Beauty from Afar

Today, we continue the short saga of the U.S. and its media vs. cosmetic surgery in the Dominican Republic in 2004.

Chapter 2 Page 3 | A warning lives on, mostly unheeded

When I was writing Beauty from Afar, I remember being somewhat concerned about the fact that I was saying that the U.S. State Department was still warning in 2006 against having cosmetic surgery in the Dominican Republic based on a 2004 CDC report … surely, I thought, that warning will be taken down at some point in time.I was careful to note the time element.

I needn’t have been concerned on that count, anyway. The warning is still up in 2009.

In this passage, I quote Dr. Roberto Guerrero. I remember the conversation well and regret that I never have gotten to meet him in person. His web site isn’t in the book. I see he can now be found at PlastiCenter: New Concepts in Plastic Surgery.

News coverage can make — or break — the medical travel business of a doctor, a hospital or even a country. Reports of poor health care abroad — or reports of bad results in otherwise good health care — can have a significant impact on medical travel decisions.

One can imagine that the news media coverage in 2004 of illnesses allegedly connected to cosmetic surgery done in the Dominican Republic might have led to a significant decline in the number of people going to that country for procedures.

Chapter 2 Page 2 | News Gets Around

As I  have noted, however, the story was short-lived and in this particular case, may have done more to publicize the availability of inexpensive cosmetic surgery in the Dominican Republic than it did to convince prospective patients of danger! More on that in the next post …

There are occasions in Beauty from Afar when I use contemporaneous news reporting about medical travel and tourism as kind of a foil: “This is what was reported,” vs. “This is what actually happened,” or “This is what they didn’t say.”

As someone who has spent a lot of years in a newsroom, I didn’t take any fiendish glee in pointing out the shortcomings of reporting. I am only too aware of how difficult the job can be and how hard it is to do well. The anecdote with which I lead in Chapter 2, about a brief panic in New York City over mysterious illnesses attributed to botched cosmetic surgery done in the Dominican Republic, is a case in point.

Chapter 2 Page 1 | Comparing Quality, Comparing Costs

You’ll have to stop back to get the rest of the story, since I’m taking this a day at a time. But I recall that I managed to track down the reporter who did the original story — which was fine, as far as it went. But as I pointed out, the story cried out for a follow-up that never came. (Until Beauty from Afar.) The reporter was an intern, gone by the end of the summer. No one else followed up. That kind of thing happens a lot in journalism. Even at The New York Times.

Chapter 2 Page 1 | Comparing Quality, Comparing Costs

Why care abroad is just as good as in the United States, and
why it is so much less expensive than in the United States and Europe

If ever there was a day that America was going to be persuaded that traveling abroad for inexpensive plastic surgery is foolhardy and dangerous, it was July 2, 2004. On that day a story about cosmetic surgery overseas that came out of a news conference called by the city of New York made the front page of The New York Times; it subsequently made every major newscast, in fact. “A Warning on Cut-Rate Surgery Abroad”, was The Times’ headline.

At least nine women in New York and seven more elsewhere had been diagnosed with serious infections, all traced to their having had cosmetic surgery in the Dominican Republic. The Times attributed the problem to “what has apparently become a phenomenon among New York City’s Latinas: cosmetic surgery conducted in the Dominican Republic after being arranged through beauty salons in Washington Heights and other city neighborhoods.”

The city’s health commissioner, Thomas Friedman, M.D., and other officials called the bilingual news conference in the city’s Washington Heights section for the express purpose of warning New Yorkers (and anyone else who would listen): Don’t even think about going out of the country to have plastic surgery — especially to the Dominican Republic.

“It is so important to get the message that something that is cheap can be very costly,” said New York City Councilman Miguel Martinez. “It can cost you your life.”

Officials vowed to shut down what they said was a loosely coordinated network for recruiting patients, which they referred to as a “big business.” They called in the national Centers for Disease Control and Prevention to investigate.

