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Medical Travel: What It Means,Why It MattersElisa J. Sobo aa San Diego State University ,Published online: 10 Nov 2009.

To cite this article: Elisa J. Sobo (2009) Medical Travel: What It Means, Why ItMatters, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 28:4,326-335, DOI: 10.1080/01459740903303894

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Medical Travel: What It Means,Why It Matters

Elisa J. Sobo

Markets for medical travel have grown immensely in the past few years. Theyhave attracted the attention not only of healthcare consumers, providers, andpayors but also of scholars from various disciplines. This editorial demon-strates some of the ways that anthropology can contribute to current effortsto better understand medical travel. Such contributions have more thanimportant academic implications. Properly packaged, anthropological workon medical travel can be of great value to policymakers and program plannersas they grapple with the changes that geographically and subjectively newpatterns of healthcare procurement entail.

Key Words: globalization; health care consumerism; health services; health tourism; medical

tourism; medical travel

MEDICAL TRAVEL: AN EMERGING CONCERN

Throughout time, people have traveled to natural and sacred sites in pursuitof health or healing, and we know a good deal about this kind of pilgrimage.In comparison, scholarly knowledge about contemporary travel for theprimary purpose of obtaining indicated or elective dental or biomedicalservices—‘‘medical travel’’—is sparse. Why? To begin, until recently,medical travel accounted for a minimal share of global trade flows. As such,

ELISA J. SOBO is Professor of Anthropology at San Diego State University and a member of

the editorial board of Medical Anthropology. Recent publications include Culture and Meaning

in Health Services Research: A Practical Field Guide (2009). Correspondence may be directed to

her at Department of Anthropology, Mail Code 6040, San Diego State University, 5500

Campanile Drive, San Diego, CA 92182-6040, USA. E-mail: esobo@mail.sdsu.edu

MEDICAL ANTHROPOLOGY, 28(4): 326–335

Copyright # 2009 Taylor & Francis Group, LLC

ISSN: 0145-9740 print=1545-5882 online

DOI: 10.1080/01459740903303894

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it went unnoted and so unquestioned by most. Further, and again untilrecently, medical travel mostly involved trips from economically poorernations to wealthier ones. The United States in particular has served as akey destination for medical travelers in search of advanced biomedical care(indeed, what is now thought of as ‘‘cultural competence’’ was initiallyconceived in many U.S. organizations in response to the needs of‘‘international’’ patients).1 Today, however, the tide has turned.

On this turning, medical travel has attracted the attentions of health careregulators and policymakers charged with keeping patients safe, as well asbusiness concerns posed for great profits and those slated for losses aspatient populations migrate. The United States, for instance, could forfeitover $67 million in 2010 due to lost domestic spending and more than$100 million in 2011 (Keckley and Underwood 2008).

Scholars, too, have taken note. To offset the possibility that medicaltravel’s more sensational dimensions dominate anthropology’s attention,as they seem to do the public’s right now, this editorial takes inventory ofsome areas set to profit from increased anthropological investigation. Butfirst, it briefly situates the change in medical travel patterns.

THE GLOBAL BUSINESS OF BIOMEDICINE

In part due to ‘‘the liberalization of trade in services, the growing cooperationbetween private and public sectors, the easy global spread of informationabout products and services, and, most importantly, the successful splicingof the tourism and health sectors’’ (Bookman and Bookman 2007:95),patients outbound from various North American and European nations havejoined the medical travel consumer population. In the United States, thanksto (among other things) high numbers of uninsured and underinsured indivi-duals; an increasing demand for so-called lifestyle care, such as knee replace-ments and aesthetic or cosmetic surgery; technological developmentsallowing for quicker, less invasive surgical procedures; increased awarenessof options due to word-of-mouth regarding the quality and value of out-sourced care (including Internet discussions); and increased general mediacoverage of medical tourism, the number of medical travelers is growing atastounding rates. According to Deloitte Center for Health Solutions, ‘‘in2007, an estimated 750,000 Americans traveled abroad for medical care; thisnumber is anticipated to increase to six million by 2010’’ (Keckley andUnderwood 2008:3).2

While some outbound travelers seek treatments unavailable in the UnitedStates, the majority of medical travel has been explained by financial logic:a hip replacement costs about $37,000 in the United States and about

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$13,000 in India. An $80,000 U.S. heart bypass is $16,000 in Thailand (Hig-gins 2007). Using weighted average procedure price, Deloitte put the aver-age savings from the U.S. perspective at about 85 percent (Keckley andUnderwood 2008). Moreover, care procured at certified facilities is generallyof equal or better quality than the U.S. standard (Milstein and Smith 2006).

