Beauty from Afar

Our little history lesson continues today with a segment about how a plastic surgeon in Costa Rica started marketing to the U.S. market in the early 1980s; and continues with a discussion of a somewhat prescient World Bank report on prospects for health tourism exports in the Caribbean.

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

I thought I’d be sailing through Chapter 3 easily but have had a lot of reformatting to do from the version of Beauty from Afar from which I am working … which I have now realized is probably the penultimate digital copy. Aaaaiiieee! An alert reader, Debbie, caught a mistake the other day in which I had named someone other than Alexandre Dumas as author of The Three Musketeers. Fortunately, the error was fixed before the book was printed. I do remember how I felt when I found the mistake initially — after I’d “finished” writing the book and after it had been twice edited. I felt both as though I’d dodged a bullet and as though I was nearly too stupid to live.

There are a couple of minor errors in the paper version of Beauty from Afar. It is nice to have the opportunity to fix them.

I used to be appalled when I found typos or any kind of mistakes in books. How could it happen? Well — now I know the answer. It can happen in all sorts of ways. Human beings are involved. With Beauty from Afar, they mostly happened because I was allowed to fuss with and add things right up until the last second — as though we were producing a newspaper story instead of a book. Overall, I think the additions and last-minute changes made for a better book … but there is a tradeoff. Typos, however minor, are just disheartening.

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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