Notably absent from the story, however, was any comment from doctors, surgeons, or officials in the Dominican Republic, though The Times quoted several women from the Washington Heights area, who shrugged off the warning. One woman said she had had a $3,000 tummy tuck done in Santo Domingo a few years earlier without a problem. She told The Times she knew of hundreds of women from Washington Heights who had cosmetic surgery procedures done in the Dominican Republic and that only a few had complications. In fact, she said she was planning to go back again for more cosmetic surgery the next month.

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

Global competition for health-care dollars is relatively new. The balance is shifting. From the perspective of many health-care professionals in the United States, Canada, and the nations of western European, this is unsettling. It highlights some of the deficiencies in western medical systems: In the United States, high costs and a high number of uninsured; and in Canada and western Europe, long waits and similarly high costs for elective procedures. At one time, only a small number of people from the developed nations went abroad for inexpensive plastic surgery, while a large number of wealthy people from countries with lesser medical care came to the West for advanced care, treatment, and surgery. The estimated 100,000 people (and growing) who now leave the United States annually for plastic surgery only represents the tip of an iceberg for medical tourism as big business.

There are already large success stories that have legitimized this point of view. Bumrungrad International Hospital in Bangkok, Thailand, is the best known; in 2004 it boasted treating more than 350,000 patients from 150 countries. India is hurrying in the same direction, projecting that medical tourism could be a $2.2 billion business by 2012. Put this way, it sounds huge and economically threatening to the United States and its medical-care system. 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. This is a highly exaggerated scenario.

Medical tourism, as such, does not represent a substantial immediate threat to the medical system of the United States, or any other country for that matter. What, after all, is a few billion dollars compared to the $1.7 trillion spent on health care in the United States each year? The billions represent a small shift in revenues in a worldwide multi-trillion dollar health-care system. By serving the uninsured and the underinsured in the United States and by providing an alternative to long waits for treatment or surgery in Canada and western Europe, medical tourism in a sense is augmenting the health-care systems of developed countries, filling and bridging gaps, providing another safety net.

As for aesthetic and cosmetic surgery — the “tip of the iceberg” for the medical tourism phenomenon — overseas surgeons are filling a need. Time and time again, I have heard from surgeons in Mexico, Brazil, Costa Rica, and the Dominican Republic: We are not taking patients away from U.S. plastic surgeons. Our patients come to us because they cannot afford U.S. prices. If not for us, they would not have surgery at all.

There are many doctors and surgeons in the United States who would prefer that medical tourism just go away. And cosmetic surgeons, personally and through their membership organizations, have thus far expressed most of the public concern and opposition. This is understandable, but there are degrees of opposition, and one would be mistaken to think that all are of the same mind. It is reasonable to suspect that, as time goes on, more medical professionals in the United States will take a less U.S.-centric position and, generally accept that they have an international community of peers.

Just a few months after I returned from my dentistry adventure in Costa Rica, I had an appointment with my ophthalmologist. I am extremely nearsighted and have been from an early age. I’ve worn contact lenses for 36 years, which seems an impossibly long time. In the last several years, my eyes changed such that I was perilously close to requiring bifocals or, as an alternative, reading glasses to wear with my contact lenses. My eye doctor, on this visit, told me that I was an excellent candidate for Lasik eye surgery. I knew what Lasik was, certainly. I knew a lot about it. What lifelong myopic didn’t read up on that when it came out? But I had never before been told I was a good candidate for it.

“It’s improved a great deal in the last two years,” she told me, in response to my questioning about the procedure’s reliability and success rate. “They’ve refined it. We probably won’t see it get much better than it is right now, not anytime soon.”

I knew that Lasik surgery costs more if one is severely nearsighted. She nodded when I guessed the cost. “Yes, you’d probably be paying around $4,000.”

I hesitated, and then told her my Costa Rica story, the short version. And I asked, point blank if she would help and support me if I chose to get Lasik surgery done overseas? Would she work with the foreign doctor, help me get the best care I could? Because I didn’t have $4,000 for Lasik surgery.

She looked me right in the eye.

“Absolutely,” she responded, firmly, surprising me a little. And we had a long talk about where would be the best place to go. My ophthalmologist had a slight preference for India, though we agreed, laughing, that as a second-generation Indian, she perhaps has a prejudice.