Consequently—critical debates regarding ‘‘quality’’ and ‘‘evidence’’notwithstanding—some U.S. insurance companies (such as BlueCrossBlueShield of South Carolina) and government payors (such as the stateof West Virginia) have given serious consideration to sending patientsoverseas for certain types of care or offering them cash rebates for doingso (Bramstedt and Xu 2007; Carrol 2007). In California, several insurancecompanies now offer bi-national (U.S.–Mexico) coverage. Hannaford, aNewEngland-based grocery chain, offers its employees the option of flying toSingapore for a number of medical procedures (Economist 2008a).

While saving money is serious business for insurers and consumers,making money from medical travel is also an incentive to participate inthe global health care market. Asian nations are among those that haveactively pursued transnational patient-consumers as well as programmati-cally encouraging necessary infrastructural development (Whittaker2008).3 Hotelmarketing.com estimates that ‘‘the industry in Malaysia,Thailand, Singapore and India, currently worth around half a billion dollarsa year in Asia, is projected to generate more than U.S.$4.4 billion by 2012.India’s medical tourism business is growing at 30 percent per year and isforecast to generate at least U.S.$2.2 billion a year by 2012’’ (Anonymous2006). Similarly rosy prognostications abound in trade magazines andindustry newsletters.

ADDING THE ANTHROPOLOGICAL PERSPECTIVE

With more and more people around the world engaging in medical travel,the value of medical travel expertise in all fields is on the rise. The medicalliterature has addressed the phenomenon, but mostly through editorials. Interms of research, we have seen a flurry of publications on medical travelin the fields of economics and in hospitality and tourism management.Anthropological publication in this area also is expanding, and that is good.Carefully conducted and strategically disseminated anthropological researchregarding medical travel can help immensely as policymakers struggle tocome to grips with the ramifications medical travel has for health andwell-being, both nationally and globally as well as at the local level, forpatient and host populations alike. Moreover, anthropology can advancetheoretical insights regarding the topic, and topics with which it intertwines.

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Global Flows and Their Ramifications

Perhaps most obviously, medical travel may be examined for what it canreveal about the complexities and nuances of globalization, still too oftensimply conceptualized as the hegemonic diffusion of artifacts and ideas fromthe West. Some see the worldwide application of U.S. health care standards,for instance via the U.S.-based Joint Commission International’s worldwideaccreditation and certification services,4 in this light.

In actuality, the flows entailed are multidirectional and whatever travels isgenerally altered at least a bit (and sometime a lot) wherever it alights.For example, foreign-generated models of care can be re-invented domesti-cally; examining how this happens (as well as what happens) in the contextof medical travel may be quite revealing. So might examinations of the multi-local origins of ideas, artifacts, and etcetera flowing through the medicaltravel industry spur helpful developments in our thinking. Many nations haveongoing clinical research and advances occur around the globe; not all cuttingedge biomedicine comes from the West. Some advances actually haveoccurred because of global demand, not just before it (e.g., in plastic surgery,particularly gender reassignment; in infertility treatments). Some of whatflows is itself engendered by the transnational nature of the industry, too;new information technologies are one example (Economist 2008b). In explor-ing these developments, we would do well to bear in mind other aspects ofbiomedicine that have traveled, such as pharmaceuticals and public healthmodels. There is much we can learn from contrasts and comparisons.

Regarding the flow of patients, ramifications for social arrangements andcultural practices need much more exploring. The concern here is not justforeign nationals seeking offshore services, and their value to the local socialstructure (and its discourses), or the myths they endorse regarding the‘‘exotic’’ (for instance) locations visited for care, or the selves they are creat-ing. Of concern, too, are migrant workers who now may find it easier to gohome for health care. Someone from India, say, who lives in the UnitedStates or England can, more easily now than in generations past, go homefor cardiac or other necessary health care rather than to undergo procedureson foreign ground—and they can do so more safely, too, in terms of overallincreases in the availability of high-quality care in many developing nations.Returning citizens may receive care that is more culturally relevant to them.Trips home may serve to reinvigorate or reconfigure kinship connectionsand ethnic identities or to stimulate the development of new cultural prac-tices. Moreover, they may help bolster their nations’ health care industries,adding to the synergies already building.

Returning providers also may help strengthen their homelands’ healthcare offerings. Nations such as Trinidad and India have seen doctors

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return home to practice now that they can do so in world-class facilities(Economist 2008a). Nurses, doctors, and other health care specialists whopreviously emigrated to places like the United States may return home;many may stay home to begin with when practicing at home becomes morepractical. Their newly stationary careers will, of course, affect the flow ofideas and practices in new and interesting ways.

