Beauty from Afar

Chapter 4 Page 6 | Other Cosmetic Procedures

Hair Implants

Hair implants involves the transplantation of thousands of tiny patches of hair-bearing scalp tissue to the balding areas of the head. Results vary from patient to patient and are by no means guaranteed. Though Costa Rica’s Dr. Cohen mentioned that he does not see as many hair transplant patients as he once did because transplantation has become less expensive in the United States, research indicates that there is still a substantial “overseas discount” of 25 percent to 50 percent. Hair transplant prices are generally based on the number of hair/skin grafts done. U.S. prices range upwards from about $3,000, depending on the extent of the work.

Ear Pinning (Otoplasty)

Prior to research, I’d had no idea that fixing protruding ears was a popular cosmetic procedure. Otoplasty is the general term for cosmetically enhancing the appearance of the ears. Roughly 25,000 U.S. residents underwent some sort of cosmetic surgery of the ear in 2004, according to ASPS statistics. Prices in the United States range from $2,500 to $4,000; prices abroad range from $800 to $1,500.

Weight Loss Surgery (Bariatric Surgery)

Bariatric surgery that is designed to cause significant weight loss is increasingly popular in the United States. The surgery alters the digestive process, either restricting the amount of food the stomach can hold or causing food not to be absorbed. There are several different procedures and techniques with more continuing to evolve. The intestinal bypass was the first and is still the most common in the United States.

There are eight recognized types of bariatric surgery including laproscopic bariatric surgery, bariatric bypass surgery, and vertical banded gastroplasty (VBG). Bariatric surgery is considered a drastic lifesaving solution for a major health problem. In this instance, it is covered by some medical insurance plans and prospective patients in the United States who have health insurance are generally well-advised to explore the option with their insurer. However, many patients do go abroad to afford the surgery. For those interested in bariatric surgery and wondering where to start, I recommend without qualification the Obesity Help website (www.obesity-help.com), an online support group that boasts more than 200,000 members.

Dental Procedures and Appliances

My personal experience with going abroad for costmetic surgery is limited to dental work. It is ironic, perhaps, I did far less research prior to going to Costa Rica for full-mouth reconstruction than I now recommend that others do before making a decision. Readers interested in the extensive details of my own experience should visit my Web site Beauty from Afar (www.beautyfromafar.com).  Since having my work done in 2004, I have recommended at least dozens of patients to Drs. Cordero and Rubinstein at Prisma Dental in Costa Rica.  Invariably, however, I point out that there are other excellent dentists in Costa Rica and around the world, and I urge prospective dental patients to thoroughly explore their options at home and abroad before making a decision.

Dental insurance in the United States rarely covers the full cost of extensive cosmetic work. There is certainly little reason to go abroad for routine dental work. However, when the prospective out-of-pocket expense for wanted or needed dental work climbs into the thousands of dollars, going overseas can become the pragmatic option.

Generally, dental patients do not require extended convalescence abroad, or significant immediate after-care and support, as do medical surgery patients. Costs range widely based on various dental proceedures, but my general statement that patients can expect to save from 40 to 75 percent on medical services abroad holds true for dental work. Many cosmetic surgery patients abroad opt to get at least minor cosmetic dental work, such as teeth whitening, done on the same trip.

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We commence today with Chapter 4 of Beauty from Afar, for which I half apologized in advance. I really needn’t have, now that I look at it again. Immodestly, I don’t mind saying that I like the way it starts out, and I have Joseph Cohen, M.D., of the Rosenstock-Lieberman Center for Cosmetic Plastic Surgery in San Jose, Costa Rica, to thank for that.

Chapter 4 Page 1 | You’re Going Abroad for…What !?

Dr. Cohen’s candor made him a terrific person to interview on the subject of what surgical procedures people go overseas for, and why; that he, a prominent cosmetic surgeon in Costa Rica, would consider going to the U.S. (hypothetically) for his own care, under certain circumstances, I think makes for a nice balance in a book that is mostly about people going in the other direction. And it gives him credibility.

We’ve now covered 76 pages of the original text of Beauty from Afar, which has worked out to 37 web pages. That seems about right to me … and it means I’m about a third done, which feels substantial.

I’ve mostly resisted the journalistic urge to step too far outside the boundaries of the book, but anyone interested in the business of medical tourism ought to go read Brendan Borrell’s Reuters story, published today:

Controversial couple dominates U.S. medical tourism

I don’t see how this has any real impact on patients, mind you, or I’d be more concerned. As a nascent “industry,” though, medical tourism has not traveled all that far since I first wrote about it in 2004-2005. The squabbles are a little bigger.

