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Medical care shoppers bet on diagnosis, benign bugs

by Kevin Rafferty

HONG KONG — The reception area is welcoming, open and airy with tropical green trees and plants. The rooms have sofas, tables and chairs, well-chosen paintings, as well as the bed. Menus are prepared by international chefs who compete for the privilege of being chosen for a month at a time. But you won’t find this hostelry on the hotel listings of Expedia, Orbitz or Asiarooms or any other Internet websites offering accommodations in exotic Asia.

That’s because it is not a hotel but Bumrungrad International Hospital in Bangkok, which openly advertises for business on its sophisticated Internet site. It offers detailed information in English, Japanese and Thai, and boasts that its treatments cost 50 to 80 percent less than similar procedures in the United States, Europe or Japan.

Welcome to the multibillion dollar world of international medical tourism, a booming business in countries as far apart as Argentina, Costa Rica, Cuba, Hungary, India, Mexico, Singapore and Thailand, with the Philippines belatedly trying to climb aboard a business expected soon to be worth $100 billion.

South Africa is promoting “medical safaris.” South Korea is encouraging medical tourists but has suffered from charging foreigners two to three times what Koreans pay.

This year Japan’s ministry of economy, trade and industry (METI), the successor to the once almighty MITI, the guiding hand behind Japan’s postwar economic miracle, inspired the visit of 20 foreigners for checkups in Japan as the intended first wave of a sea of medical tourists. It is hard to decide whether to laugh or cry when Japan’s hospitals, which have won bad reputations for turning away mothers-to-be in advanced labor, believe that they can cash in on visits by foreign tourists.

As an immediate example of the world of unreality that Japanese bureaucrats and politicians live in, just look at the tiny number of guinea pig patients — 20 — and consider that the best foreign hospitals welcoming medical tourists are dealing with hundreds of thousands of patients a year and treating almost everything from life-threatening diseases to cosmetic procedures.

Yes, selected Japanese hospitals might attract international attention for their superior treatment of a handful of specialized diseases, but how will they overcome the multiple disadvantages of distance from major markets, expensive flights to get there, expensive accommodations and high costs of living, not to speak of the need for (expensive) interpreters.

One of the basic needs for patients already worried about where a medical procedure might lead is a word of comfort and reassurance in their own language or one they understand. Unlike Japan, most of the other countries offering medical tourism have many doctors fluent in English and in other languages.

There are lots of still untouched opportunities, but there are also looming problems in medical tourism. The big unanswered question of the last few weeks is whether a new superbug, NDM-1, resistant to the most powerful antibiotics, will kill or mortally wound medical tourism. NDM-1 stands for a bacterial gene, New Delhi metallo- beta-lactamase, so-called because it was discovered in India. It has the ability to alter bacteria to make them resistant to existing drugs.

World Radio Switzerland, a country with its own vested interest in the health care business, noted that the advent of NDM-1 came just as the World Health Organization declared the end of the H1N1 pandemic. The U.K. journal The Lancet Infectious Diseases warned that the bacteria “can be traced back to the boom in medical tourism — a trend toward going abroad to save money on medical procedures, usually cosmetic ones.”

The Indian government, unhappy about the capital city becoming associated with a potentially lethal bug, has claimed that the disease is everywhere, and that the report was an attempt to damage medical tourism.

The respected British medical journal The Lancet, whose Internet site published and named the superbug, responded by defending its reputation. The World Health Organization endorsed The Lancetreport and revealed that it had warned India about over prescription of antibiotics.

This month Japan also announced that NDM-1 has reached the country. One man in Tochigi Prefecture was hospitalized last year after returning to Japan from a medical visit to India; he was later discharged after treatment. The Japanese hospital had kept a preserved sample of the bug and re-examined it after The Lancet article.

Of more concern, not merely for medical tourism but for the health system in Japan, is that Teikyo University Hospital belatedly admitted that 27 out of 46 patients infected with an antibiotic-resistant bacterium called Acinetobactor had died, including nine possibly attributable to the superbug that the hospital did not report until this month, although it had launched an inquiry in July.

Experts dispute how many medical tourists there are globally. Ian Youngman, writing for International Medical Travel Journal, said: “By definition, almost every official figure is flawed. They are often badly collected, imperfectly collated, and spun to infinity.”

Problems with the statistics include whether to count each patient or each visit, and whether to count only inpatients who stay overnight. Some hospitals inflate their figures by counting each visit to each department, which could mean that one patient on a single visit might be counted as five or more, starting with reception and finishing with billing.

