Beauty from Afar

It’s hard not to be a little pleased with myself, sometimes, as I slog through my own four-year-old prose. It looks as though I managed to not allow myself to be blinded by the sun bouncing off the shiny newness of medical tourism. I was cautious and felt my way. There’s not a lot of money in that but smugness, years later, is worth something.

I used the *T* Word — Trend — in the segment of Beauty from Afar that I just posted. Editors just love trends. They love to turn good stories into stories about trends. And I am a little guilty there — maybe even a lot guilty. After all, I took a story about going to Costa Rica for major dental work and turned it into a story about lots of people going every-damn-place for medical care. I mean, I wanted a book contract and I knew I had to … extrapolate.

But I was careful. In today’s segment:

Chapter 1 Page 8 | Tip of the Iceberg — and a Trend

… I said what a lot of people have been saying …

“One can imagine that 10 years from now, the lion’s share of the U.S. cosmetic and other elective surgery businesses will be offshore; that U.S. insurers and Health Maintenance Organizations (HMOs) will be putting a hefty percentage of nonemergency-care patients with expensive treatment or surgical needs on airplanes out of the country rather than sending them to local doctors, hospitals, and surgeons.”

But had the smarts to walk away:

“This is a highly exaggerated scenario.”

(Pats self on back. Hey, I have to come up with some motivation to do this every day.)

When I was writing Beauty from Afar, my publisher really, really, really wanted me to say how many people traveled abroad for medical care, surgery, cosmetic surgery and dentistry.

I probably should have accommodated my publisher’s wishes, and thrown a number out there and backed it up as best as I could. That is pretty much what McKinsey and other researchers have done since. What I chose to do has invited a lot less ridicule and a lot less controversy. I could have stood up to the former and the latter probably would have been good for book sales.

What I did, instead, is mostly in the segment/page I put online today:

Chapter 1 Page 7 | 100,000 Fellow Travelers — or More

I came up with a very reasonable estimate on the number of U.S. residents who were having cosmetic surgery abroad in 2004-2005.  I didn’t have any basis, I thought, for guesstimating how many Americans were going abroad for anything other than cosmetic surgery or dentistry. Four or five years later, I think I am still on the non-ridiculous side of the argument.

But that doesn’t keep journalists from asking the question. How many people go abroad for medical care? And the answer is — who do you want to count? I have no trouble saying “a million” — if you want to count dentistry, and cosmetic surgery, and every person who drives to Mexico for any kind of medical care at all. Throw in some millions of Americans living abroad who already get medical care overseas … you want to count them, as well? I can make the number quite large.

But the number of people who get on an airplane and fly overseas for life-saving or extending surgery, non-cosmetic surgery, is a relatively small number, no matter what you’ve read elsewhere. It is perhaps in the tens of thousands annually. It’s not trivial. But it’s not huge, either.

Most medical travel is regional. Americans are not lined up to go to the Far East for new hips or heart valves. Numbers that suggest otherwise should be looked at very carefully.

Reading back over today’s segment:

Dear Dr. Rubinstein …

… made me remember just how nervous I was, originally — just how strange it felt — in 2004, to head off to Costa Rica to spend thousands of dollars to get my teeth fixed. Even though, as I briefly mentioned, I’m no stranger to travel or adventures. At 20, I’d run off to South Africa for a job, knowing only one person there, and I had an amazing time there. I’ve called it the best year of my life, out of many good ones …

But anyway, going to Costa Rica for dental work was also a life-changing experience for me, because,  besides getting my smile back, better than ever, I never would have gotten to write Beauty from Afar if I hadn’t gone. I still like the magazine piece I wrote about the trip better than how I handled it in the book but that’s because it was more concentrated, more detailed, more about … well, me.

In the book, Prisma Dental comes up a few times. I sort of deliberately broke up the experience. It comes here, in Chapter 1, just by way of telling readers how I came to be a medical traveler, a dental tourist. There is much more about Prisma and Drs. Rubinstein and Cordero later, in the chapter about Costa Rica.

I was in Costa Rica in June and met a gentleman from Cheshire, Conn., who had read my original article about getting my new smile back in 2004, and had finally, in 2009, decided to do what I had done. I asked him if he felt as though the article had been accurate, had prepared him for his own journal and dental work. He said that it absolutely had. So I felt good about that.

We’re up to page 32 of the book, by the way.

For the purposes of Beauty from Afar, I did not think I had to prove that medical care in the United States was of lesser quality than in other countries. I don’t claim to be competent to make that determination. I don’t think anyone is.

But I had to make a convincing argument that the care in many countries, at their best hospitals, was certainly comparable to that in the best facilities in the United States. And that was, and is, do-able.

The two main components of the equation, in determining whether medical tourism makes any sense for an individual, or as part of a system of health care, are quality — and cost. It is a relatively simple matter to show that costs of medical services in the U.S. are much higher than they are in other countries that offer comparable quality. If one is making a decision based solely on economics, a substantial proportion of non-emergency surgery currently done in the United States ought to be done in other countries.

So why isn’t it? There are overriding, almost overwhelming political and psychological factors that figure into healthcare as well, of course, and I address those throughout Beauty from Afar. But one has to set the table and I bring up the costs and benefits in Chapter 1 here:

U.S. Healthcare and Spiraling Costs

Though it does not have much to do with medical tourism, I recommend Timothy Egan’s

The Way We Die Now

for his writing and for his insight into the problems of U.S. healthcare. He quotes former Oregon governor John Kitzhaber. M.D.:

“The fundamental problem is that 1 percent of the population accounts for 35 percent of health care spending.  So the big question is not how we pay for health care, but what are we buying.”

