Beauty from Afar

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.

Chapter 1 Page 6 | Dear Dr. Rubinstein …

When I contemplated traveling abroad for dental work, it took me a month of research on the Internet before I was finally ready to make a direct inquiry. A month — and that was just to feel confident about choosing a country from which I would select a dentist! I picked Costa Rica over Thailand because proximity to the United States played a big role in my thinking. “I don’t want to go too far if I don’t have to.” This, from someone who had thought nothing of taking off for Africa for a year, at age 20. (Which is a whole ‘nuther story.)

There was a wealth of information available on dentists and dentistry in Costa Rica at the time, more so than anyplace else (except for the United States, of course).  I wrote to the aforementioned Telma Rubinstein, D.D.S., of Prisma Dental in San Jose, Costa Rica, on February 16, 2004.  Prisma had a Web site.  I confess I chose them as first contact because they had a female dentist. I felt sure I would have a lot of questions,  and my instinct was that a woman would be more likely to be patient with me.

Dear Dr. Rubinstein,

I am writing to inquire about having cosmetic dental work done at your practice in Costa Rica.

My dentist here in Connecticut, two years ago, had taken a mold of my bite and recommended, as I recall, eight or 12 porcelain crowns. I must say I concur with his opinion. My teeth are quite worn and small, at 47 years of age. I also have a badly chipped front tooth. I could send you digital photographs, if you’d prefer to see that way.

My dental insurance at the time would not cover any of the considerable fee, however. I now find myself without dental insurance at all, but I recently heard that practices such as yours could do a fine job on the work I require at a significant savings. What can you tell me beyond what I have read on the Internet? How would we proceed?

Thank you for your time,

Jeff Schult

I never had to write to another dentist in Costa Rica or elsewhere. During the next 6 weeks, I peppered Telma, as she asked me to call her, with more than 20 e-mails filled with questions about her credentials and experience,  my teeth, prices, travel and accommodations, and Costa Rica in general, and she patiently answered every one.

Still, I didn’t really make up my mind until after I asked her if she had any problems with my writing a magazine article about my experience.  She had no qualms at all, and I took that as a sign of her complete confidence in her ability. I realized that I already knew more about Telma Rubinstein than I had ever bothered finding out about any doctor or dentist who had treated me in the United States.  Later, I felt kind of bad about having been so difficult.  “I put you through the wringer,”  I told her when we finally met. She laughed. I had been easy, she said, compared to many of her other prospective patients from the United States: “Some of them, Jeff, they ask me so many questions that I feel I have been stripped naked!” Since then, I have heard similar stories from doctors, dentists, and surgeons around the world who treat patients from the United States.

As I’ve already stated,  I believe that the United States has the highest quality of medical care in the world, the most and the best medical facilities, the highest level of technology, and the most stringent regulations and standards. Does that mean that all doctors and dentists and surgeons in the United States are better than all of their peers abroad, or even that most of them are?  I do not think even the most xenophobic member of the American Medical Association (AMA) would dare make such an assertion in intelligent company.  Even the most vociferous critics of medical tourism acknowledge that there are many fine doctors, surgeons, and dentists around the world working in facilities that are as modern as anything in the United States.

But the official party line of the medical establishment in the United States is:  Traveling abroad for surgery is generally far more risky than having surgery in the United States. Bad things are far more likely to happen. You shouldn’t do it.

The recent history of medical tourism in the United States suggests that more and more prospective patients for elective surgery, particularly candidates for cosmetic and plastic surgery, are rejecting the medical establishment’s No. 1 considered wisdom in this matter.  By far, the No. 1 reason they are doing so is cost. Aesthetic and cosmetic surgeries are elective services, paid for out-of-pocket by patients. Wealthy patients are not so price-sensitive, but procedures are no longer for just the well-to-do.

The demand for aesthetic and plastic surgery has skyrocketed in the United States and around the world.  U.S. surgeons performed three times more face-lifts in 2004 than in 1992;  nearly eight times as many people had liposuction. (5) A whole new business in so-called minimally invasive procedures (like Botox and injectible fillers) was born in the space of a few years. In 2004, U.S. cosmetic plastic surgeons performed more than 9.2 million separate procedures.  The most visible sign of the broad acceptance of aesthetic and cosmetic surgery in mainstream society was the emergence of several popular (and controversial) reality television shows such as Dr. 90210, The Swan, and Extreme Makeover. The Swan and Extreme Makeover were short-lived, but that they made it to television at all was a sure sign that plastic surgery is no longer seen as just for the affluent.  Americans of more modest means also want to look good — but price matters.

(5) American Society of Plastic Surgeons Statistics. at www.plasticsurgery.org.

(Next)

(Previous)

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.

***

(Next)

(Previous)

Introduction Page 3 | Seeking Beauty from Afar: How I Got My Smile Back

A Nose Job in Iran?

