The USA medical tourism market is developing in new ways by exporting healthcare expertise. Rather than expecting patients to come to the USA, leading hospitals are building overseas networks and partnerships to take hospitals and doctors to overseas patients. After the 9/11 terrorist attacks, when travel visas into the U.S. were delayed, the Cleveland Clinic saw its traffic from abroad slow to a trickle. So it began opening or managing hospitals overseas. Since 2007, it has managed Sheikh Khalifa Medical City, a 750-bed hospital in Abu Dhabi in the United Arab Emirates. In 2015, it opens Cleveland Clinic Abu Dhabi, a 360-bed hospital in the UAE. University of Pittsburgh Medical Center sees going global as a natural extension of UPMC’s services. UPMC operates a multi-organ transplant centre and specialty surgery hospital in Palermo, Italy, that has been responsible for more than 1500 transplants; is collaborating with a Singapore medical centre on a new transplant centre; and runs a radiation therapy clinic in Ireland. Last year the Mayo Clinic added an international hospital, Medica Sur in Mexico City, to its network. Medica Sur is not owned nor managed by Mayo, but had to meet strict criteria for quality and safety, such as low readmission rates, and can use Mayo’s research and expertise Johns Hopkins Medicine International, based in Baltimore, has links and affiliations in a dozen countries, including Brazil, China, Saudi Arabia and Singapore. It part owns cancer hospital Johns Hopkins Singapore and Johns Hopkins Aramco Healthcare in Dhahran, Saudi Arabia. Partners HealthCare International, of the Boston-based health system affiliated with Harvard teaching hospitals Massachusetts General and Brigham and Women’s, is active in seven countries. While some of these links will bring a few medical tourists to the USA, most accept that the vast majority of patients will be treated in their own countries, in hospitals owned or run by top US hospitals, and using US expertise, a sort of cloud based virtual medical tourism where the cloud is knowledge and revenue.

November will see the launch of a major new book on medical tourism from a US lawyer who divides the medical tourism community between those who believe he raises important points, and others who believe he is “bad for business”. Glenn Cohen’s new book "Patients with Passports: Medical Tourism, Law, and Ethics" is from Oxford University Press. It claims to be the first comprehensive legal and ethical analysis of medical tourism; examining both the legal and ethical issues raised by medical tourism and how the two interact. It provides data and explanations of the industry and tackles what the publisher says are the most prevalent legal and ethical issues facing medical tourism today. The publisher’s advance notice for the book says, "Can your employer require you to travel to India for a hip replacement as a condition of insurance coverage? If injury results, can you sue the doctor, hospital or insurer for medical malpractice in the country where you live? Can a country prohibit its citizens from helping a relative travel to Switzerland for assisted suicide? What about travel for abortion? Glenn Cohen tackles these important questions, and provides the first comprehensive legal and ethical analysis of medical tourism. Some seek legitimate services like hip replacements and travel to avoid queues, save money, or because their insurer has given them an incentive to do so. Others seek to circumvent prohibitions on accessing services at home and go abroad to receive abortions, assisted suicide, commercial surrogacy, or experimental stem cell treatments. The author focuses on patients traveling for cardiac bypass and other legal services to India, Thailand, and Mexico, and analyses issues of quality of care, disease transmission, liability, private and public health insurance, and the effects of this trade on foreign health care systems. He goes on to examine medical tourism for services illegal in the patient’s home country, such as organ purchase, abortion, assisted suicide, fertility services, and experimental stem cell treatments. Cohen examines issues such as extraterritorial criminalization, exploitation, immigration, and the protection of children." Cohen is Professor of Law at Harvard Law School, and his publishers claim he is one of the world’s leading experts on medical ethics and health law.

