outcomes in new forms of alternative medicine. It is the right of anyone to travel in search of innovative cures in the hope of finding the ability for recovery, even where experimental procedures are against our norms and values.

An other aspect is the time people have to wait, people can not or do not want to wait. People visit other countries for medical treatment because there is an eliminating of waiting time. People also visit other places for surgery that could be illegal in their home county, for example: abortion or something that is not yet approved in their hometown. Where this could lead to socially inequalities. People do not care always about this when it is about their health. Other reasons could be: the longer waiting lists for donors or transplantations. The ability to pay for a foreign treatment and the free time to travel can be an important influence. It is very attractive to combine medical care with a ‘holiday'.

Where the rise of plastic surgery is an important aspect of the rising of medical tourism, its contribution is enormous. (Lirola and Chovanec 2012) Because the high costs of plastic surgery and the none compensation of health care institutions this kind of medical tourism happens more often. Where people care a lot to their appearances nowadays, these kind of industries try to make profits and convince people to visit them. For example, the Tango in Argentina combines plastic surgery with all kind of animation things like, shopping nightlife, restaurants, clubs etc. it makes it even more attractive for people to visit and undergo their plastic surgery over there. At the moment there are even books to look up the best place to undergo your surgery and enjoy your holiday at the same time. (Viladrich and Baron-Faust, 2013)

The growth of the medical world the last years and decades goes together with the commoditization of health care, this involves the change of person's physical characteristics for social and material gains. (Aizura, 2009) Plastic surgery is mostly related with physical changes it is not only about repairing physical flaws anymore. It has become some kind of leisure activity that seeks to improve someone's appearance in the capitalistic economy of today. (Aizura, 2009).  The importance for people's appearances has changed over time. The image and boost of self esteem that takes his place in the new social world gives a boost to the plastic surgery industries. This is of course intertwined and going together with medical tourism. The new self image of an individual with the help of plastic surgery is more about the 'beauty' and 'youth' of the person. The opinion of the society towards this industry is changing and getting more appreciated. Modifying their body is nowadays much more an acceptable phenomenon, with the upcoming and new ideology of the perfect body. Some people try it by exercising or training and others with simple adjustments. But not everything can be changed by exercise, so people are now more willing to undergo surgery. Breast implants is a famous example for cosmetic surgery for many years already, however this industry is changing, developing and adding new surgeries. there is now even a possibility to undergo a six-pack for-ever operation. This is for people who are not willing or do not have the patience to create this by exercise, instead they prefer it surgical. After this operation, this individual has a muscular abdominal and abs. (Percival, 2015) The new developments of the last decades with pictures and magazines of the perfect body and shapes of women and men. People are seeing themselves as ideology. The phenomenon of cosmetic surgery fits into a broader cultural norm that requires women to define their femininity and men their masculinity. It happens through the consumption of particular products, such as clothing, fashion accessories, cosmetics products, methods of relaxation, etc., Before it was more common for women, Women has a lower body satisfaction than men, along with the trend of the media related to body satisfaction. (Adams, 2010) frequently also men are doing these kind of procedures more and more. The self-image of a body with imperfection, creates the need for body improvement as a universal solution to one's problems. The rise of relative domains as beauty, health and sex, are lying at the core of female and male identity (Lirola and Chovanec 2012)

Researchers have shown that attractiveness not only affects the romantic life, but it also has a positive effect on psychological adjustment and even economic well-being. (Adams, 2010)

Political

In most developed countries the demand for organ transplants is growing much faster than the supply of organs donated through traditional means, hence a small but growing number of the world's poor are providing body parts, especially kidneys, for sale. This shortage means a lengthy and uncertain wait for critically ill patients or the resort to overseas transplantation, which may mean either trafficking in organs or their being obtained in dubious circumstances from unwitting, unwilling or dead donors. Most overseas transplants take place in relatively poor developing countries and are highly controversial because of the potential negative medical impact on the ‘donor' and, in some countries, their excision from executed prisoners. This is a hard to prove business and can happen everywhere of course. The changes of this happening in the les developed countries are bigger. It is something of ethical proportions and one of the darker sides of medical tourism. There is one place where you can legally sell your organs and that is in Iran, but only to the government. (Ghods and Savaj, 2006). So sometimes, rather less positively, Medical tourism has grown because of the impossibility of undertaking various procedures at home, and their availability overseas, which in the case of abortion, some forms of organ transplantation and stem cell therapy, even contraception and ultimately ‘death tourism', have raised ethical issues. Where in less developed countries the rules are less strict or easier to avoid. If people want to survive, ethical issues will slide away and their own live will be the first concern. The wider presence of medical tourism in a neo-liberal world of reduced regulation and enhanced freedom of choice, state policies, global markets and technological change are within complex debates over moral and ethical dilemmas in a globalizing world, where cultural differences remain significant.

