Valorie Crooks at Simon Fraser University in Canada was thrilled to hear that CBC radio reporter Debbie Wilson won a major national award for a three-part series on medical tourism. Wilson’s one-year investigation into the impact of medical tourism on Canadian consumers drew on research and information from SFU’s Medical Tourism Research Group, headed by Crooks. The series won the 2014 Dave Rogers, Association of Electronic Journalists (RTNDA) long feature award. The series highlighted the SFU group’s analysis of how medical tourism can prey on Canadians desperately seeking quick and economical quality-of-life operations such as hip replacements in foreign countries. In British Colombia patients can wait years for such an operation. Valerie Crooks says, “Debbie reviewed all of our published work for her stories. She was particularly interested in a Canadian Institutes for Health Research funded study my team led that examined Canadians’ decision-making around going abroad for medical tourism and another study examining the health equity impacts of medical tourism. Her interest in the research also shows that people outside the research community care about the group’s findings. The radio stories have had a direct impact on getting Canadians talking about medical tourism. This type of media coverage is incredibly important as it gets people thinking about why everyone needs to care about medical tourism and the complex ways in which this global practice is impacting so many Canadians in direct and indirect ways.”

Medical tourism needs to understand that there are trends in cosmetic surgery that it must keep up with to compete. And new trends are often how domestic cosmetic surgery businesses fight off the potential of medical tourism. The latest two are Vampire facials and Cinderella surgery. Cosmetic surgery specialist lawyer Amy Milner of Penningtons Manches explains the Vampire facial – the latest blood curdling anti-ageing beauty treatment that is rapidly gaining popularity. Since Kim Kardashian underwent the procedure on her reality television programme in 2013, there has been an 800% increase in demand. “The Vampire facial is a treatment where a doctor uses a patient’s own blood to give the skin a more youthful appearance. The procedure itself is said to stimulate collagen and elastin as well as to enhance skin colour, texture and make fine lines and wrinkles look less noticeable. The surgeon who carries out the procedure will make small puncture wounds on the face and will apply the patient’s own blood. This is not a procedure for the faint hearted, as the puncture wounds on the face are clearly visible following the procedure. However, the results can be noticed immediately with the full results becoming apparent within a matter of weeks. The procedure can be quite painful, particularly when the surgeon is making the puncture wounds and a patient may experience some bruising. The cost of one treatment is around £538.The procedure is considered a safe and effective way to lift up the skin and smooth out wrinkles if properly done by a trained surgeon.” Amy Milner goes on to explain that as a new procedure, it is not yet known whether there might be longer term side effects, “ The common side effects are: •Mild irritation and itching (depending on the sensitivity of skin. •Mild swelling or oedema. •Bruising caused by the reaction of skin to the injection." Sarah Gubbins of Penningtons Manches has studied the latest offering of Cinderella surgery, named after one of the favourite fairy tale princesses. In the USA it is better known as a foot facelift. As the name suggests, this procedure is for women seeking to change the size and/or shape of their feet so that they can fit into, or look better in, designer shoes. To achieve this, some women ask for the removal of bunions while others want their toes to be shortened and straightened so they look better in peep-toe shoes. Increasing the arch in someone’s foot in an attempt to make high heels more comfortable is also a popular request. Some women have even opted to have fat inserted into the soles of their feet so they can walk more comfortably in high heels. As well as allowing women to wear designer heels, Cinderella surgery can help to repair the damage caused by wearing high-heeled shoes. When you wear high heels, your foot slides forward in your shoe, redistributing your weight and creating unnatural pressure points and misalignment. Over time, problems can develop, particularly if you wear shoes with narrow, pointed toes.” Some of the problems that can arise from wearing high heels include: •Hammer toe – a deformity where a toe curls at the middle joint. High heels cause this because they force the toe against the front of the shoe, causing unnatural bending. •Corns and calluses – thick hard layers of skin that develop as a result of friction. •Bunions and bunionettes - bony bumps that form on the joint at the base of your big toe (bunions) or on the joint of your little toe (bunionettes). Tight-fitting high-heeled shoes do not necessarily cause bunions but can exacerbate an existing problem. •Stress fractures - tiny cracks in the bone caused from the pressure that high heels place on your forefoot. •Toenail problems – constant pressure can cause in-growing toenails and nail fungus. •Joint pain in ball of the foot (metatarsalgia) - high heels put