Medical Tourism in the Caribbean

Medical Tourism in the CaribbeanAuthor(s): Annette B. Ramírez de ArellanoSource: Signs, Vol. 36, No. 2 (Winter 2011), pp. 289-297Published by: The University of Chicago PressStable URL: http://www.jstor.org/stable/10.1086/655908 .

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S I G N S Winter 2011 ❙ 289

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❙

Medical Tourism in the Caribbean

Annette B. Ramırez de Arellano

Health-related travel has a long history. From taking the waters tovacationing at a spa promising physical and psychological renewal,combining the quest for health with that for adventure has long

appealed to some. In addition, some have traveled in search of servicesthat are inaccessible or unavailable in their home countries. Pre-CastroCuba, for example, catered to American women wanting an abortion;

[Signs: Journal of Women in Culture and Society 2011, vol. 36, no. 2]� 2010 by The University of Chicago. All rights reserved. 0097-9740/2011/3602-0003$10.00



290 ❙ Symposium: Gender and Medical Tourism

indeed, the “Havana weekend” was a standard package including airfare,medical care, and hotel accommodations (Ramırez de Arellano and Seipp1983, 146). But whereas this type of travel was once a cottage industry,crossing borders to get health care has now become a worldwide phe-nomenon involving large-scale medical complexes that specialize in com-bining healing and hospitality. The enterprise has also created a marketfor ancillary services to orchestrate travel and medical care, guide thepatient through the maze of choices, and provide support at key pointsin the process, from appointments to discharge.

Medical tourism, defined as travel with the express purpose of obtaininghealth services abroad, is a growing international trend. There is no singlemarket for medical tourism; rather, the market is segmented by purpose,complexity and type of care, and cost. Medical tourists are motivated bya variety of forces—including a desire for privacy, a desire to avoid longwaiting lists in travelers’ home countries, and the promise of first-classservices at third-world prices—and different destinations have positionedthemselves to tap into these requirements.

While the United States has long been a destination for relatively af-fluent patients from other countries, more recently it has also become anexporter of patients, with a growing number of U.S. patients travelingabroad in search of less expensive and often more luxurious health care.Many countries are therefore marketing their services to patients fromaffluent nations who may be in search of lower-cost or more accessibleservices, with the possibility of travel as an added bonus. Because one keydriver of medical tourism is price, many go abroad for routine servicesthat are less expensive than at home. In such cases, propinquity is a greatasset. In the case of the United States, its long borders with two countrieshas catalyzed medical tourism both between the United States and Canada(in the form of cross-border prescription drug purchases) and the UnitedStates and Mexico (where some border towns have become “dental oases”or offer other forms of specialized care; Kher 2006).

Countries as different as Costa Rica, South Africa, Singapore, andGhana, among many others, are actively capitalizing on the market formedical tourism. They are therefore offering health care–resort packagesthat promise the best of medicine, combined with the attractions of tour-ism, for a fraction of what equivalent health services would cost in theUnited States. This essay will explore the phenomenon as it has played outin the Caribbean. The examples of Cuba, Jamaica, Barbados, and PuertoRico shed some light on what is at stake nationally and internationally.




The local versus the global

Countries see medical tourism as a path toward economic development.Investing in the health industry is a way to increase gross domestic prod-uct, upgrade services, create jobs, generate foreign exchange, and boosttourism. Other more subtle benefits include stemming a brain drain ofhealth professionals and buying international goodwill.

As I have noted elsewhere (Ramırez de Arellano 2007), the full impactof what this means for both destination and sending countries is the subjectof intense debate. What does the trend mean for the public’s health? Whoreaps the benefits of medical tourism? Advocates of medical tourism stresstwo main points: first, that the revenues provided by medical tourism canbe plowed back into health care to benefit the population at large and,second, that upgraded facilities catering to foreigners can have a demon-strative effect on health services throughout the system, that is, demon-strating what is possible given existing know-how and additional resources.Both of these arguments assume a redistribution of revenues favoring thosein need. The opposing view is that luxury health care designed for for-eigners (or, in some cases, expatriates) widens the gap between the havesand have-nots and that poor countries are being lulled into thinking thatthey are improving their health services by having high-tech hospitals thatserve only the needs of affluent outsiders (Ramırez de Arellano 2007).Additionally, the current recession has affected some of the exportingcountries and underscored the vulnerabilities of this international tradein services. As the number of medical tourists from Europe and the UnitedStates has declined, some destinations are facing a reduced foreign cli-entele, which is not being replaced by local demand. Furthermore, muchof the marketing to U.S. tourists has assumed a health care system thatleaves many uncovered, a situation that is likely to change once the pro-jected U.S. health reforms are implemented. The full effects of medicaltourism, and the vagaries to which it can be subjected, vary from onecountry to another. As a result, trends are being watched by other coun-tries and global organizations. Even within the Caribbean, medical tourismdiffers from one island to another.