It was really in 2004 and 2005 when the U.S. media “discovered” Medical Tourism … about the same time I did. (Maybe just a little after I did. 😉 ) And it was discovered because the media noticed that people were going overseas for serious, life-saving procedures, not just cosmetic surgery and dentistry.

Chapter 3 Page 5 | The Media Imprimatur

Medical tourism and travel has been episodically in the news in the U.S. ever since and remains a story in parallel with the dominant narrative about healthcare reform in the U.S. that arose in 2008 — 2009.  I’ve often been asked if real healthcare reform in the United States would be the end of medical tourism, and the answer is no. Medical tourism and international medical care will remain less costly alternatives and U.S. patients and insurers will continue to explore and integrate the travel-for-care options that are available.

We’ve hit the end of Chapter 3. Chapter 4 will look at what surgeries and procedures that patients choose to have done overseas — specifically, it is mostly a list of cosmetic procedures and average prices and savings in 2004 — 2005. As I go through it, I’ll try to put forth any updates of which I am aware. Chapters 4 and 5 (which is a tutorial on doing Internet research) are, to me, the driest parts of the book but I’ve encountered readers who thanked me for them. So … off we go. Tomorrow, probably.

Chapter 3 Page 5 | The Media Imprimatur

The media in the United States did not really discover medical tourism until 2004-05, and it was found in the Far East rather than in central and South America. It was Bumrungrad Hospital in Thailand and the Apollo Hospital Group in India and Penang Adventist Hospital in Malaysia that made 60 Minutes and the front pages of the Wall Street Journal and The New York Times, not the plucky surgeons and dentists of Costa Rica, Mexico, and Brazil — even though far more U.S. citizens were heading South for inexpensive medical and dental care and surgery than were heading to the Far East. There are a few good reasons for that, which I offer not as an apology for the media but as explanation:

1. The story wasn’t about cosmetic surgery, which, despite its popularity and the professionalism of its practitioners, doesn’t get the same treatment in the news as does “real” medicine. Cosmetic surgery news is fluffier, more frivolous, than open-heart surgery news. The international hospitals of the Far East, wisely, didn’t play up cosmetic surgery — though they do a lot of it. They played up cardiothoracic surgery, and their state-of-the-art technology and facilities, and thus were taken more seriously. For the first time, much was made of the fact that there is an estimated 42 million people in the United States who lack adequate medical insurance who could go out of the country to get treatment they could not otherwise afford.

2. The story was delivered in part as a business story with big dollar signs, the kind that gets attention from the media. India put a $2 billion sticker on medical tourism. As previously noted, Bumrungrad sees more than 350,000 patients a year.

3. The story was generated by big multipurpose hospitals, and supported by the tourism and economic development officials of their respective countries. This is the way countries in the Far East go after markets, and there is nothing in Central or South America to compare as yet.

As we move through the first decade of the 21st century, medical tourism is still both newly discovered and in transition. The tip of the iceberg remains elective medical care, mostly cosmetic surgery and dentistry; beneath the surface is the larger consumer health-care market of North America and Europe.

And the media is paying attention. In February 2006 a West Virginia state legislator introduced the first bill in the country providing for the outsourcing of medical care to foreign countries. In Chicago, Blue Cross/Blue Shield investigated and then approved payment for an insured child’s heart surgery in India. And when President Bush visited India for the first time in March 2006, the two countries released a statement pledging American support for Indian efforts to support medical tourism, saying there is “enormous potential for collaboration” in health tourism.

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I don’t know anyone who likes to refer to “Medical Tourism” as “Medical Tourism.” Funny, huh? But someone came up with it in the 1990s, and we are still about half-stuck with it. Increasingly, people in the business prefer the reference “medical travel,” which doesn’t have the the assumed frivolity of “tourism” as baggage.

Chapter 3 Page 4 | Origins of  the term “Medical Tourism” (cont.)

The earliest references I found for the phrase “Medical Tourism” were in 1998, as noted in today’s segment.

Chapter 3 Page 4 | Origins of  the term “Medical Tourism” (cont.)