more weight on the ball of your foot that causes increased pressure, and therefore pain, in your forefoot. Sarah Gubbins highlights the problems, “Shortening the toe may include shaving off the bone and, because toes help to support people’s weight and balance the body, cosmetic surgery can affect people’s balance and redistribute their weight. This can lead to complications later in life, such as the development of serious arthritic pain. Surgeons have also warned of months of swelling after foot surgery. Any shaping of the bones will be subject to swelling and bruising but the feet are even more susceptible. After foot surgery, patients must stay off their feet for several days but many do not have the patience to do this, putting weight on their feet before they have properly healed and injuring themselves. Many people end up with long term issues with their feet even after surgery – with no fault on the part of the surgeon.” And she warns of an even scarier trend; “As people start having all kinds of procedures for purely cosmetic reasons, their judgment of what is reasonable can become distorted and the pursuit of beauty can go too far. It was recently reported that one patient asked her surgeon to amputate her little toes. Thankfully he refused but this highlights concerns that some people will stop at nothing to achieve their cosmetic goals. It is unclear whether this particular patient had ever considered that removing her little toes was likely to significantly affect her ability to balance. Before rushing out for Cinderella surgery in the hope that your perfect feet will help you catch your very own Prince Charming, it is important to consider the realities of this type of surgery.” The UK and the USA are the leaders in these new trends but they can be very tricky operations so there is cause for concern if poorly qualified surgeons in other countries begin offering cut-price surgery; the long-tern consequences of getting treatment wrong are horrific.

Meghann Ormond of Wageningen University has presented an academic paper, on Academia.edu:“Intermediaries, facilitators, agents, guides: Steering international medical travel to Malaysia” and presented it at the World Congress of Sociology in Yokohama in July. The thesis is that Malaysian authorities desire for medical tourists from higher-income countries and the medical tourism infrastructure being developed to cater to them exists in contrast to the actual everyday flows of intra-regional lower-income medical tourists and what people actually want and get. Key points from the paper: “Medical tourists going to Malaysia for non-invasive procedures or cosmetic surgery are more likely to undergo procedures or consultations at the same time as their accompanying family members or friends. Medical tourism agents have a responsibility to provide practical local help for solo who undergo major surgery and may be dependent for long periods. The practice of organizing opportunities for customers to meet and support one another may not be as good as an agent taking patient-clients out for meals and drinks. Some agents ensure that clients have Skype-enabled devices and mobile phones at their disposal to easily reach family and friends back home. Most commonly, they either provide personal service or support from paid destination managers who are similar to travel reps. In spite of the dominant role of Malaysia’s Ministry of Health in the promotion of medical travel, one Australia based agent commented; “They do not properly stress the seriousness of what we are doing. The perception is that Malaysia is a tourist destination and not so much a health destination.” If the quality and price of a routine procedure are perceived to be equal across different destinations, some medical tourists will select a destination based on its recreational potential. In particular, those with longer periods of recovery who are travelling with family members or friends routinely ask agents to include time to recuperate at beach resorts (Penang and Langkawi ) in their travel packages. Agents suggest that not all clinics or agents stress that when combining treatment with a holiday that doctors’ permission must be granted and patients advised what they can and cannot do. As one Australia-based agent observed, “You say to them that they must not swim but they want their spa and their wellness and they want to be pampered." Indonesian medical tourists are widely acknowledged by agents to be principally focused on receiving speedy, value-for-money medical care and want nothing else as they can get that at home, but still a few set aside time for sightseeing and shopping. The paper concludes that it is wrong to compare medical tourism to normal leisure tourism, because medical is niche. So the ways to promote it, the ways to get customers, the ways to handle these customers- are different from tourism. Agents and hospitals need to be capable of handling situations with the customers. They will need to be trained, to be taught the right things to say, because patients are very sensitive, they demand a lot of things, and sometimes they think the agent has the knowledge of a doctor. Agents are learning and adapting to the different needs of those from various countries. Australians and Malaysians may be most aware of legal risks. Agents from Indonesia tend to work more closely with