I first focused on the bigger picture, which was plastic and cosmetic surgery in Costa Rica and elsewhere, and soon found myself swimming in a sea of Internet message boards. Mexico — was it safe? Had anyone been to Malaysia? Did South Africa make any sense at all? Why Spain for weight-loss surgery? Nose jobs in Iran, tummy tucks in Colombia, sexual reassignments in Thailand, new boobs in Brazil … it seemed that in every corner of the globe, plastic surgery was being performed for fees dramatically less than those charged by doctors in the United States and Europe, and it was even being done in places prospective patients could consider going to for a vacation.

Still, it was something one had to know about to find. It was a phenomenon, perhaps even a trend, but small — in fact tiny — when measured against the number of people who don’t leave the country to want cosmetic surgery. It didn’t even really have a name yet, though the mainstream media made periodic attempts to label it. “Lipotourism” was tried on for size (notably by The New York Times), but it didn’t really stick, describing, as it did, mostly a quick trip for fat suctioning and not much else. I’d run across “medical tourism” and used it once in an article, but it wasn’t in common usage. “Health tourism” was another borderline misnomer. As time passed, the term “medical tourism,” as uncomfortable as it is to some people, caught on.

(Next)

(Previous)

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.

(Next)

(Previous)

Introduction Page 1 | Seeking Beauty from Afar: How I Got My Smile Back

Stumbling upon an open secret

I became a “medical tourist” in the early spring of 2004, when I traveled to Costa Rica for major dental work I could not afford in the United States. I use the term medical tourism, with the benefit of hindsight, as a catch phrase for the unusual business of traveling a long way for health care. It did not gain currency in the media until later the same year. At the time, I considered myself … as what? Not a tourist. More of an exile, perhaps. Though there are certainly terrific dentists in
the United States, I couldn’t afford them. I was on the outside of the health-care system looking in.

My teeth and gums had deteriorated prematurely in my forties to the point where smiling was no longer an instrument of charm. I needed what dentists call full-mouth reconstruction. Insurance companies generally call it unnecessary and would rather wait a few years before contributing to the cost of what by then would be an entirely necessary full set of dentures. In any case, there was not an insurance plan in the world that would cover the $18,000 to $30,000 that a United States dentist would have charged for my full-mouth reconstruction — not unless I’d lost my teeth in a horrible accident, as opposed to simply having them wear away over time. I know. I shopped around.

All this I knew in 2001. By 2004, I had mostly resigned myself to having bad teeth. A quirky grin had become my all-purpose expression of approval. If my misshapen teeth appeared in a photograph, I touched them up with a bit of virtual dentistry. I hoped that what was left of my teeth would last me, functionally, until I was eligible for Medicare. I admit that the molars were still fine for chewing, that the ragged fronts could still tear food. “Let vanity go, you’re 48 years old,” said a voice in my head. I avoided looking at my teeth even when brushing them and tried not to be bitter.

On the evening of February 16, 2004, I was reading the latest messages on the Interesting People (IP) e-mailing list, an influential Internet forum hosted by Professor David Farber, often called, without much exaggeration, the Father of the Internet. The topic was the outsourcing of technology jobs overseas. Jim Warren, a computer professional and long-time online activist, went off on a mild tangent about how it is not just technology jobs that are leaving the country:

“… Many Americans fly to Bangkok to get needed (or simply desired) medical and dental procedures … everything from crucial transplants and sex reassignments to cosmetic surgery and liposuction. The surgery, hospital, and drug costs are almost nothing by comparison to U.S. medical, surgical, and hospital charges.”

Warren told of a good friend who had a laparoscopic adrenalectomy — an operation to remove a benign tumor of the adrenal gland — that would have cost $30,000 or more in the United States. In Thailand, she paid 100,000 baht — a little less than $2,600. The quality of care, he said, was outstanding.

Immediately, I was thinking about my teeth again. It had never occurred to me to shop outside of the United States for dental care. Thailand! It sounded a little crazy.

Nevertheless, 3 months later, after a lot of reading, correspondence, and consideration, I was reclining in a dental chair; not in Thailand but in San Jose, Costa Rica. The cost of my full-mouth reconstruction fit inside my credit card limit.  Six root canals, 14 crowns, and 10 days later, I was heading for home with perfect teeth and a dazzling smile for less than half of what it would have cost me at home.

I chronicled my journey for Northeast, the Sunday news magazine of Connecticut’s Hartford Courant. The article over time provoked more gratitude than anything I had written in 20 years of journalism. It also got a chilly reception from dentists in Connecticut. “Hey, maybe the Courant could get a cheaper reporter from Botswana,” was one of the more memorable gibes.

“You were very brave,” a friend told me. She meant, “I wouldn’t have done it. You always were a little crazy.” But I knew that I wasn’t crazy, and I also knew I wasn’t alone. While in Costa Rica, I’d met dozens of people who were in the country for health care — mostly cosmetic surgery and dentistry — and learned that San Jose had, for years, cultivated a reputation as the “Beverly Hills of Central America.” It was an open secret, decades old, spread first solely by word of mouth and later via the Internet.

(Next)