Outpatients:
The Astonishing New World of Medical Tourism
Copyright © 2016 by Sasha Issenberg
All rights reserved
Published by Columbia Global Reports
91 Claremont Avenue, Suite 515
New York, NY 10027
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Library of Congress Control Number: 2015949774
ISBN: 978-0-9909763-9-4
Book design: Strick&Williams
Cover illustrations:
Crown © mustafahacalaki/DigitalVision Vectors/Getty Images
Stamp shapes © edge69/DigitalVision Vectors/Getty Images
Stethoscope © fairywong/DigitalVision Vectors/Getty Images
Heart © Rakdee Phakhasup/DigitalVision Vectors/Getty Images
Baby and Bones © lushik/DigitalVision Vectors/Getty Images
Map design: Jeffrey L. Ward
Author photograph: Akiko Horiyama
CONTENTS
Prologue
Chapter One
Orbán’s Dentist
Chapter Two
Bismarck and Beveridge
Chapter Three
Torn Curtain
Chapter Four
Brain Drain
Chapter Five
Flying Bodies
Chapter Six
Europa
Chapter Seven
The Bulgarian Method
Chapter Eight
The Eastern Front
Epilogue
Acknowledgments
Further Readings
Endnotes
To Olga Issenberg, whose love and strength made everything possible for her grandson, including a return to the land of her birth under such curious circumstances
The Tokushukai Medical Corporation operates more than 280 hospitals in Japan, enough for the company to often find itself described as the world’s largest hospital chain. In 2006, Tokushukai opened its first overseas facility, in Bulgaria, and I had been prepared for its incongruity amid the dreary blocks south of Sofia’s downtown. “If you drive there, you will drive through a really bad area, then you see there is some kind of an island,” Robert Gerl, the Munich-based CEO of the Bavaria International Health Association, told me. Indeed, the Tokuda Hospital Sofia did stand out from a distance—a nine-story ivory puzzle piece in a sort of corporatized-Bauhaus style—although indoors there was little besides Japanese prints adorning random corridors to distinguish its unusual heritage.
It wasn’t until I walked through the orthopedics ward that I fully appreciated what kind of incongruity was possible within the modern hospital. Part of the reason Tokushukai officials had selected the Sofia site was the promise of serving patients throughout the region, but Tokuda began drawing them from other continents as well. Eastern Europe was becoming a destination for Middle Eastern knees, and Tokuda became popular with patients from Oman, one of several Persian Gulf states suffering from abnormally frequent joint injuries. (The culprits appear to be stress from repeated bending at prayer, along with the high rates of non-fatal car accidents that typically accompany a country’s belated motorization.)
During a tour of the facility, a hospital staffer mentioned to me the significant number of knee surgery patients from Libya. As Libya’s civil war raged on, the country’s already limited medical system became even more overcrowded, and Tokuda contracted with authorities there to receive their patients. The staffer gestured toward an open door, and when I poked my head past the threshold, my eyes met those of a woman tucked into the bed, and then those of a man I assumed to be her husband hunched over her. His hand clasped hers, a gesture of comfort that appeared unable to weaken the uncertain fear frozen on her face. A head covering suggested the expectation of modesty, which I was clearly in the midst of defying. I didn’t know what to say, or in what language I would possibly say it, and neither did she. I moved along, wordlessly, steadied by the relief that I could not be the source of her anxiety. Here was a Libyan woman trapped in a Japanese hospital in the Bulgarian capital, all when at her most vulnerable. At this point, could the momentary intrusion of a strange American man with a notebook possibly faze her?
Medical tourism can best be defined as cross-border travel for the primary purpose of securing treatment. The term may suggest carefree holidaymakers, but like the Libyan knee patient, many medical tourists are engaged in a uniquely modern form of rebellion, asserting an individual’s independence from the persistence of political geography.
For a long time, such “patients with passports”—as Harvard Law Professor I. Glenn Cohen called them in the title of his recent book on the legal and ethical dynamics of medical tourism—were only the unfavorably situated. They were wealthy patients stuck in underdeveloped countries, those unable to afford complex procedures where they live and desperate enough to hunt down a bargain, and patients suffering from peculiar maladies in places without the right specialists. Indeed, the most famous classical examples—Gulf sheiks flying to the Mayo Clinic on a private jet, or North Americans heading south for inexpensive breast implants—share in-extremis attributes, either for care that is an absolute necessity or pure luxury. In short, people traveled for the same reasons tourists always have: to find what they are unable to get at home.
For medical tourists coming to the United States, that tends to be access to care. For American medical tourists heading elsewhere, it is usually lower costs. After all, the same system that produced the Mayo Clinic—and enough doctors, specialized equipment and empty beds to welcome the world’s well-heeled walk-in patients—leaves many local residents unable to afford even basic procedures. A 2014 study from the Commonwealth Fund concluded that American health care was both more expensive and less effective than that of ten other similarly industrialized western countries, economics that trickle down to individual patients. The National Center for Policy Analysis in 2007 estimated one with insurance could expect to pay $90,000 for a heart bypass in the United States, but only about $20,000 if traveling to Singapore, $12,000 in Thailand, and $10,000 in India. One of the 30 million Americans without medical insurance could expect to pay more than $200,000 for the procedure at a local hospital.
No institution has pursued opportunity in medical tourism like Bumrungrad International Hospital, in Bangkok, Thailand. First opened in 1980 with 200 beds, it has expanded to several times that, claiming to serve 1.1 million patients annually, about half of them from abroad. For those from countries more developed than Thailand, Bumrungrad is a bargain. For those from countries less developed, Bumrungrad offers access to specialized expertise or equipment unavailable at home. In other cases, Thai doctors will perform specific procedures—most notably,