The case of Cuba

If there is a country that got a head start in medical tourism, it is Cuba.While the U.S. trade embargo has precluded any influx of patients fromthe United States, Cuba has positioned itself to attract medical touristsfrom Europe and Latin America. In the process, it has strengthened its




political links to many countries, using health care as a diplomatic tool togain potential allies and neutralize its isolation from its immediate neigh-bor to the north.

Since Cuba’s socialist revolution in 1959, the government has soughtto bolster its health services, devoting an increased proportion of its re-sources to the medical sector even in the face of a deteriorating and unstableeconomy (Dıaz-Briquets 1983). Cuba invested in its health infrastructureand implemented an aggressive public health strategy; this paid off inimpressive health indicators, comparable to or better than those of manyindustrialized countries (Cooper, Kennelly, and Ordunez-Garcia 2006).Following the revolution, Cuba decentralized its health services, offeredpreventive and curative care to its citizens at little or no cost, and workedto increase the number of health professionals, both to replace thosewho had left the island and to insure a surplus of practitioners who couldbe deployed as needed, including internationally. Health care thereforewas seen as both an end in itself and as a means to achieve other goals.

Committed to universal health coverage of its own population, Cubaalso saw the opportunity to showcase its services by sending its healthresources abroad in response to natural disasters and chronic shortages.When Kashmir experienced a catastrophic earthquake in 2005, Cuba sent3,000 medical staff and enough equipment to erect thirty field hospitals;more recently, 400 Cuban doctors were among the first to install a hospitaland begin providing care to the victims of Haiti’s 2010 earthquake (CalvoOspina 2006; Fromson 2010). Thousands of Cuban doctors have beenexported to Venezuela to provide primary care in rural areas and urbanbarrios. In March 2006, 25,000 Cuban health professionals were workingin sixty-eight countries, more than the World Health Organization andDoctors Without Borders collectively could deploy (Calvo Ospina 2006).

At the same time, Cuba has instituted measures to attract patients fromabroad. Faced with the fall of the Soviet Union and an expanding tradedeficit, the country gave priority to its pharmaceutical and biotechnologyindustry and to boosting health tourism (Carrillo de Albornoz 2006). In1995–96, Cuba generated the equivalent of 25 million U.S. dollars inmedical tourism by attracting more than 25,000 foreign patients (Davisand Erixon 2008). While there is some concern that this may be siphoningresources away from services to the Cuban population, the extensive healthinfrastructure that was in place prior to the tourism initiative minimizesthis possibility. Moreover, revenues derived from foreign patients go di-rectly to the Ministry of Health to be reinvested in the national system(Carrillo de Albornoz 2006).




Other islands follow: Jamaica, Barbados, and Puerto Rico

The example of Cuba, together with that of Asian countries such as Thai-land and India, has prompted several Caribbean islands to join the medicaltourism bandwagon. While Jamaica, Barbados, and Puerto Rico all haveextensive experience in marketing themselves as tourist destinations, theyare now engaged in luring visitors who are primarily interested in findinghealth services at a lower cost than offered in the United States. Each isexploiting a different niche, thereby avoiding competition with the others.But all are aiming to attract U.S. patients, who do not have easy accessto services in Cuba.

Jamaica

Building on its experience in selling itself as a tourist-friendly, English-speaking environment, Jamaica is attempting to position itself in the well-ness market. Because the country cannot compete well in the surgicalfield, Jamaica is promoting low-tech healing to become a global healthdestination. As the largest English-speaking island in the Caribbean andone of those closest to the United States, it is trying to divert a segmentof patients now traveling to Asia from the United States and UnitedKingdom. As in other countries in the area, the proponents of medicaltourism in Jamaica cite the island’s climate, rainforests, and “environmentfor recuperation” (Treatment Abroad 2007).

Other than the market for plastic surgery, which operates from Mon-tego Bay (Silvera 2009), or for the spa treatments that are part of manytourist packages, there is little evidence of demand for broader medicalservices. Moreover, many of those traveling to Jamaica for health care areexpatriates. The island faces a number of hurdles in entering the medicaltourism market. These include the inadequately equipped public and pri-vate hospitals and the lack of trained professionals in the services that arein greatest demand, such as renal transplants and joint-replacement sur-gery. One Jamaican physician therefore cautions that medical tourism willnot be politically acceptable in Jamaica unless “all procedures [are] avail-able to the local population in public hospitals” and “the quality and rangeof services offered in public hospitals achieves internationally acceptablelevels” (East n.d.).

Barbados

Like other Caribbean islands, Barbados is looking beyond the attractionof sun, sea, and surf to build health tourism based on its “relatively strongintellectual capital, an established hospitality industry, and an ambient




environment” (Caribbean Export Development Agency 2008, 11). Todate, it has achieved some success in positioning itself as a destination forinfertility treatments, particularly in vitro fertilization (IVF). Its marketincludes women who cannot afford such treatment in their home countries(particularly if they require donor eggs for the procedure) or who lackaccess to such services because of long waiting lists, age restrictions, orlack of insurance coverage.