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

(Author’s Note: The reader should be aware that the following numbers were calculated for 2004-2005. I do not claim they are representative for any other time. If I had to guess right now, in 2009, a time of global recession, I’d say that cosmetic surgery abroad might well be in the doldrums, just as it is within individual countries such as the United States.)

Today, with access to the Internet, the millions of prospective and actual cosmetic surgery patients in the United States can be remarkably well-informed before ever setting foot in a surgeon’s office. They are familiar with the procedures;  they’ve seen before-and-after pictures. The Internet and television have supplemented traditional word-of-mouth marketing of cosmetic surgery, and many U.S. doctors build their practices substantially through their Web sites.

But the Internet also opened up this vast U.S. market to aesthetic and cosmetic surgeons abroad.  And in increasing numbers, they are going after the U.S. market directly.

How many people from the United States are actually going south of the border (or anywhere else) to save money on liposuction, face-lifts, tummy tucks and the like? In recent news stories, the conventional line, almost to the point of cliche, was  “no one knows.” I have been told by several U.S. surgeons who cared to speculate that the numbers are negligible;  however, these have been the same surgeons who are most concerned about (or opposed to) people going overseas for surgery. Some doctors and journalists have guessed it to be in the  “low thousands”.

This is almost certainly bad guesswork, though it all depends on who and how one wishes to count.  Consider, and do the arithmetic along with me: Costa Rica, the “Beverly Hills of Central America,”  where there are perhaps 35 to 40 cosmetic surgeons who work primarily on patients from the United States. The best and most experienced are busy constantly, and some will do several surgeries a day. These board-certified surgeons each handle as many as 40 to 50 U.S. patients a month.  Even accounting for slackers, one cannot put the annual total at less than 5,000. It could be double that or more.  A prominent surgeon I know puts the total at more than 20,000.

One can speculate conservatively that a similar number of people visit Costa Rica for just dental work, as I did. There are a lot more dentists,  according to one surgeon, and there is some overlap, as many patients will have both plastic surgery and dental work done on the same trip. Many procedures are also done by non- board- certified physicians and surgeons.

Brazil,  a mecca for cosmetic and plastic surgery with a reputation that precedes and, in much of the world, overshadows that of Beverly Hills:  There are more than a million Brazilian-Americans in the United States. The population has tripled since 1990.  Perhaps there was a time when only hundreds or a few thousand U.S. residents traveled to Brazil for cosmetic surgery annually, but that time is past. Brazilian surgeons are polishing their English and their Web sites and building new facilities. Count another 10,000 and growing.

Mexico, the most telling of all: There, more than 900 board-certified plastic and cosmetic surgeons ply their trade. Despite a stream of cautionary and negative news reports about the practice through the years, undoubtedly far more U.S. residents visit Mexico for cosmetic and plastic surgery than any other country. There are more than 30 million Mexican-Americans in the United States, as a receptive base market. Mexican surgeons advertise in the United States and even visit our country regularly on marketing expeditions, mostly in the South and West. It is not reasonable to guess that “a few thousand” U.S. residents head for the border annually for cosmetic surgery. I venture an educated estimate that the number is at least 40,000.

Tourists seeking liposuction or face-lifts do not declare their intentions at the border, and I have run across only a few doctors and surgeons abroad who can give a good estimate of the number of U.S. patients they see themselves, let alone an aggregate number for their country.  But the number for Mexico adds up quickly. I’m told that perhaps half the doctors do little or no work on patients from the United States.  Still, if the other half averages two U.S. patients per week, the total would come to nearly 50,000. This does not account for cosmetic dental work or the number of patients who get cosmetic surgery from non-board-certified physicians.  It also ignores the fact that there are hundreds of thousands of U.S. citizens living in Mexico, perhaps as many as a million, who presumably are likely to seek medical care, including cosmetic surgery, from local doctors and surgeons.