Asiana Airlines, one of Korea’s flagship carriers, has seen that it can increase business by attracting medical tourists to South Korea. Rather than passively carrying more medical tourists each year, it is now working with hospitals and clinics in South Korea to promote the country as a medical tourism destination with advanced medical techniques and facilities. Asiana looks to become the primary carrier for foreign medical tourists and has formed business partnerships with 24 hospitals and clinics. The first was in 2009 with Hanyang University Hospital. It plans to add more hospitals and clinics to the partnership list. The latest is a cooperation agreement with Yonsei University Healthcare System to jointly attract non-Korean patients. They will together develop a health check programme for foreign tourists and have promotional events abroad. The airline will offer discounts to those visiting Yonsei University Healthcare System for healthcare services. In return, the hospital plans to make it more affordable for Asiana passengers to use its medical services. Kim Soo-cheon of Asiana Airlines says, ’’ We have been actively promoting Korea abroad as an attractive medical tourism destination. By doing so, we have been able to secure this segment of non-Korean visitors. We will continue to boost cooperation with domestic medical institutions to encourage more foreigners to visit Korea to take advantage of advanced healthcare services.’’ According to the Korea Tourism Organization (KTO), the number of medical tourists will likely reach 250,000 in 2014, up from 211,000. In 2013, the Chinese topped the list, with 56,000 going to Korea. The United States came in second, followed by Russia, Japan and Mongolia. KTO expects the number of Russian medical tourists to increase as airlines have launched new routes into more Russian cities.

Unless it is a wellness holiday, most people return from holiday feeling less revitalised than when they left, claims Spafinder Wellness. A global survey of 3,352 people says that 85% returned from a holiday feeling less revitalised than when they left unless they are opting for a wellness break which puts relaxation at its core. According to the Global Wellness Institute, wellness tourism is one of the fastest-growing travel categories, already representing one in seven tourism dollars and experiencing nearly 50 % more growth than global tourism overall. Spafinder defines wellness travel “as holidays, getaways and business trips that help travellers stay or get well when travelling” by offering distinct wellness-related programmes and facilities. From nutrition, healing and mindset to state-of-the-art spas, fitness and wellness centres, health travel destinations make the wellbeing of travellers a top priority. 82% of travellers want a holiday where they can unwind and enjoy spa treatment. 87 % want healthier food and 70% would like to use a gym when they are abroad. Hotels are offering destination-spa-like programming during special weeks, often headlined by celebrity trainers and wellness gurus. Four Seasons Resort Marrakech offers multiday, juice-regimen-themed retreats, combining cleansing with daily yoga and nutritional counselling. More hotels are also offering healthy sleep fitness and treatments. Park Hyatt Tokyo has a free, instructor-led “Good Night Sleep Stretch” in its fitness studio.

In a recent speech to the Middle East Society for Organ Transplantation in Istanbul, Canadian international human rights lawyer David Matas shed light on one of the hidden aspects of medical tourism. The focus was on transplant tourism from the Middle East into China. Matas concluded, “ There is every reason to conclude that there is substantial transplant tourism from countries in the Middle East to countries where the patients are not nationals and to China in particular. Transplant tourism into China means receiving organs from prisoners of conscience killed for their organs. The efforts in the region to combat this transplant tourism are underdeveloped. There needs to be more of an effort in the Middle East to combat transplant tourism. National professional associations should require compliance with international standards.” The key professional international standards on transplant tourism are:• The Transplantation Society Ethics Committee Policy Statement Chinese Transplantation Program November 2006 and Mission Statement (TTS).