There is also the flow of body parts to consider. Many already havewritten about how transactions involving gametes and organs underwritenew conceptualizations of ourselves or others as partible or even disposablein increments (e.g., Inhorn and Patrizio 2009). This, as well as all the otherglobal flows (or shut-offs) mentioned, can underwrite particular subjectiv-ities. Subjectivities of the well-off as well as those of the disenfranchisedmerit examination, perhaps especially regarding how global markets affectpeoples’ experiences of the local, the other, and health care consumption.

Local Impacts

Anthropologists often examine health-related topics from a human rightsor social justice perspective, and some already have begun to ask howthe global trade in health care affects communities where services areprovided. Most initial forays have concentrated on immediate costs to per-sons, for instance regarding the globalized demand for transplant organsor gestational surrogates. The latter, for example, may exploit poorwomen, putting them at risk for complications during impregnation, gesta-tion, and childbirth (for instance when Cesarean sections are called for totime the birth as desired by the legal parents) and it discourages adoptionand fostering.

However, as The Economist already has noted with its usual candor, ‘‘Theprivate sector cannot be blamed for the failings of state-run health bureau-cracies in developing countries, which neglected the poor long beforemedical tourists arrived’’ (2008b). And, as important as such local impactquestions are, other research questions—including other local impactquestions—need to be asked, too.

Care must be taken to identify opportunities created by medical traveland to call out divisions deepened. For example, competition introducedfrom abroad may stimulate improvement in health care offerings at home.Also, hospitals—even those catering to medical travelers—employ local resi-dents. Job creation fueled by the medical travel boom may even lead moreresidents in medical travel supply zones to seek out medical training, addingto local knowledge, and perhaps increasing the sustainability of programsserving the local poor as well (whose ranks of course may wane somewhatthrough hospital employment). The policy climate is clearly important here,

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not only in terms of workforce issues but also in terms of policies meant toensure that a portion of medical travel profits themselves are earmarked forthe poor, and that the poor are not exploited by the industry.

Taxonomic Contributions

Another area in which the anthropological perspective might be veryproductively deployed concerns labeling standards. Many refer to medicaltravel as ‘‘medical tourism.’’ This in part reflects the tourism industry’s earlyrecognition of the trend and their use of the label to promote medical travelconsumption. Media sensationalism also played a role in shaping thelanguage used for talking about medical travel. However, academics whodeploy provocative terms like ‘‘transplant tourism’’ are increasingly eclipsedby those who take issue with the connotations of touristic terminology.My own research suggests that a tourism narrative may help sell medicaltravel packages, but it does not represent the practice in a way that isuniversally applicable.

Beth Kangas has refused the tourist designation outright, as do theparticipants in her research who travel for needed care, not leisure (Kan-gas forthcoming). Likewise, participants in Marcia Inhorn and PatrizioPasquale’s research on reproduction-related medical travel report thattheir experience is not vacation-like but rather akin to exile (Inhorn andPatrizio 2009; ‘‘exile’’ is borrowed from Roberto Matorras). ArnoldMillstein and Mark Smith, U.S.-based medical doctors, have proposedanother alternate label: they call U.S. medical travelers ‘‘medical refugees’’(Milstein and Smith 2006). Most scholars, however, prefer ‘‘medicaltravel’’ for its neutrality.5

We must also create an anthropologically informed taxonomy of medicaltravel types. The lack of specificity in present discussions underwrites someconfusion. For example, statistics might indiscriminately include expatriatesseeking health care in their adopted country as medical travelers simplybecause of their foreign national status when in fact they have not traveledinternationally for care. Figures also may include tourists who became sickor injured during their travels, such as a tourist who has a heart attack whileon holiday. These patients are (or should be) categorically different to thosewho embark on a trip away from home with the intention of assuming thepatient role (Cohen 2008).

Patients undertaking travel for complementary or alternative care to bio-medicine are also different. People interested in treatments not yet approvedor even outlawed in their home nations have long crossed borders to get it.How to treat those whose care is considered biomedical in the nationwhere it is procured, and what counts as a trip (must one cross a national

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border?) also needs careful consideration. Beyond the home–abroad orCAM–biomedicine distinction we also should consider, in designing ataxonomy, the qualitative differences between various subtypes of healthcare. Organ transplants, obesity surgeries, face lifts, breast augmentations,cardiac surgeries, infertility treatments, gestational surrogacy services,orthopedic surgeries—these all are very different in terms not only of patientneed but also cultural meaning, cost, stigma, etc. How each type of medicaltravel is constructed, both by patients and those on the supply side, maydiffer significantly. As study in the field of medical travel develops, andour literature grows, we can no longer lump them together. Cognitivemethods, interpretive ones, and the political economic framework all canprove helpful in delimiting various categories of medical travel for investi-gation and cross-comparison.