The Dominican Republic, another medical tourism destination that has been vilified, more often than not, in the popular media in the United States:  There are approximately 60 busy cosmetic surgeons in and around the capitol, Santo Domingo. For many of them, more than half of their patients come from abroad, mostly from the United States. Moreover, there are more than a million Dominicans residing in the United States, at least 600,000 of them in the New York City metropolitan area alone.

Dominican surgeons travel to New York regularly to make presentations to prospective patients.  The prices of even the best, most-qualified surgeons in the Dominican Republic for common surgical procedures are 50 to 70 percent less than what is charged in the United States. Business is booming. It is not unreasonable to guess that board-certified plastic surgeons in the Dominican Republic, plus other doctors and surgeons who perform cosmetic procedures,  see at least 10,000 patients a year from the United States, not including dental patients.

The rest of the world: A “few thousand”  more from the United States travel to other Central and South American countries, all of which are represented in the United States by growing immigrant groups. Destinations in the Far East are growing in popularity;  Eastern Europe and South Africa are more popular with western Europeans as places to go than they are with Americans, but surgeons in those countries have only just begun competing for the huge North American market.  And Malaysia and Thailand are both increasingly popular destinations. Add another 10,000 to 20,000 to the total, easily.

I am comfortable, then, in conservatively guesstimating the number of U.S. citizens currently traveling abroad for plastic and cosmetic surgery at something in the high five figures, approaching 100,000. This would be about 5 percent of the 1.7 million estimated cosmetic surgeries performed in the United States.

I don’t have a similar feel for the total number of U.S. patients who go abroad for dental care, other than to suspect that it is similarly substantial. Certainly, at least a dozen major dental practices in Costa Rica thrive on serving the U.S. market.

An assertion that the number of U.S. residents, mostly women, who would travel abroad for cosmetic surgery might be rapidly approaching 100,000 annually, or even higher, will no doubt nettle some doctors and surgeons in the United States. Yet how are we to get a grip on the phenomenon (or “problem,”  if that is your point of view) if we do not attempt to get a handle on its size?  Until the last decade, the story of what is now called medical tourism was mostly about people in other countries coming to the United States for sophisticated medical treatment, if they could afford it. And the traffic has by no means completely reversed.  Many thousands of people still come to the United States for health care, including cosmetic surgery. Almost certainly, far more money comes into the United States from abroad to pay for medical care than leaves the country.

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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.

Chapter 1 Page 1  | Medical Tourism: Here, There and Everywhere

More than 100,000 United States residents leave the country for
cosmetic procedures every year. Where do they go? Wherever they like …

It is April, 2004, and I am having breakfast with a few new friends at Las Cumbres Inn outside San Jose, Costa Rica. Sandy, perhaps 45, a Californian, is nearly recovered from her nips and tucks, and is contemplating having her teeth bleached. “Might as well do it while I’m here,” she mutters, knowing she’ll be heading home in a few days.

Vicki, also forty-something, and a self-described vagabond, wears dark glasses to cover the swelling from the work done on her still-healing eyes. She is a U.S. citizen who has lived frugally but comfortably in a Costa Rican village for most of the past 11 years. She is thinking she is going to need to get a job again, soon.

Nina looks like she had been in a car wreck. She has had a face-lift, a neck lift, a “medium chemical peel,” and perhaps some other “work” that does not fix in my memory. She shows me the estimate she had gotten from a cosmetic surgeon in New York City for the major procedures she wanted. It came to $22,420: $18,000 for the face and neck lift, $2,100 for an operating room fee, $1,320 for post-operative nursing care, and $1,000 for anesthesia. Her entire bill in Costa Rica will come to $5,700, she says. On this morning, she wonders if she will ever again look anything like she had looked before, let alone better or younger. We assure her that she will, and later, we are proven right.

Me? I tell Sandy about my dentists, Josef Cordero, D.D.S., and Telma Rubinstein, D.D.S., childhood sweethearts who went to college and dental school together, got married, and have spent more than 20 years building an international practice. Sandy decides to go with me in the van that day to see if they can squeeze her in for a teeth bleaching.

They can. We all feel pretty smart, in the way people do who have a shared secret.