Tourism is a well known attribute to contribute to the economy of a country.  For the poorer countries this could help to stimulate their economy. Besides the normal tourism what politics stimulate they try to stimulate medical tourism to. (Viladrich and Baron-Faust, 2013) So countries try to make a trend of differentiation of their product by making it attractive and unique. Additionally, an example; the Indian government has supported the country's growing medical tourism market. It has reduced import duties on medical equipment and created a special visa that doubles the time foreign visitors can stay in-country (up to a year) to receive medical treatment. Other medical tourism destinations are, to a greater or lesser extent, very similar to India and Thailand. For many years, Mexican hospitals have attracted patients from the United States to cross the border for plastic surgeries. (Burkett, 2007)

As a result of the globalization and privatization, the medical tourism has grown in the recent years. (Crooks, Kingsbury, Snyder, & Johnston, 2010).  Globalisation is a result of among other things the new technologies. The privatization is a new political flow. With liberalism and neo-liberalism as upcoming political ideas, where individuality and privatization is encouraged the healthcare industry change.

Conclusion

There is an idea that travelling and tourism will always be there, with or without the medical developments. Of course there will be always adventures people that are willing to risk their lives to explore the world. But without the healthcare of these days, there would be a big decrease in tourism. Without the medical world a lot of people will think twice before they are traveling.

There are a lot of changes in the world of tourism going on. This is also happening in the Medical tourism industry. It changed from natural Healthy tourism aspects to a total different kind of medical tourism. Where it started in the spas and hot springs of Greece, it is now going to the less developed countries with (plastic) surgery, dental treatments and so on.

The crossing of borders for healthy reasons started with relaxation and getting some fresh and healthy air and water. With the social, economical and environmental changes like globalisation, technical developments and new political standards like neo-liberalism. It is now more likely to cross borders for surgeries or other medical treatment. Where it started with migrations for the wealthy people from underdeveloped countries to more developed countries. It is now the other way around. People who could not afford medical help, do now have the possibilities to go somewhere else and get the care they wanted. The medical developments of the last decades are a real benefit for these people and so for this kind of tourism.

Globalization manifestly offers new opportunities and greater mobility, new flows in a compressed world, yet at the same time it enhances structural inequalities, that tend to empower those who are relatively well off at the expense of the less privileged, so that globalization is far from a uniform process. The globalization of the market for medical treatment parallels what has become a global market for skilled health-care workers the steady privatization of health care and the emergence of global insurance and pharmaceutical companies. This has been matched by the individualization of patients who have an unprecedented freedom to choose as long as they also have a capacity to pay. Patients are both outsourcing and globalizing themselves.

Increasing numbers of people are willing and able to pay more to get well or look ‘better', but also to avoid waiting lists, high costs, arrogance and cultural dissonance at home, by becoming medical tourists. Many see this as an entitlement. Others are effectively forced to travel, because of urgent needs. Increasing links between traditional and modern systems may develop as holistic therapies become more popular than purely medical interventions. Good health demands a careful approach, which in terms of medical tourism involves greater integration of spas and surgery, but perhaps also some withdrawal from materialism, individualism and consumerism.

Medical tourism is probably slowly growing out of infancy. In an unequal world it meets many genuine needs, and offers greater patient autonomy. However, whether that growth is healthy in terms of rising materialism, the continued obsession with body shape, self-indulgence and the distortion of health care in various countries raises questions. The growing privatization of health care, its drift away from traditional notions of ‘family doctors' and neighbourhood care, and consequently growing international competition for markets, has meant that health care is increasingly global rather than local and is to be traded. The Internet and global media have led to a bigger cycle for the healthcare. Convenience and speed are central to modernity, as they are to medical tourism, which has grown from the conjuncture of all of these. It has become a particular niche in the tourist industry. Whether it is tourism, medical travel and procedures abroad or ‘transnational medical care', it would seem to have a healthy future. Ironically, that ‘healthy' future will continue as long as providing medical care takes priority over creating and sustaining good health, and as long as preventative health care and demands for the instant body take priority. The future will be a more competitive, corporate and uneven one, where healthy medical tourism mirrors the inadequacies of national health care systems.

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