• The Declaration of Istanbul on Organ Trafficking and Transplant Tourism May 2008 (Istanbul)• World Health Organization Guiding Principles on Human Cell, Tissue and Organ Transplantation, May 2008 (WHO)• World Medical Association Statement on Organ and Tissue Donation October 2012 (WMA) Every national and regional professional association and society should develop a written ethics policy on the clinical practice of transplantation, including the subject of executed prisoners. (TTS) There should be no recovery and no complicity in the recovery of organs or tissues from executed prisoners. (TTS and WMA) Organ trafficking and transplant tourism violate the principles of equity, justice, and respect for human dignity. (Istanbul) There should be no advertising (including electronic and print media), soliciting, or brokering for the purpose of transplant commercialism, organ trafficking, or transplant tourism. (Istanbul) The practice of donation and transplantation requires oversight and accountability by health authorities in each country to ensure transparency and safety. (Istanbul) Mechanisms for transparency of process and follow up should be established. (Istanbul). The organization and execution of donation and transplantation activities, as well as their clinical results, must be transparent and open to scrutiny. (WHO) Collaboration amongst transplant professionals in different countries must protect the vulnerable, promote equality between donor and recipient populations, and not violate other basic organ transplant principles. (Istanbul). Matas used the Omar Healthcare Service to illustrate the problems. The website in Arabic and English dated from 2007 and targeted transplant tourists from the Middle East. Its opening page used both the Arabic and English languages at the same website, which explains the use of the name Omar. It promoted transplants in Tianjin, China with “We are here to assist you in getting a kidney, liver or heart transplant in China. We work with the most qualified two hospitals in China: Tianjin First Central Hospital and International Cardiovascular Hospital.” The Transplantation Society write to President of China Xi Jinping “The Tianjin website continues to recruit international patients who are seeking organ transplants … the fact that foreign patients are still undergoing transplantation in China suggests that some hospitals are boldly and irresponsibly violating Chinese government regulations, thereby rendering the law a mere paper tiger. These hospitals are jeopardizing the public trust at home and tarnishing China’s reputation on the international stage.” The website vanished Matas says, “While transplant tourism generally is a concern, transplant tourism into China has to be of particular concern because of compelling evidence that the bulk of organs for transplants comes from innocent prisoners of conscience in China detained arbitrarily because of their beliefs.” It is easy to attack his evidence as outdated or generalistic, but his response to such attacks from China is, “ Investigators made calls to hospitals throughout China, claiming to be relatives of patients needing transplants, asking if the hospitals had organs for sale. We obtained answers on tape, transcribed and translated admissions throughout China.” Matas and his research ream interviewed patients who went to China for transplants and found:• Waiting times for transplants of organs in China are days and weeks. Everywhere else in the world waiting times are months and years. A short waiting time for a deceased donor transplant means that someone is being killed for that transplant.• There is a heavy militarization of transplantation in China. Hospitals with a ready supply of available organs are often military hospitals. Even in civilian hospitals, the doctors performing operations are often military personnel. The military have access to prisoners as organ sources and the sale of organs is a prime source of funds. • The standards and mechanisms that should be in place to prevent the abuse are not in place, neither in China nor abroad. • The Government of China attributes the sourcing of the bulk of organs to prisoners sentenced to death and then executed but then refuses to provide death penalty statistics on the basis that they are state secrets.• China is the second largest transplant country in the world by volume after the US. Until this year, China did not have an organ distribution system. The organ distribution is limited to the relatively small donated organ numbers, and does not distribute organs from prisoners. The living donor sources are limited in law to relatives of donors and officially discouraged because live donors suffer health complications from giving up an organ. Hospitals in Tianjin cater to Arabic speaking transplant tourists. In Tianjin there have been 100 voluntary donations after cardiac death donors in the last four and a half years. There were 870 registered voluntary donors. Tianjin is a city with a population of 7.5 million. Tianjin has a 200-bed transplant centre that has done 6,000 transplants within the last 11 years. It is apparent that those 6,000 transplants did not come from donors.