***

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I recall that one of my favorite moments in researching Beauty from Afar came not from the travel and not from the interesting people I met along the way. It was in finding out that Michael Crichton had written about medical tourism in — of all books! — Jurassic Park.

I’m not making this up; and the information made it into the introduction as a short section, which I added today.

I’m finding that I have to edit the text of Beauty from Afar, onscreen, with an actual copy of the book on my lap. The digital version I have to work with is missing words, occasionally, and is also entirely … mispunctuated. (Is that a word?) This is because I’m working from a Quark file turned into an Acrobat file, from which I copy and paste text into a text file, and then massage it.  Copy changes and even vanishes. Note to any other authors who try this: Yes, of course you could use the final version you submitted to your publisher in MS Word, or whatever. But … are you sure that’s the final version of the book?

P.S. The physical copy of Beauty from Afar has 215 pages. When I started this project, I thought that this online version would … mimic that. It made sense to me … the book has some 65,000 words and I thought that 300 or so at a time would be about right. And given that I’d like this project to at least pay for itself, I thought that having 215 pages with advertisements was not a bad idea.

Just a few days in, though, I’ve discovered what you would have, soon enough, if I had stuck to the plan. Page breaks are artifical and annoying unless you have pages you can turn immediately. (Well, it bothers me, anyway.)  So I’m repaginating as I go. This online version of Beauty from Afar, I’m thinking, will be more like 100 pages, in the end. I intend that each page will end as unjarringly as possible. There are no “widowed” words in the book; there will be no widowed paragraphs in the online version.

Introduction Page 2 | Seeking Beauty from Afar: How I Got My Smile Back

Jurassic Park It’s Not …

I remember what I had known about Costa Rica before I had started thinking of it as a place where I might get fine dental work done inexpensively.  Not a lot — but perhaps about as much as did my friend.  In fact, I am somewhat embarrassed to admit that I had not been 100 percent sure that Costa Rica was not an island, though I vaguely recalled that Costa Rica was somehow prominent in the 1991 bestseller, Jurassic Park.  I had to look it up. Michael Crichton’s ill-fated island was located off the coast of Costa Rica.  It is hardly a friendly reference point for a potential visitor.  In fact, it seemed to cause a little embarrassment when I mentioned it to a few Costa Ricans, as though they worry that North Americans might actually fear that there are T-Rexes and raptors in the outskirts of San Jose. But in the book, there is a casual mention of Costa Rica as a destination for those interested in having cosmetic surgery.

“Bowman, a thirty-six-year-old real estate developer from Dallas, had come to Costa Rica with his wife and daughter for a two-week holiday. The trip had actually been his wife’s idea; for weeks Ellen had filled his ear about the wonderful national parks of Costa Rica, and how good it would be for Tina to see them. Then, when they had arrived, it turned out that Ellen had an appointment to see a plastic surgeon in San Jose. That was the first Mike Bowman had heard about the excellent and inexpensive plastic surgery available in Costa Rica, and all the luxurious private clinics in San Jose.”

This, in 1991! I asked Michael Crichton, through his publicist, how he had come to include this aside. Though Jurassic Park is, of course, fiction, it seemed unlikely that the author would have wholly invented his characterization of Costa Rica. The response I received was that it was a long time ago; Crichton didn?t remember how he had come to include the passage. In any case, I felt as though I was more than a dozen years late to a party. I found out later that Costa Rican plastic surgeons have been catering to U.S. patients since at least the late 1970s. Who knew?  Lots of people, obviously; and at the same time, hardly anyone.

“We can’t say it’s a new thing,” I told my editor at Northeast, Stephanie Summers. “It?s been going on for a long time.” She was unimpressed.  “It’s new to our readers,” she said.

And it was.  Months after the story ran I was still getting e-mail. I put the article online, more or less as a roadmap for others who might want to think about undertaking a similar journey. I thought — there’s a book in all this. And there was. Dentistry in Costa Rica barely touched the surface of the cosmetic work being done outside the United States — the same or comparable quality, just for a lot less money.

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