Management consultants McKinsey in 2008 suggested that there were 60,000 to 85,000 medical tourists a year, but they counted only selected U.S.-accredited hospitals and only inpatients, which would exclude most people traveling for cosmetic and dental treatment. Hundreds of thousands of Germans cross to neighboring Hungary each year for dentistry.

U.K. official statistics say that more than 100,000 people go abroad for medical treatment, but the figure falls to 15,000 if dental and cosmetic care are excluded and to fewer than 1,000 if outpatient treatment is excluded.

All in all, Youngman thinks that 5 million is an accurate figure for medical tourists, excluding expatriates and emergencies, but including outpatient care and cosmetic and dental procedures. The value of medical tourism is estimated at up to $40 billion a year today and expected to rise to $100 billion as early as 2012. Deloitte Consulting in August 2008 projected that medical tourism from the U.S. alone could rise by a factor of 10 in the next decade, as the number of Americans going abroad tops a million and grows fast. Americans tend to go close to home for dental and cosmetic procedures, but are increasingly looking at Asia for more complicated operations.

Asia has a large number of countries aspiring to host medical tourists. Singapore, even though a developed country, receives several hundred thousand medical tourists each year who are impressed by the fluency in English, the high ranking in the World Health Organization listings for health care — sixth in the world in the survey (now discontinued) for 2000 when the U.S. was 37th — the cleanliness of its hospitals, the latest high-tech equipment and the ability to perform complicated procedures, all still below U.S. prices.

Bumrungrad in Bangkok is not unique even in Thailand, where several top-notch hospitals offer medical care for procedures from the routine to the specialized at a small percentage of the costs in rich countries. Thai hospitals are developing “wellness” specialties, encouraging patients to live healthy lifestyles to avoid expensive diseases and even more expensive operations.

As part of its helpful service, Bumrungrad lists the costs of its procedures. For example, the median cost for a hip replacement is $14,000; for cataract removal, $2,650; and for a heart bypass, $27,000. It also lists the names of its doctors with their pictures and qualifications, so you know whom you will be dealing with. It is not the cheapest hospital in Thailand, but has the advantage to foreign patients of being under international management, with many of its doctors and surgeons possessing U.S. or U.K. qualifications.

Under Thai law, doctors and surgeons operating in the country must pass exams in Thailand. This is not unusual since the medical profession is perhaps the last restricted trade practice in the world. (National groups of doctors or dentists are known to slam the doors to otherwise qualified outsiders.)

A dentist wishing to practice in Hong Kong must pass Hong Kong University exams, just as a non-European, however well qualified or experienced, seeking to practice in the United Kingdom must pass U.K. exams. There is a two-year waiting list to take the exams.

Countries like Japan, the U.S. or the U.K., with aging populations or creaking health systems, could save money by encouraging patients to go abroad for treatment — after all, a hip replacement in Thailand plus a recuperation holiday afterward would cost 25 percent of the procedure in Japan or the U.S. In return, these countries could seek to expand cooperation and opportunities for their doctors to operate in Thailand (or other destinations). It is surely important to share the best medical knowledge and practice, and absurd that medical care should be defined by political boundaries.

Sometimes the quality of medical care and attention in countries that are cheap for tourists puts the rich ones to shame. A close friend developed a sarcoma strangling her carotid artery in her neck in her early teens. Doctors advised her parents to prepare for the worst or pray to their favorite saint since this was incurable. Luckily she was an Indian and her father had close friends in Mumbai’s medical world.

Following three pathbreaking operations, plus a fourth to recover a swab that had been inadvertently left behind, and radiation, she was discharged, probably clear of cancer but told she should not expect to see 50; today she is 50-something and in excellent health.

Equally instructive is the case of a peripatetic woman rushed to an emergency hospital in Tokyo, complaining of severe stomach pains at three in the morning. Common gastric problems, declared the Japanese doctor, who gave her some pills. Some weeks later, she went to one of the best clinics in central Hong Kong with similar complaints and, after similar prodding, was given the same diagnosis and the same medication.

Another month later she checked into St. Louis Hospital in Bangkok with the same complaint. There the doctor did not merely prod her and take her temperature; he put her through a battery of tests, at the end of which he declared that, although she had some problems with her uterus that were not life threatening, hers would be the third emergency appendectomy he would perform that afternoon.

The appendix, when extracted, was angry and about to explode. The cost was 10 percent of what it would have been in Japan or Hong Kong, had they understood her ailment, a reminder that medicine is not just about the latest equipment or drugs, and has an all-important comfort zone of knowledge, experience and correct diagnosis.

Kevin Rafferty is editor in chief of Plain Words Media, a group of journalists specializing in economic development issues.