A new Indian study of medical tourism in Kolkata warns that allegations of hospital dumping of medical waste means a proper environmental impact assessment is vital before the City seeks to promote medical tourism. Another report says that Karnataka too cannot be an effective destination until it solves problems of air connections and lack of combined promotion. A joint KPMG and the Federation of Indian Chambers of Commerce and Industry report, ’Medical Value Travel in India’ says that while Bangalore has the potential for medical tourism, lack of air connectivity and promotional initiatives act as a deterrent. It says as few as 10 to 15 international patients a day go there for cardiac, oncology or neurosurgical treatments. The region struggles to compete with Chennai and New Delhi. With the state government keen on promoting Bangalore for medical tourism, addressing these issues is essential. An academic study by Anu Raia and others “Regional Imbalance in Medical Opportunities: Bridging the Gap by Medical Tourism” published in the, Thematic Journal of Geography, looked at Kolkata as a medical tourism destination. The authors identified 13 medical tourism agents specifically promoting treatment in the city. They all concentrated marketing on accessibility to low cost quality care without any waiting period and identified 22 hospitals and clinics accepting medical tourists. These were a mixture of large and small, general and specialist, well-known brands and lesser-known locals. Most agents seek to sell every possible type of treatment, while others concentrated on the better paying markets of cosmetic surgery, cardiac care, and orthopaedic treatment including hip and knee replacements which generate maximum global demand. More than 70% offer neurology and neurosurgery, dental care, cancer treatment, eye care, infertility treatment, gastroenterology, spinal surgery, multi organ transplants etc. The agencies offer medical care case managers to assist customers with pre and post procedure medical issues. These case managers interact with doctors and hospitals. Some also offer second opinions and follow up care upon the patient’s return along with the individual nursing facilities during operative and recovery period The medical packages offered often include all costs associated with medical care, air and ground transfers, visa assistance, hotel accommodation, food, interpreter assistance along with other value added services such as money exchange, provision of a cell phone and local SIM card for ease of communication, practical assistance from a local company representative at the health care centre, and arrangements for companions Agencies mainly sell online. Most sites advertise the treatment they offer, the hospitals’ profile, the medical technologies, doctor credentials, success stories; the price they charge or free quotes on request The study concludes that medical tourism opens up opportunities in bridging the regional imbalance of medical opportunities but also brings some social and medical responsibilities along with it. Kolkata is a city where allegations are arising on disposal of medical wastes in and around hospitals, so before promoting medical tourism a proper environmental impact assessment is vital. Kolkata is not well established in medical tourism compared to national competitors such as Delhi, Chennai, Mumbai, Bangalore and Kerala but the strategic location in Eastern India offers Kolkata potential to attract international patients. But to sustain the potential of Kolkata as a medical tourism destination in the long run it is the duty of hospitals and local government to be proactive in solving potential problems rather than waiting until after a major mishap.

The Economic Development and Commerce department of Puerto Rico has presented its strategy for promoting itself as a medical tourism destination, especially among the Hispanic population of the Caribbean and the U.S. East Coast, the main target for medical care including dental treatment, liposuction and weight-loss surgery at prices far lower than in the USA. The Puerto Rican administration commissioned a market study from which it deduces that medical costs on the island are between 40 % and 60 % lower than in the USA. An Advantage Business Consulting study commissioned by the government identified a wealth of opportunities in a variety of specialties including: dental, cardiology, orthopedics, bariatric surgery, cancer treatment, neurosurgery, gynaecology and infertility, pediatrics, ophthalmology and certain cosmetic procedures. Alberto Baco of Economic Development and Commerce explains, "This has been talked about for a decade. Now we are taking action. Puerto Rico has a privileged situation in this market. 