customers and more personally involved in medical care, transport, accommodation and leisure services While there are no officially licensed agents there is a growing demand for training and professionalism. Some agents accept that they need real help to establish professional standards within a fragmented, volatile and easily tarnished industry. It is essential to further study the important ways in which informal care and support are provided by medical travellers’ family and friends either traveling with the patients themselves or managing things from back home One possible solution is to develop the US method of patient navigation. This ensures patients get timely access to treatment and follow-up care. This is achieved by helping them overcome health system barriers by- •Coordinating diagnostic or treatment care from multiple providers, assisting with paperwork, scheduling and attending appointments, •Constant communication; access and discuss information about their medical conditions, test results and treatment/care options. •Help patients with resolving personal financial, social and educational barriers to accessing treatment/care. •Provide psycho-social support, either directly or by referring patients to trained providers and support groups. Patient navigation is not case management or patient advocacy, as these are focused on improving individuals overall health over long periods of time and with improving the care systems in which patients are embedded. The work of patient navigators is similar to agents as it is targeted and finite with a focus on improving the outcomes of a specific medical concern. Many come from nursing, social work or health education; others are former patients or survivors themselves or their family members. Just like medical tourism agents, navigators are paid rather than volunteers or family members; may operate independently or be affiliated or an employee of a medical institution; and no licensing requirements exist, so navigators have no specific training. Transforming medical travel agents into transnational patient navigators can help to de-ghettoize them from being regarded as a marginal niche of intermediaries in the travel industry. Placing agents in a more mainstream healthcare and patient-centric context recognizes the significance of what they actually do and has the potential to better link them up long-term with the broader healthcare sector, with medical tourism just part of what they can offer to patients.”

A new website from Canadian academics specializing in medical tourism research warns potential Canadian medical tourists to carefully consider the risks and rewards of medical tourism. SFU’s Medical Tourism Research Group has launched a free consumer website Medicaltourismandme.com, just for Canadians. It uses the power of personal testimony to educate consumers about the perils and pluses of medical tourism. The website presents former medical tourists’ stories under three headings — your health, your home and your destination. The headings represent three perspectives from which SFU’s researchers want consumers to evaluate the practical and ethical concerns associated with medical tourism. The stories profile consumers weighing medical pros and cons; home countries saddled with returning medical tourists who may now have more medical problems than they left with; and medical-tourism-providing countries’ residents whose health care needs can be subjugated by the needs of wealthier medical tourists. Prompted by concerns from customers, doctors and academics about issues such as malpractice in destination countries and inadequate consumer guidelines, Jeremy Snyder and his colleagues created an information sheet. It is the basis of their website. They plan to have their website translated into French and Spanish. Jeremy Snyder at Simon Fraser University explains, “We have drawn on real stories from medical tourists to whom we have spoken, in the hopes that these real experiences will be eye-opening for people thinking about engaging in medical tourism. Historically, government and industry sources have provided limited consumer guidelines largely geared to addressing patient health and safety issues. They do not capture third party issues such as the extent to which medical tourism is preventing destination countries’ residents from accessing quality healthcare at home. Israel, for example, has recently restricted the use of public facilities for medical tourism for this reason. Several studies, including ours, have shown relying on industry sources for guidelines is problematic because communication of health risks is often biased.” The SFU advice to consumers includes: 1. Should I go abroad for medical care?2. Is this procedure offered locally? If not, why?3. Am I able to access independent information about the effectiveness and safety of the procedure?4. Is traveling abroad for medical care likely to have negative impacts on others? If so, is my going abroad for care still justified?5. If I have caregivers at home, with they be able to go abroad with me and help care for me when I return? What will that caregiver’s experience abroad be like realistically?6. Have I discussed this decision with my family doctor or other medical expert? 7. Am I fully aware of the risks of receiving this procedure abroad and potential for long term follow up care?

