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Health care at a crossroads

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Title:
Health care at a crossroads medical tourism and the dismantling of Costa Rican exceptionalism
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Lee, Courtney A. ( author )
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English
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xi, 206 pages : illustrations ;

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Medical Tourism ( mesh )
State Medicine ( mesh )
Privatization ( mesh )
Health Policy ( mesh )
Costa Rica ( mesh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references.
Original Version:
Facsimile of: 2012. Health care at a crossroads,
Statement of Responsibility:
by Courtney A. Lee.

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University of Colorado Denver

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Full Text
HEALTH CARE AT A CROSSROADS: MEDICAL TOURISM AND THE
DISMANTLING OF COSTA RICAN EXCEPTIONALISM
by
Courtney A. Lee
B.A., Skidmore College, 2001
M.A., University of Colorado at Boulder, 2006
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Health and Behavioral Sciences Department
2012


This thesis for the Doctor of Philosophy degree by
Courtney A. Lee
has been approved for the
Health and Behavioral Sciences Department
by
Stephen Koester, Chair and Advisor
Jean Scandlyn
Sarah Horton
Sara Yeatman
Date April 20. 2012
n


Courtney A. Lee (Ph.D., Health and Behavioral Sciences Department)
Health Care at a Crossroads: Medical Tourism and the Dismantling of Costa Rican
Exceptionalism
Thesis directed by Professor Stephen Koester
ABSTRACT
Based on a year of ethnographic fieldwork, this dissertation explores the development of
the global medical tourism industry in Costa Rica and the social, ethical, and ideological
implications that its growth may have for the existing socialized health care system. This
study seeks to understand the ways in which medical tourism, as a model of global
neoliberal health care, affects how Costa Ricans think about delivery of and state
responsibility for health care. The research draws deeply on the social, economic,
political, and cultural contexts in which medical tourism is unfolding. It addresses the
ideological tensions and contradictions that surround medical tourism, as the line between
conceptions of health care as local and global, socialist and capitalist, public and private,
blurs to accommodate this emerging industry. Rather than emphasizing the view of
medical tourism from the top, the focus is on local perceptions, understandings and
engagements with medical tourism. Grounded in the experiences of Costa Rican health
care providers, educators, policy makers and citizens, this paper tells the story of a
system in flux.
The form and content of this abstract are approved. I recommend its publication.
m
Approved: Stephen Koester


ACKNOWLEDGMENTS
Though writing a dissertation can be a lonely process, it is not a solitary one, and I
am grateful for the support and encouragement of many people and institutions. First, I
would like to express my thanks to the many Costa Ricans who participated in this
research project and let me into their very busy lives. They were doctors, nurses,
administrators, teachers, parents, and students, who not only made time for me in their
hectic days, but often thanked me for talking about topics that were of importance to
them; their respect for social research is truly inspirational. I would like to thank the Caja,
the hospitals where I conducted my fieldwork and the University of Costa Rica for
allowing me access to their facilities and institutions. The University of Costa Rica, in
particular, provided a welcoming and intellectually stimulating environment to think
about this research, and I found myself always going back there when I felt stuck.
I owe an enormous debt of gratitude to my wonderful research assistant and
friend, Karina Valverde Salas, a brilliant social researcher who flawlessly guided me
through the culture, geography and language of Costa Rica. During my first month in
Costa Rica, I met Karina by chance on three separate occasions, which is when I knew
our working together must have been fate. I dont know what I would have done without
her. This research is as much hers as it is mine.
A very special thank you to my committee and academic advisers, Steve Koester,
Jean Scandlyn, Sarah Horton and Sara Yeatman, whose insightful comments and
conversation helped improve this dissertation tremendously. Jean and Steve, especially,
have heard endless versions of this project since I came up with the idea to study medical
tourism while taking their Global Health and Qualitative Methods classes in 2005. They
encouraged my very rough idea and tactfully helped me to shape it into a respectable
research project. Throughout this long process, they have been wholeheartedly on board
during the times when I loved this project and the times when I hated it guiding me with
their expertise, kindness and humor. I cannot say how much this has meant to me.
I would also like to thank the Health and Behavioral Sciences Department, where
I have felt at home during these years. I have been afforded every opportunity by my
department and have felt supported and valued as a researcher, teacher, student and
person. Abby Fitch has been an ever-patient and helpful guide through the bureaucratic
processes of graduate school and a much needed ear whenever I walk into her office
unannounced and seat myself in the chair across from her. The enthusiasm, support, and
positive outlook of our Chair, Debbi Main, always made me feel like I was doing
interesting work, even on the days when I was just not convinced. I would like to thank
as well Paul Shankman, adviser from my masters program in anthropology, whose
encouragement helped me to find what I was looking for within medical and applied
anthropology. Thank you to the group of brilliant and inspirational anthropologists,
researchers and teachers who have helped me to think critically about the world and seek
out its contradictions. I have learned so much along the way.
I would like to acknowledge the generous funding from the National Science
Foundation (Dissertation Improvement Grant #0852414), the Wenner Gren Foundation
(Dissertation Fieldwork Grant), the University of Colorado Denver Health and
Behavioral Sciences Department (Dissertation Grant) and the International Institute for
Applied Systems Analysis (YSSP summer fellowship), that supported my dissertation
IV