3,000 jobs can be created linked to the industry, which is expected to serve 30,000 patients over the next three years. It is a new sector in Puerto Rico, which is going to create business, and will require more hotels. We more expensive than Latin America, but as a U.S. jurisdiction, offer more security and guarantees. When going to have surgery, your main concern is the training of the doctor. The majority of our doctors have studied in the USA and our hospitals are accredited, and certified by Medicare, just like those in the USA." The ambitious target of 10,000 medical tourists a year would produce $200 million revenue over a three-year period, and to do that Puerto Rico must make itself known as a healthcare destination that is able to attract Americans and compete with established markets in Central and Latin America. Ingrid Rivera of the Puerto Rico Tourism Agency comments, "Whoever travels to have surgery does not do it alone. They always go accompanied by one or two people, at a minimum, and often they remain for some additional days for the patient’s rehabilitation." The Puerto Rico government has created Medical Tourism Corporation, an entity overseen by a board that includes the Puerto Rico Trade & Export Co., Puerto Rico Tourism Co., Health Department, and members of the medical community. Medical Tourism Corporation will co-ordinate the establishment of legal, administrative and operational guidelines for services ranging across all parts of the medical tourism industry: transportation, hotels, hospitals, medical professionals and tour operators. Rather than setting up a government body, the government wants to outsource medical tourism and will soon seek a private, for-profit entity that will manage the flow of patients and providers and market Puerto Rico as a leading medical tourism destination. The logic is that government should work to stimulate a self-sufficient private sector, not do what the private sector may do better and cheaper. The government will provide seed money for the first couple years with the aim of having the operational and logistics entity achieve profitability after then through fees for concierge and other services. As a U.S. territory, no passport is required for U.S. citizens to travel to Puerto Rico, which is within easy air access to major stateside cities, including those up and down the East Coast.

High care costs in the United States for patients with Alzheimer’s disease are prompting families to look to other countries, including Costa Rica, as an alternative treatment option. According to the Alzheimer’s Association, more than 5 million Alzheimer’s patients live in the U.S., and someone is diagnosed with the condition every 67 seconds. Out-of-pocket health care costs paid by family members of Alzheimer’s patients will total $34 billion in 2014. Seeing a potential market, some care centres in Costa Rica now offer bilingual services targeting Alzheimer’s patients. La Casa Sol, in the San José suburb of Escazú, is a day care centre offering physiotherapy, psycho geriatric evaluations and sensory stimulation. Jenny Mora of La Casa Sol advises, "Patients have several options, including music therapy that includes singing and dancing, table games, gardening, a literature club, and sports such as volleyball and golf. La Casa Sol has about 45 patients, but they do not attend every day. Some attend once a month, while others visit two or three times a week. Some are from the United States, and others are from Venezuela, Spain, Colombia, Chile and Brazil. We have staff who speak English, and those who don’t speak Spanish won’t feel isolated. Dancing exercises explanations are given in both languages.” The centre offers care, and has links to doctors and hospitals for medical care at affordable prices. It can also help patients find and purchase affordable prescription drugs. The centre offers a nutritional menu designed to manage cholesterol, triglycerides and uric acid for diabetics. Dispelling the belief that paying for care is only for the well off, Jenny Mora explains, “People have the wrong impression that Americans coming here have a lot of money. That is not true, because we are aware of the costs associated with aging. This is one of the reasons we always look for the best and most affordable pharmacies.” Another centre that offers services for Alzheimer’s patients is Verdeza, in Escazú. Verdeza has four floors of varying residential care. The second floor caters to Alzheimer’s patients and has specialized staff. Daily services include housekeeping, laundry, lifestyle activity assistance, prescription drug management, meals, social programmes and therapeutic activities .At Verdeza, a monthly payment of $3800 includes an apartment, targeted care and meals. A similar care package in the U.S. could cost up to $9,000 a month, depending on the state Maybell Araya of Verdeza says, ”We have permanent residents from California, Arizona and North Carolina. Temporary guests stay from two weeks up to three months, or longer." There is a debate between health experts as to whether or not sending Alzheimer’s patients abroad is workable. Some argue that it is important to keep them at home and near family, friends and in familiar neighbourhoods to stimulate with memories, language and familiar culture. But other experts say that depending on the advancement of the disease, patients are able to adjust to new environments, and what makes the difference is the quality of care they receive. Both sides agree that patients should only be sent abroad to specialist centres, not general care homes, clinics or hospitals.