Dr. Fournier claims he was the seventh cosmetic surgeon in the world to put up a Web site and I have no reason to doubt him; whether he was 7th or 17th, or 70th doesn’t matter much. U.S. cosmetic surgeons were quick to seize on the new medium of Internet marketing to spread information and awareness, but several of the Costa Ricans were right there with them, as were surgeons in other countries. Once reliant for marketing solely on word of mouth, occasional visits to the United States, and flight magazines, cosmetic surgeons around the world found they had a platform from which they could reach customers directly and at a minimal cost. As the demand for cosmetic surgery in the world’s No. 1 market, the United States, shifted into overdrive in the late 1990s, more surgeons abroad targeted the United States. Though their market share was tiny,  their growth rate likely was faster than that in the United States, and it remains so today. Business for foreign surgeons in 2005 was threefold, or fivefold (depending on who you ask) what it was in 1995, when things were already going well.

Around 1998, the phrase “medical tourism” finally began creeping into news accounts. The Washington Times noted in March of 1998 that medical tourism was one of the few bright spots in the economy of Castro’s Cuba. In April, officials in Miami, Florida were touting “the concept of medical tourism” in an Associated Press article. They were not talking about patients going abroad or even coming from abroad; the Miami Health Care Alliance simply thought maybe vacationers who were coming to Florida might like to visit a few doctors, seeing as how they were in town anyway. If you look in a big database of periodicals and magazines published prior to 2001, most of the references to medical tourism come from overseas. The New Straits Times of Malaysia ran a number of stories about the potential of medical tourism for that country, for India and for the rest of the Pacific Rim nations. The Jerusalem Post in 1999 referred to medical tourism as “a huge business.” But if it was a huge business, it was a remarkably unreported one in the United States in the late 1990s. For me, the earliest reference to medical tourism that bestowed proper global context to the term belonged to Prof. Sander Gilman, author of Making the Body Beautiful: A Cultural History of Aesthetic Surgery, published in January 2001.  He wrote:

The globalization of aesthetic surgery has spawned numerous centers that link surgery and tourism. North Americans have long gone to Mexico, the Dominican Republic, and Brazil; now the United Kingdom has started to offer “aesthetic surgery” tours for Americans as well. People in the United Kingdom flock to Marbella in Spain for discrete face-lifts, but Poland and Russia are now competing for this market. For medical tourists in the Middle East,  Israel has become the country of choice for many procedures, even for citizens of countries that do not have political ties to Israel;  Germans visit South Africa for breast reductions and penis enlargements as well as to see the Kruger National park;  South Korea and Singapore are important for the Asian market; and Beirut, Lebanon, is the place to go for quick, no-questions asked transgender surgery. Medical tourism has become big business, and aesthetic surgery, because of its elective nature, is a large part of the action. For every procedure recorded in one country, similar procedures are being undertaken on that country’s citizens elsewhere … Aesthetic surgery has become a worldwide phenomenon in the past few decades. (3)

(3) Sander L. Gilman, Making the Body Beautiful: A Cultural History of Aesthetic Surgery. (Princeton University Press, Jan 15, 2001), 8.

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Chapter 3 Page 3 | Build It, and They Will Come …

Arnoldo Fournier, M.D., a cosmetic surgeon in San Jose, Costa Rica, was one of the pioneers in marketing his services abroad. He came to Costa Rica in the early 1980s, fresh from his residency at St. Luke’s Hospital in New York, and was told that there was no demand for aesthetic procedures in Costa Rica.

Stubbornly, he stayed and went after the U.S. market. He placed his first ad in the Tico Times, the Central American country’s English-language daily; later, he turned to the flight magazines of the international airlines: LACSA, Eastern, Skyward and Passages among them.

By the 1990s,  Dr. Fournier and other Costa Rican cosmetic surgeons, dentists, and doctors thought they had a pretty good thing going. Costa Rica was beginning to prosper as a tourist destination and U.S. retirees were making the country their home in increasing numbers; the number of Americans desiring cosmetic surgery was starting to rachet up.

Prices for cosmetic surgery in Costa Rica then, as now, were much lower than in the United States. I received an e-mail in December of 2004 from a woman in Florida who had read what I had written about my own trip for dental work; she affectionately recalled going to see my dentist, “Dr. Telma,” in 1986. She wrote:

In 1986, Dr. Telma installed 13 crowns in my mouth for $1,200. At that time, if I had this work performed in the U.S., it would have cost about $4,000 to $6,000 … As she worked, Dr. Telma and I also had incredible intellectual discussions on the anthropology of Central American Indians, their bone structure and diet, and where they came from. Both she and her husband are very well educated in many other areas, and not just dentistry … I came across your article as I was searching the ‘Net for her services again. I need two crowns and some teeth bleaching, and a minor face lift, which I am going to coordinate and schedule this summer if possible.