The European Free Trade Association (EFTA) and the European Union (EU) have incorporated 26 EU legal acts into the European Economic Area Agreement, including measures relating to cross-border healthcare The EFTA member states, which are part of the EEA but outside the EU, are Iceland, Liechtenstein, Norway, and Switzerland. Liechtenstein is particularly important as in this tiny country most people have to go to nearby EU countries for medical care. The EU Directive on the application of patients’ rights in cross-border healthcare provides clarity about the rights of patients who seek healthcare in another EEA country. The new rules clarify that the citizens of one EEA Member State can be reimbursed for healthcare received in another member state, as long as the type of treatment and costs would have been covered in their own country. Many but not all EU countries have fully implemented the rules. Authorities may require patients to seek prior authorization for treatment requiring an overnight hospital stay or highly specialized and cost-intensive healthcare, although refusals will need to be justified according to a restricted list of possible reasons.

The uninsured rate in the U.S. fell to 13.4% in the second quarter of 2014. This is the lowest quarterly average recorded since Gallup and Healthways began tracking the percentage of uninsured Americans in 2008. The previous low point was 14.4% in the third quarter of 2008. The figures do not yet show the full impact of stage one of Obamacare and raise questions about estimates of large numbers of uninsured Americans who could be a target for medical tourism. The uninsured rate has decreased sharply since the Affordable Care Act’s requirement for most Americans to have health insurance went into effect at the beginning of 2014. The uninsured rate has dropped by 3.7 points since the fourth quarter of 2013, when it averaged 17.1%. The decline in the uninsured rate last quarter took place at the start of the quarter. The drop reflected a surge of health plan enrollees in early April, prior to the April 15 extended enrollment deadline for people who had previously experienced technical difficulties with the federal healthcare exchange website. The second-quarter results are based on more than 45,000 interviews with U.S. adults from April 1 to June 30, 2014, as part of the Gallup-Healthways Well-Being Index. Gallup’s quarterly trends show that the uninsured rate dropped by about three points from the fourth quarter of 2013 among each major age group under 65. The uninsured rate in the second quarter averaged 18.7% among 18- to 25-year-olds, 23.9% among 26- to 34-year-olds, and 13.4% among 35- to 64-year-olds. Given the availability of Medicare and Medicaid benefits, very few seniors report being without health insurance, although the uninsured rate among those 65 and older is now 2.0%, down from 2.8% in the third quarter of 2013. With regulations on individuals and those employed by businesses still to take effect-it will be another two years before we see the full impact of Obamacare The figures will never fall to nil as there are millions of people in prison, illegal immigrants, temporary residents, very rich people and the estimated one in ten Americans who pay no taxes, buy no compulsory insurance and ignore any Federal law. Insurance at Q 2 2014- • Employer or former employer 43.5% • Self funded 20.7%• Medicaid 8.4%• Medicare 8.9% • Military or veteran cover 4.7% • Trade union 2.5%• Other 3.8% As well as 3 million children, 10.3 million American adults have gained health coverage since Obamacare enrollment began last October, with the biggest gains among young adults and Hispanics, according to a study from the Harvard School of Public Health, Brigham and Women’s Hospital in Boston New England Journal of Medicine also found evidence that more Americans had a personal doctor and fewer difficulties paying for medical care within the first six months of gaining insurance. Obamacare provides federally subsidized private coverage through new online insurance marketplaces and an expansion of Medicaid in 26 states and Washington, D.C. The U.S. Department of Health and Human Services said in May 2014 that more than 8 million Americans signed up for private plans through new online insurance marketplaces during a six-month open enrollment period. Official data show another 7 million people gaining coverage under Medicaid, but the data includes renewals in existing Medicaid programs as well as new enrollments. Private health insurance exchanges are experiencing hyper-growth. There is enthusiasm and adoption among many employers, consumers and carriers alike. Accenture predicts that private health insurance exchange participation will approach public exchange enrollments by 2017, if not sooner, as enrollment figures indicate an earlier-than-expected growth spurt. Accenture estimates 3 million individuals have already enrolled in private exchanges.

