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PROPOSAL FOR MINI-STATEMENT OF THE CAGH TAKES A STAND

MEDICAL TOURISM IN COSTA RICA

By Courtney Lee

Health tourism, defined in a broad sense, is nothing new-- for thousands of years, people have

traveled to foreign lands for healing purposes. In the past century, it was the more developed

nations of the world that were considered popular medical tourist destinations because thesenations had the education and technology to provide high quality medical services that may have

been unavailable in many developing nations. Today, however, this trend is being reversed.

With health care systems in crisis in the developed world, patients and insurers are now seeking

high quality, low cost health care options outside of their national borders. This form of health

travel has grown tremendously in the past decade and has been labeled medical tourism by the

media and industry actors. Though this term has been criticized by some for its suggestion of

leisure and frivolity and its disregard for more urgent cases wherein patients travel for procedures

that are unavailable in their home country (Kangas 2010), I use the term medical tourism

throughout my research nonetheless because I am referring to the formal industry and this is what

this industry has dubbed itself.

In 2007, 750,000 Americans traveled abroad for medical care. This is projected to increase to

more than 1.6 million by 2012, with sustainable annual growth of 35% (Deloitte 2009). Powerfulplayers with interests in the industry have made incredible ideological and financial investments

in medical tourism, which has translated into media inundation with upbeat, optimistic accounts

of medical tourism and its benefits and muted criticisms. Very few questions have been asked

about the potential harms of this industry for health systems in destination countries to which

patients are traveling. Ethnographic perspectives on medical tourism are especially lacking, and

yet are an important means to bring to light the local worlds that are often overshadowed by more

powerful forces, as well as the effects that medical tourism has on understandings of health care.

Medical tourism represents a fundamental shift in the way that we think about health care in a

global world. No longer a merely local activity, this flow of patients occurs across lines of

national and regional income disparities, and across social class divisions. Its very existence and

prosperity depends upon these divisions, as well as entrenched inequalities within and between

nations. Critical anthropological research of medical tourism needs to be undertaken to addressthe potential implications that medical tourism can have within destination countries with varied

political, economic and social situations.

A growing number of Latin American nations are becoming involved as the medical tourism

industry expands. The number of facilities in Latin America that are accredited by the

international arm of Joint Commission (which accredits U.S. hospitals grew from 10 in 2006 to

44 in 2011 (Joint Commission International 2011). The Latin American region largely focuses on

cosmetic and elective surgeries for medical tourists, although there have been concerted efforts

recently to promote medical interventions beyond the scope of elective cosmetic procedures,

which are more profitable for hospitals.

I conducted a year of ethnographic research in Costa Rica to examine local perceptions of

medical tourism and the potential impacts that medical tourism has on the socialized health care

system. In Costa Rica, health care provision is public, controlled by the Costa Rican SocialSecurity Administration (Caja Costarricense de Seguro Social, or CCSS) which, by law, must

cover all Costa Rican citizens. With a national GDP far eclipsed by the industrialized nations of

the world, Costa Rican health indices are among the best in Latin America and rival many of the

most developed nations of the world. This Central American success story is lauded as a

potential role model for other developing nations seeking to achieve health without wealth

(Morgan 1987). This made it an interesting case study for examining the interaction between

medical tourism as a global private industry and local health care delivery, which is a public

endeavor.

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impactthatthisshiftmighthaveonthenationalhealthsystem,potentiallycreatinga

contradictorydualtrackofmedicalcare-aprivatesectorprimarilydrivenbyprofit

versusapublicsectorresponsibleforthehealthofallofitscitizens(e.g.Brotherton2008;

Rylko-BaurandFarmer2002;Wilson2006).

The socialized health system in Costa Rica, founded on principles of solidarity, equity, and

universal access is a national symbol of Costa Rican values. Although there may have been

negative opinions of how the CCSS operates in Costa Rica, throughout my research, no oneargued that the CCSS shoud not exist or once questioned the logic that that wealthier Costa

Ricans subsidize health care for the poor. Costa Ricans love the CCSS system, and are deservedly

proud of its achievements. It is when this social mentality is positioned alongside a model of

private for-profit health care, that these messages of solidarity get convoluted. One CCSS nurse

stated:

I think what is happening now with this type of tourism, is that its making the private

sector grow. They are building hotels right next to these hospitals, or in the hospitals

andwell, you can see the connection. So the private hospitals are growing but it is

only for a certain group that has acquisitive capacity and has foreign capital. In a

certain way, this brings changes to our culture. Because medical tourism is for people

with higher income, and above all for foreigners-- this changes the character of ourculture. It becomes more elite focused and things happen that are for this other

population, not for Costa Ricans (Personal Interviews 2009-2010).

In addition to ideological shifts in thinking that medical tourism presents, a few participants

felt that it was at its core an unethical or exploitive practice, taking advantage of the lower health

care costs in Costa Rica rather than fixing the problems of the health systems from which medical

tourists are coming. An academic in Costa Rica said if you take resources away here from Costa

Ricans, then you are doing something wrong and you just do it, because those people coming here

can pay so much money (Personal Interviews 2009-2010).

In Costa Rica the benefits of medical tourism seem to be little more than hypothetical and no

direct benefits can yet be identified for the public health system. It appears instead that there are

concerns that the industry, if not controlled properly, might do more harm than good to the public

health system. Costa Rica today is caught between two competing visions of nationaldevelopment- on one hand adhering to principles of socialized medicine that have allowed for its

noteworthy achievements of the past, and on the other, a vision of neoliberal growth and

establishing its position within the global marketplace. Confronted with industries like medical

tourism, which is one example, but not the only example of this neoliberal vision, the state finds

itself in a contradictory role, promoting a national ideology based on social medicine for Costa

Ricans within the public sector, while at the same time opening its borders to foreigners who

come to consume private sector services which local Costa Ricans cannot afford.

At present, medical tourism is operated as a business, separated from the Costa Rican

national health care system in all but the most superficial ways. Current evidence indicates that

there is very little benefit to the public system, and in fact, there is real potential for harm. To

maximize the benefits and reduce negative impacts of medical tourism to health systems, there is

a need for regulatory measures and oversight of global private industries like medical tourism toensures socially responsible practices and sustain the health care achievements that Costa Rica

has made in the past century, rather than dismantle them. To this end, more critical attention is

needed to the ways in which the practice of medical tourism interacts with and impacts existing

health systems globally.

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