Because Barbados does not have a large enough population to supportsuch highly specialized care, the Barbados Fertility Center sought to mar-ket its infertility services internationally from the beginning. While patientsfrom the United States and the neighboring Caribbean islands are partof the clinic’s catchment area, the facility also handles patients from theUnited Kingdom, where waiting lists for IVF can be as long as three years(Abeng News 2009). The facility also caters to the needs of patients ofCaribbean heritage, who may not have easy access to eggs from donorsof similar ethnicity (Simpson 2009). The clinic provides complete “IVFholidays,” which include transportation, hotel accommodations, clinicaltesting, and treatment.1 Costs are advertised as being one-third of whatclinics in the United States and United Kingdom charge for a full IVFcycle (Abeng News 2009).

During its eight-year history, the Barbados Fertility Center has achievedaccreditation from Joint Commission International and claims a clinicalpregnancy rate of 62 percent for women under age 40, a higher rate thanthe national statistics for the United States and United Kingdom.2 Inlanguage that is typical of the marketing effort underway, this success isattributed not only to the skill of the medical team but also to Barbados’s“turquoise sea, dazzling white sandy beaches and exquisite weather, whichcreate an ideal environment for stress-free IVF” (Simpson 2009). In 2009the clinic expanded its operations to Trinidad and Antigua so that couplescan begin treatment in their home country and travel to Barbados onlyif a full IVF cycle is required (Abeng News 2009).

Puerto Rico

Puerto Rico has always attracted patients from the British and U.S. VirginIslands, which lack the population to support a full array of high-tech-nology, tertiary-care medical facilities. But it is currently marketing itselfas a medical destination for U.S. patients seeking lower-priced care.

1 See http://www.barbadosivf.org.2 Ibid.




The government has been enlisted in this effort, and the island is tout-ing its advantages: excellent connections by air, making it a convenienthub; major cruise ship ports; an established U.S. market with no passportrequirement for U.S. visitors; and an extensive, well-developed healthinfrastructure (Ryan 2009). The legislature recently passed a bill givingtax breaks to new initiatives in medical tourism; the legislation also directsthe government to issue licenses and certifications for medical tourismfacilities and activities, and to monitor such activities (Santana 2009).

Individual hospitals are also advertising themselves in U.S. publicationsand are promoting themselves as part of the network of the medical travelfacilitator Companion Global Health Care. This company has incorpo-rated two Joint Commission International–accredited private hospitalsoutside San Juan as part of its offerings. Their services include cardio-vascular surgery, orthopedic surgery, neurology, and oncology “at priceslower than mainland facilities” (Commins 2009).

The disparate effects of medical tourism

As these cases suggest, medical tourism can target specific markets or bemore broadly based. It can also have different impacts, largely dependingon whether it supplements or replaces the health services provided by acountry to its own population. In the case of Cuba, medical tourism doesnot appear to have diverted resources from basic services but rather ex-tended the scope of care provided. In addition, it has broadened theisland’s sphere of influence by allowing it to connect with institutions andpatients from close to a hundred countries. The other Caribbean islands,however, face a different set of circumstances. Without national systemsguaranteeing access to care for their own populations, increased invest-ments in services aimed at attracting medical tourists run the risk of dis-torting care, redistributing resources away from the basic primary carethat most of their populations still lack.

As other countries join these pioneering nations in developing theirown brands of medical tourism, they should examine the long-term im-plications of the trend. The area of medical tourism is very much in flux,and those countries that entered the field early have a comparative ad-vantage in marketing their services. As the cases of Cuba and the otherCaribbean islands suggest, there are different ways to exploit this emergingeconomic sector. But countries that opt to market themselves as medicaldestinations need to ensure that they are not shortchanging their owncitizens in the process.




Latinos for National Health InsuranceWashington, DC

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“Almost Invisible Scars”: Medical Tourism to Brazil

Alexander Edmonds

It is now a truism to say that illness and medicine function as metaphorsfor political and social relationships. Nations can be “sick,” statesmen“doctors.” Boundaries between the ill and the stigmatized or deviant

are permeable. But if new illnesses and treatments can indicate largerdistress in the body politic, it’s not clear what exactly cosmetic surgerytourism—which involves long-distance travel for elective procedures—symbolizes about health, whether understood as the patient-consumer’swell-being, the viability of health care systems, or the global relationshipsunderpinning the movement of patients and scientific technologies. Draw-ing on ethnographic fieldwork in Brazilian plastic surgery wards, I examinethe local and transnational relationships shaping Brazil’s rise as a desti-nation of medical tourism.

Western technological superiority is often seen as a symbol—and ve-hicle—of geopolitical domination. Hence, it is perhaps understandablethat the ability of hospitals in developing countries to attract medicaltourists has been trumpeted as a national achievement. Countries likeThailand and India market not only their low prices and the tropical locales

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Medical Tourism in the Caribbean