I wonder how that compares to other countries? I don’t know. Here’s Kitzhaber’s blog.

In Chapter 1 of Beauty from Afar, I suggested that medical tourism was already a big business in 2005 and that it might be acting as a safety valve for the U.S. health-care system. I was right on both counts.

Chapter 1 Page 4 | Patients Going Abroad: A Burgeoning Industry

Medical tourism was and is a big business and that fact has been a source of great frustration to entrepreneurs who believed then, and even today, that therefore it can be tamed, routinized and turned into a corporate profit engine.  The biggest problem with that has been that the part of medical tourism that looks like it would be very profitable — putting Americans on airplanes and sending them overseas for surgery — is not a very big part of the medical tourism business at all. It is a very small part of the picture, relatively speaking, and will remain so unless and until American businesses and government embrace medical tourism.

Most of medical tourism from the United States is still for elective procedures, dentistry and cosmetic surgery; and the Great Recession has affected that business substantially. Yes, people are more interested than ever in saving money. However, through the medical tourism boom of 1998-2007 or so — a lot of Americans were paying for their cosmetic surgery and dentistry with credit cards or by taking second mortgages out on their homes. That is not happening quite so much any more, for obvious reasons.

Yet medical tourism is working well as a safety valve for many people the world over who cannot get or afford the care they need or want locally. It has been consumer driven. It is in the hands of patients.

Big research companies talk about medical tourism being worth many billions of dollars, with many more to come. They are right, though their methodology is often deeply flawed and even laughable. But those medical tourism dollars are spread out all over the world and are very difficult to count.

The next segment will talk about spiraling medical costs in the U.S. There’s a topic that certainly hasn’t gone stale in a few years. I’ll be interested in whatever it was that I had to say. 😉

… and I am quite sure I am the only one who noticed.

Here is what should have been yesterday’s update:

60 Minutes and Medical Tourism Part 2

And yesterday’s update, of course, should have come today:

Vignettes … Didi, Fabio … Part 3

I fixed the internal navigation of the site. And if I haven’t mentioned it before — I will be wildly grateful to anyone who points out any technical or factual errors I might make in the course of publishing the text of Beauty from Afar.

The 60 Minutes show in 2005 that featured Bumrungrad International hospital in Thailand did much to legitimize medical tourism in the United States.  It spurred more serious journalistic coverage of the subject and, thereafter, people who went abroad for medical care were treated with a little more respect.

It also got the attention of my publisher, which asked me if I could write Beauty from Afar faster than I had agreed. By contract, I owed them the book in January 2006. After some hemming and hawing and looking at the calendar, I said I could turn it in by October 2005.

It was April 2005 at this point. I was saying, “Sure, I can write this in six months.” And I did.

I sometimes compared writing Beauty from Afar to shooting at a moving target.  I’m proud of how it has held up for three years, but some things, of course, are not the same now as they were then.

I ruefully notice one such thing in just the three paragraphs of today’s vignette, the second segment of Chapter 1.

Didi Carr Reuben used to call her web site for Dr. Alejandro Lev, her cosmetic surgeon, terminallyvain.com … which was meant tongue-in-cheek, poking fun at her own beautiful self. It is now eternallyvain.com. Still funny, though obviously less morbid.

We also meet Dr. Fabio Zamprogno of Brazil, who we’ll find out a lot more about later in the book.

If you’re keeping track, we’re on page 25 of BFA now … the next segment will start to describe the medical tourism industry.

When it come to writing about places to which I have traveled, I have almost always chosen to write about the people I encounter and what it is like to be *me* when I travel. This is perhaps remarkably egocentric, yet I don’t see an honest way out of it. People can have wildly different experiences from a trip that is supposed to be more or less the same for anyone. I imagine that most people have very similar trips to DisneyWorld, for example. Yet my first visit there was on a belated honeymoon, nearly a quarter of a century ago; and my strongest recollection of the trip is a fabulously nonsensical fight I had with my then-wife over a game of miniature golf. This is not Disney’s fault; for all that they try to homogenize the American Vacation Experience, not everyone leaves with the intended memories.

Anyway —  I tried to make Beauty from Afar as much a book about compelling personal stories as it is a general guide to traveling overseas for cosmetic surgery, dentistry and medical care. So Chapter 1 starts out at a breakfast table at Las Cumbres Inn in Costa Rica, with patients sharing experiences, before I head in to Prisma Dental for a long second day with my mouth open.

Chapter 1 | Medical Tourism: Here, There and Everywhere

We’re up to Page 23 of the actual book, out of 220.

So the introduction to Beauty from Afar is now completely online. The concluding segment is Competition for the United States.

The intro seems short to me, maybe because I vaguely remember agonizing over writing it a few short years ago. There are only five segments; in the physical book, the introduction is only nine pages. Online, it is just five.

But it says what it needed to say. The difficulty in writing it, originally, was in deciding what to leave out; what to save for later. That was where having written a book proposal came in really handy. I trusted my outline.

Beauty from Afar was primarily aimed at readers in the United States, though I tried to make it clear that consumers of hospital care, cosmetic surgery and dental services in other countries could also learn a thing or two and might want to consider traveling for medical procedures. But by reasons of history, geography and national psychology, it seems that it is Americans who had the biggest leap of faith to make, to trust doctors in countries other than their own.

I touch on this in the brief “It’s so … Foreign” segment of the Introduction.

One more intro section to go and I can move on to Chapter 1 …