But despite Thailand’s claim, the impression that medicine revolves around any particular hospital or country has been unmasked as the type of fiction devised by investment-promotion authorities and indulged by their ad agencies eager to promote someplace as “the medical capital of the world.” Due to developments as seemingly banal as the ability to quickly move high-resolution X-ray images as email attachments, patients can travel for care anywhere, even to hospitals that don’t have their own hotels connected by walkway.
Across the world, globalization has transformed the pursuit of better health outcomes. Linking high-speed fiber optic networks via undersea cable has made possible the field known as telemedicine, in which the internet is used to facilitate long-distance care through real-time monitoring of patients. tThe integration of once geographically bounded labor markets has led doctors to outsource support tasks, like the reading of X-rays, to countries where they can be completed at lower costs. (Many X-rays taken in American clinics are viewed by Indian radiologists.) In the pharmaceutical industry, multinational corporations have proven able to simultaneously exploit advanced economies’ research capacity and legal systems to support innovation, and developing countries’ lower manufacturing costs to bring the resultant products cheaply to market.
But more than other high-skilled services (like finance and law), most medical talent and infrastructure remain stubbornly grounded in place. When it comes to medical procedures, there is only so much marketers can do to shuttle goods or facilitate the delivery of services. Medical tourism has never demanded much beyond air travel and payments across currencies. Sometimes, as in the plentiful cases of Americans driving across the Mexican border and paying doctors and dentists in dollars, it requires neither.
In the years since Bumrungrad opened, medical tourism has become a dizzyingly multidirectional affair. While one can easily rationalize how Brazil found so much of its national identity tied up in a role as a provider of plastic surgery, many of the grooved routes of medical tourism don’t display a self-evident logic. Emiratis fly to South Korea for organ transplants. Canadians travel to Costa Rica for checkups. Yemenis with heart disease often end up in India. Cypriots requiring bone-marrow transplants go to Israel. Each pairing seems to be conjured from a game of Risk, which in its way makes sense, because the unique risk management involved in medical care has bonded countries that have never had particularly deep trade links, migration flows, or military or diplomatic ties.
The logic that sustains the routes of medical tourism has less to do with the connections between countries than the gaps between them. Medical tourism requires seeing national differences as inefficiencies that can be exploited. Within Europe, where neighboring countries share cultural attributes and increasingly the same economic policies, medical systems often came to define the nation-state in the process of shedding its other totems of national identity. (A 2013 survey in the United Kingdom ranked its National Health Service the institution that made people proudest to be British, ahead of the monarchy and the BBC.)
The integration that has remade Europe in the twentieth century—a common currency, elimination of travel restrictions, and a deregulated airspace that has permitted low-cost carriers to take flight—has remapped the region’s medical geography. Once far-off capitals are often now no farther or pricier to get to than taking a half-day’s drive. Europeans increasingly conditioned to hopscotch the continent for leisure are finding it just as practical to do so in search of better, cheaper, or more readily available health-care services. For Europeans, political and logistical changes have conspired to make medical tourism a quotidian, even humdrum, practice.
But those who engage in it quickly learn that they will have to do so without the security of a transnational safety net. In attempting to stitch together the first strands of one, the European Union has illustrated the difficulty of coming up with any sort of health-care policy that applies equally across borders. To American eyes, the machinations that have taken place in Brussels evoke what it might be like to observe a Congress trying to simultaneously negotiate an interlocking health-care reform bill and trade pact, all under the watchful eye of a Supreme Court that has determined that core constitutional rights and freedoms are at stake. (Imagine further that the central question of health-care reform was whether Germans should pay for its citizens to use Greek hospitals by traversing the same open borders that permit Syrian refugees to settle freely in Europe.) Is it possible to develop a system that allows citizens to take advantage of the benefits they have been promised by their public and private insurers all while exercising their right to travel and trade freely?
Medical tourists have come to represent a small but revealing new tranche of the worldwide middle class, empowered to arbitrage inefficiencies created where a previous era’s institutions of political economy—namely insurance companies and national regulatory régimes—had failed to keep up with a new era’s interconnectedness. In an increasingly globalized world, national governments may be losing control over flows of money and information, but they are still responsible for health care. Medical tourism exists only because the great triumph of liberal government in the twentieth century and the neoliberal project of free movement for people and capital have proven fundamentally irreconcilable. What happens when all the other national boundaries fall and the most salient difference between neighboring countries is in their healthcare systems?
I had ended up in Eastern Europe because a sequence of political transformations had dramatically accelerated the pace of that reckoning. In the 1990s, centrally planned medical systems in former Soviet Bloc nations were exposed to domestic market forces, introducing competition for patients into a health economy that had previously known no notion of profit. Just as they were beginning to calibrate a post-communist balance between the competing interests of the marketplace and the welfare state, the countries of Eastern Europe sought entry to the European Union. In so doing, they opened themselves—their borders, their banks, their operating theatres—to any European who wanted to access them.
Almost instantaneously Eastern European countries found themselves inevitably part of what the Canadian health researcher Ronald Labonté has described as a worldwide “gold rush of primarily private, but also some public, providers in low- and middle-income countries attempting to capitalize on what they perceive to be an unfilled demand from the wealthier and demographically aging North.” My reporting in Hungary and Bulgaria is an attempt to trace the opening of one sluice in this gold rush, and its effect on the people and institutions it touches. Is medical tourism destabilizing one of the last remaining pillars of the welfare state or reinforcing it?
Many critics of medical tourism cast its existence along familiar lines of global inequality, with the implication that it is impossible to reconcile a health-care system that profits from serving foreigners and one that succeeds in serving the local community’s needs. In Tokuda Hospital Sofia’s orthopedics wing, that conundrum was given a face. What did the presence of a Libyan woman in a Bulgarian hospital bed mean for a Sofia resident with knee problems? And could Libya ever develop a modern health-care system if all the local patients who had a way of financing their care took their problems—and their money—elsewhere?
It was easy to caricature medical tourists as the world’s haves taking medicine from the mouth of its have-nots, but the woman before me certainly did not project an air of entitlement. I was reminded of the many levels of dislocation involved whenever an individual decided not to let her ability to imagine a healthier self be constrained by the boundaries of her home nation.
Among the