Years of promises by politicians to support the business of medical tourism have come to nothing. India has no national strategy, no national marketing, and a dormant trade body. Government promises to support medical tourism businesses have turned out to be limited to small grants for attending fairs and conferences with the official long overdue announcement of detail still awaited. None of this is any surprise to local hospitals and businesses that expect national and state governments to be inefficient, slow, corrupt, and more concerned with political infighting and rhetoric than any real action or fiscal support. The Progress Harmony Development (PHD) Chamber of Commerce and Industry decided they could not wait any longer for state action so commissioned their own report on medical tourism and held a summit for medical tourism businesses. After hearing reports of isolated incidents concerning poor quality health services at hospitals and wellness units in India, delegates at the ’Medical & Wellness Tourism Summit’ 2014 in New Delhi, called for a government supported national level accreditation board for medical tourism units in Indian hospitals and clinics, a quick solution to the long standing problems on visas and medical visas where ill visitors have to attend local police stations, and improvements on infrastructure so medical tourists can easily get to hospitals and clinics. The current state of medical tourism was emphasized in a paper at the conference from PHD and researchers RNCOS. Many reports still claim that Indian medical tourism has millions of customers, but current estimates from this latest paper put it at a low 230,000. You may have seen this misquoted in Western media as 2.3 million… the reason being that Indian statistics use the term lakh, and the report says 2.3 lakh. A lakh is actually 100,000 but in India is printed as 1,00,000, which people overseas tend to wrongly assume is a million with a missing 0. The report predicts annual growth of up to 20% and a potential of 400,000 by 2018; but only if the right actions to support the business are taken. Delegates expressed concern that India is currently losing many international patients due to bottlenecks such as delays on visas, a perception of the country being a third-world nation, lack of modern equipment and rising costs in Indian hospitals. India is even heavily losing patients from key traditional markets including Oman, Bangladesh and Ethiopia. The Ministry of Tourism admitted at the conference that it is still working out how to provide financial incentives to medical tourism businesses and that promised market development assistance will almost certainly now be nothing more than small marketing grants to attend overseas medical and tourism conferences and fairs; and even that will be restricted to a few small businesses. The ministry also plans to hold or promote international conferences and fairs, but only in India. More useful, or not, may be Ministry of Tourism plans on wellness tourism. Yet to be released draft guidelines will cover publicity material, training, and capacity building for service providers, participation in international and domestic wellness-related events etc. The overall feel of the conference was optimism tempered by frustration at how little and how slowly the government is doing anything to promote medical tourism.

Medical tourism tends to increase as tourism numbers increase. Demand for international tourism remained strong in the first four months of 2014 according to the latest UNWTO World Tourism Barometer. International tourist arrivals worldwide grew by 5%, the same rate as during the full year 2013. Prospects for the current peak tourism season remain very positive with over 460 million tourists expected to travel abroad in the May-August 2014 period. Destinations worldwide received 317 million international tourists (overnight visitors) between January and April 2014, 14 million more than in the same period of 2013. This 5% growth consolidates the already strong increase registered in 2013 (+5%) and is well above the long-term trend projected by UNWTO for the period 2010-2020 (+3.8%). Growth has been widely spread with nearly all sub regions recording increases in international arrivals of 4% or higher. By region, the strongest growth was registered in Asia and the Pacific and the Americas (both +6%), followed closely by Europe and Africa (both at +5%). By sub region, Northern Europe, Southern and Mediterranean Europe, North Africa and South Asia, (all +8%) were the star performers. Most destinations share in growth.• Asia and the Pacific (+6%) consolidated its growth of recent years, with South Asia (+8%) and North-East Asia (+7%) in the lead.• Growth picked up in the Americas (+6%), with all four sub regions showing significant improvement compared to 2013.• Europe, the most visited region in the world, maintained the strength it showed in 2013 with international tourist arrivals growing by 5% through April. Northern Europe and Southern Mediterranean Europe (+8% each) led growth.• Africa’s international tourist numbers grew by 5% as the recovery was consolidated further in North Africa (+8%). 
International tourist arrivals in the Middle East are estimated down by 4%. On source markets, international tourism expenditure data for the first part of 2014 indicates that the growth in demand continues to be strong out of China, the Russian Federation, Saudi Arabia and India. Demand from advanced markets is strengthening with encouraging growth from Italy, Australia, the Republic of Korea, the Netherlands, Norway and Sweden.