Meaning and Medical Travel

The above will only make sense in light of an increase in scholarship regard-ing the meaning of medical travel or the larger discourses of which it can bepart. A number of scholars have written on medical travel as part of a bidfor hope in hopeless situations (e.g., ‘‘terminal’’ illness, ‘‘irreversible’’ devel-opmental damage or delay, the ‘‘tragedy’’ of infertility) or as a method ofmaintaining privacy in the face of stigmatized procedures or conditions(e.g., sex change operations, face lifts, infertility treatments).

My own research on how medical travel is sold via the Web by travelagencies or facilitators suggests that, at least in the eyes of these entrepre-neurs, potential medical travelers in the United States are drawn by thepromise of securing for themselves ‘‘world class’’ care provided by expertclinicians with ‘‘state of the art’’ technologies. Further, website content sug-gests that consumers’ desire for such services is magnified by aspirations notonly of joining the ranks of ‘‘the rich and famous’’ in accessing top-notchhealth care but also of doing something new and trendy; actualizing libertar-ian ideals regarding freedom to determine what health care is provided, andwhen; and acting as a savvy consumer. That is, perhaps particularly in thecontemporary U.S. context, medical travel may make be undertaken as partof a discourse on health care consumption that promotes informed consu-merism and encourages close oversight of one’s own (or one’s family’s)health care over simply following doctor’s (possibly ill-informed) orders.

Another way in which medical travel has meaning is in the context of howwe create and maintain ourselves as good kin. Groundbreaker Beth Kangashas shown for Yemen that financially able families send relatives abroad forcare as a public demonstration of affection or ‘‘to prove that they did every-thing they could for their loved ones’’ as well as to avoid criticism for not

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doing so and to deflect attributions of culpability for a relative’s demise ontothe medical system (Kangas 2002:66, 2007). There may be many moremeanings to medical travel that merit investigation. We may, for example,engage in medical travel in ways that say something about our ethnic ornational identities. We may seek expression of fantasies regarding foreignlands, nature, friendly locals, and even gendered interaction patterns inconsuming offshore care, as Sara Ackerman reports for cosmetic surgerytravelers to Costa Rica (Ackerman, forthcoming). Ackerman also high-lights, as do others, the critique of U.S. care delivery made in medical travel.Clearly, we have much to learn about the various expressive meanings anduses of medical travel that exist beyond its instrumental functions.

CONCLUSION

Medical travel has caught anthropology’s eye. Pioneers in this field nolonger work alone; growth in the literature is expected. Future anthropolo-gical investigations into medical travel will no doubt extend in many fruitfuldirections. If we apply our keen appreciation of context wisely, we willgenerate information regarding how and why people engage in medicaltravel. We will contribute to typologies, conceptual models, and process-relevant theories. In addition, properly packaged, our work can be of greatvalue to policymakers and program planners as they grapple with thechanges that geographically and subjectively new patterns of health careprocurement entail.

NOTES

1. Where I worked in the late 1990s, inbound medical travelers were generally Mexican

nationals. The hospital’s first go-to person regarding cultural competence was in fact the

staff member employed to liaise with these patients’ families.

2. Taking note, the American Medical Association issued a brief set of guidelines for medical

travel in June, 2008 (American Medical Association 2008). The guidelines emphasized that

medical travel should be voluntary and non-exploitive (i.e., that financial incentives be

ethically handled). They further emphasized the need for coordination and continuity of care

across the global continuum.

3. The Joint Commission, which accredits U.S. health care organizations, organized the Joint

Commission International (JCI) in 1994. In the late 1990s, JCI began formally accrediting

health care organizations around the world. Other organizations, such as the International

Society for Quality in Health Care (ISQUA), also have participated. Organizations exist

also to promote the interests of travel agencies and others who facilitate medical travel.

In 2007, HealthCare Tourism International, which emerged in 2006 as a ‘‘portal’’ for medical

travelers as well as industry members, launched an international accreditation system for

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health tourism companies (see http://www.healthcaretrip.org/). The Medical Tourism

Association, which was created specifically to promote industry interests, began its own pilot

certification program one year later (see http://www.medicaltravelauthority.com/ or

http://www.medicaltourismassociation.com/).

4. Regarding the JCI, see http://www.jointcommission.org/AboutUs/Fact_Sheets/

jci_facts.htm.

5. ‘‘Transnational health care’’ is a term I also have used, although the transcendence of

national divisions suggested is more ideal than real.

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Bookman, M. Z. and K. R. Bookman

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