So what was to become known later as medical tourism was already growing in Costa Rica in the 1980s and into the 1990s. In what was to prove to be a prescient report, the World Bank in September 1995 published a 52-page study on Prospects for Health Tourism Exports for the English-Speaking Caribbean. (2) It noted:

Direct patient care is the major health service exported by Costa Rica. In addition to plastic surgery, a full range of pediatric and adult services including high technology dependent procedures such as open heart surgery are exported. Costa Rica’s target markets for the export of health services are the United States, other Central American countries, Puerto Rico, Barbados, and other Caribbean nations, Colombia, Venezuela, Canada, and Spain.

The prescient part of the study identified the reasons why potential for further substantial growth existed in the Caribbean countries:

• Demographics in target markets (for example, aging post-war baby boomers who are concerned about physical appearance, semiretirement, full retirement and relaxation) will mean marked increases in demand for cosmetic surgery, spas, and retirement communities.
• The growing affluent class of baby boomers may be less price sensitive and more sensitive to other aspects of the marketing mix (for example, location and confidentiality.)
• Lifestyles in Europe and North America increase the demand for services such as spas, fitness centers, cosmetic work, or addiction treatment centers.
• Waiting time for procedures in the United Kingdom and, to a lesser extent, in Canada encourages the search for outside health services.
• A large portion of the U.S. population is uninsured or underinsured.
• Private insurance does not cover selected treatments.
• Operations in Caribbean regions appeal to doctors from target markets that enjoy visiting the region, which could facilitate strategic alliances and capital investment.
• Lifestyle health-related problems in the target markets are similar to those among people in the Caribbean, and quality health and social marketing materials could be exported to these markets.

“The U.S .market is most apt to offer opportunities to the Caribbean because it has a large uninsured and underinsured population, it has very high prices, and it is geographically close to the Caribbean,” the report stated. “Moreover, the U.S. system is more fragmented and less controlled than health sectors in other industrialized countries. As a result, the U.S. market has multiple avenues of entry.”

The report also summed up the challenges facing countries going after the health tourism market as well, among them that:

• U.S. medical doctors act as “gatekeepers” for the U.S. health-care system and would not want to lose patients to the Caribbean market.
• Questions about quality of care in the Caribbean will exist in consumers minds and will be difficult to overcome.
• Neighboring countries in Latin America could provide care at lower cost, as could countries in Eastern Europe.

Other than leaving out the entry of Asian, Middle Eastern or African nations into the market, the World Bank study was a blueprint for medical tourism for the next decade for anyone who cared to follow it. However, it made no particular impact then that I can discover now. What it stated was already obvious to pioneers in Costa Rica and elsewhere, but it took years for much of the world to begin to notice. The third and final precondition for medical tourism to become a globe-straddling business was that people had to know about it; it had to be marketed to a broader audience, somehow. The Internet came along at just about the right time.

(2) Prospects for Health Tourism Exports for the English-Speaking  Caribbean by Maggie Huff-Rousselle, Carol S. Shepherd, Robert Cushman, John Imrie, Stanley Lalta. World Bank, Washington, D.C.; Social Sectors Development Strategies, Inc. September 1995.

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Traveling for medical care isn’t new. Looking for historical examples was kind of fun. Starting Chapter 3 with a quote from Alexandre Dumas’ The Three Musketeers is maybe a little pretentious to some people, but I hope others were as mildly amused as I was.

Chapter 3 Page 1 |  A Brief and Selective History of Medical Tourism

I promise, Chapter 3 moves along quickly. It runs from pages 63 to 72 in the bound version of Beauty from Afar … so I’d guess it will all be “live” by the end of the week.

By now, anyone reading along has probably figured out that I had no intention of writing what might have amounted to a directory of international medical services. Others, most notably Josef Woodman with his Patients Beyond Borders series of guides, have ably provided health care consumers with more traditional formats.

I wanted to provide more of a broad overview, a way of thinking about medical travel and tourism. Beauty from Afar, I thought, would take readers to the point where they could make educated decisions about where they might go as medical travelers without telling them where to go. As choices have expanded over the past five years, I am glad that other books have come along. There are now a number of medical travel books; there are magazines; there are newsletters; there are associations.

There were none of those things when I was first researching and writing Beauty from Afar in 2004 — 2005. Things have moved right along.

Chapter 3 Page 1 |  A Brief and Selective History of Medical Tourism

(A (necessarily) brief history of traveling for health care)

My dear Athos,

I wish, as your health absolutely requires it, that you should rest for a fortnight. Go, then, and take the waters of Forges, or any that may be more agreeable to you, and recuperate yourself as quickly as possible.

Yours affectionate,
de Treville

From The Three Musketeers
Alexandre Dumas

***

The history of cosmetic surgery, and of traveling extended distances for medical care or health reasons, goes back to the beginning of recorded time. Reconstructive plastic surgery procedures were performed in India at least as far back as 600 B.C. (1)

Literature and history are replete with stories of people who have traveled for health reasons; the healing and recuperative powers of bathing in the hot mineral springs around the world is documented in both fact and in fiction. School children are taught that the Spanish explorer Ponce de Leon allegedly went in search of the Fountain of Youth and found Florida and death by an Indian arrow instead. I say “allegedly” because a number of scholars dismiss the Fountain of Youth part of the story as myth. In more recent history, Franklin D. Roosevelt received therapeutic baths and muscle treatments for his debilitating pain from polio in Warm Springs, Georgia during his administration from 1933-1945, making the place sort of a southern White House for months at a time.

You could say that President Roosevelt was a pioneer of modern health tourism, the precursor of medical tourism, though the two are distinct, historically and even today. Health tourism is the business of spas selling weekend or week-long indulgences of luxurious massages, exotic baths, healthy foods, beauty makeovers, and soothing or exhilarating scenery for an even more exhilarating price. Some even have a spiritual component. The actual medicinal value of much of this has long been debated, though many medical professionals vouch for their therapeutic benefits.

Medical tourism, on the other hand, is entirely recent and has become the more narrowly applied term for traveling abroad for the services of a doctor or surgeon. Recuperating in a spa or vacation-like setting is an option, and an attractive embellishment for many. While, no doubt, there are scholars who could step forward with examples from history of people who traveled great distances for the services of a particular doctor or a particular treatment or surgery, they would also acknowledge that medical tourism is mostly a modern phenomenon. It tracks very closely with the 20th century refinement of cosmetic surgery as a medical specialty spawned from necessity during World War I when reconstructive techniques were developed to treat those maimed in combat.

By the 1950s, the groundwork for what was to become modern cosmetic surgery had been laid. Though far from common, surgery for purely aesthetic reasons had become less peculiar. Initially there was little competition. Through the 1950s and 1960s cosmetic surgery was the province of the United States and Europe; the clients, whatever nationality, were mostly wealthy. Quick, affordable international air travel was the first precondition for medical tourism to emerge and international patients started to head for the great hospitals of the United States and Europe, as they still do today. The main difference today is that the international competition to provide medical services has become fierce.

In addition to the patients, however, an ever-increasing number of medical students, doctors, and surgeons from around the world converged on the United States and Europe seeking medical training. As time passed, more information was exchanged and spread; more technology was were shared. Some of the medical students stayed in the United States as part of the infamous “brain drain” that was attracting the best and the brightest from around the world, to the detriment of efforts to modernize and improve economic conditions abroad. But some went home to build medical practices in their own countries and to found new institutes, hospitals, and centers of learning. Among the skills they took with them were cosmetic surgery techniques.

In time, inevitably, other destinations for patients besides the United States and Europe arose.

(1) Rana RE, Arora BS. History of plastic surgery in India. J Postgrad Med 2002; 48:76-8

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Prices for cosmetic surgery vary widely based on a number of factors, as I point out in the concluding segment of Beauty from Afar‘s Chapter 2:

Chapter 2 Page 9 | Prices in the United States and Abroad

Being a surgeon, particularly being a surgeon for uninsured, elective procedures, is a business, wherever one is located.  And the global recession has had an impact on the business of cosmetic surgery. This report is from January 2009, but I rather doubt that cosmetic surgery is less recession-proof than the rest of the economy:

Cosmetic surgeons suffer recession, says new survey

Well-established practices are weathering the storm. Not-so-well established practices are not, and some are not surviving.

Anywhere in between? Whether in the U.S. or abroad, cosmetic surgeons are getting more creative about marketing to patients and that means, often, that patients have some bargaining power when it comes to price.

No sane person chooses a surgeon solely on the basis of price. But discounts can be attractive.

That finishes up Chapter 2, hooray! I have no idea if anyone is following along day by day, but the visitor count has been rising steadily. On to Chapter 3 … which is a brief history of medical tourism.