research and allowed me to live abroad for 15 months and complete this research in the
way that I envisioned. I am so appreciative.
Finally, a thank you to my friends and family. Even my friends who have no idea
exactly what it is that I do have kept me going with their understanding, companionship
and much needed laughter. Jessica Lee, in particular, has been right there with me along
this long, bumpy road. Her ideas, input, sense of humor, and close friendship have been
so important to me throughout the program. My parents and brother have been patient
and supportive, and always keep me grounded. My Nana is my inspiration to keep going
and accomplish what I set out to do. My husband Steven has put me back together more
times than I care to admit. He has supported me unquestioningly; even when he had no
idea what kind of crazy hed be faced with from one day to the next. I am so grateful and
fortunate to have these people in my life and I could not have done this without them.
When I returned from my fieldwork, I sat down in Steve Koesters office in a
frenzy about the many snags I hit, and all the things that didnt go as I had hoped. He
patiently let me finish my exasperated rant, leaned back in his chair and said Em so
happy to hear you say that! When I looked at him a little funny, he clarified, Well if
you came back and told me that everything went smoothly and exactly as you planned it,
thats when I would have known that you didnt really do the work. This journey has not
always been smoothor even close to perfectbut I did do the work.
v


TABLE OF CONTENTS
CHAPTER 1: INTRODUCTION.........................................................1
Research Questions............................................................3
Theoretical Approaches and Organization of Text..............................4
Research Methods..............................................................6
Research Assistant.........................................................10
Challenges to the Research.................................................11
Data Sources and Analysis..................................................14
Field sites................................................................14
Reflection on Fieldwork....................................................15
CHAPTER 2: AN OVERVIEW OF THE GLOBAL MEDICAL TOURISM
INDUSTRY........................................................................17
From Individual to Industry: The Global Growth of Medical Tourism............18
Defining Medical Tourism...................................................18
Changing Patterns of Medical Travel........................................21
The Procedures Medical Tourists Travel For.................................23
Medical Tourism Destination Countries......................................29
The Current State of the Medical Tourism Industry............................32
Data Challenges and Questionable statistics................................32
Global Actors in the Medical Tourism Industry..............................34
The Role of Governments in Destination Countries.............................41
Global Impacts of Medical Tourism............................................42
The Potential Benefits of Medical Tourism for Destination Countries........44
The Potential Harms of Medical Tourism for Destination Countries...........45
The Research Project.........................................................48
CHAPTER 3: HEALTH WITHOUT WEALTH THE COSTA RICAN
CONTEXT.........................................................................50
Social Medicine in Latin America.............................................50
Costa Rica as a Case Study...................................................53
Colonial History...........................................................53
Health System Successes....................................................56
History and Development of the Health System...............................59
Medical Education and the Institutionalization of Medical Practice.........62
Quality of Care in the Caja..................................................68
Solidarity as Ideology: Principles of the Caja...............................70
The Costa Rican Image and the Medical Tourism Blueprint......................72
CHAPTER 4: PRIVATIZATION OF THE HEALTH CARE SYSTEM..............................76
The Relationship between the Public and Private Health Care Sectors..........76
The Role of the Private Sector in Health Care Provision....................77
The Private Sector Today...................................................81
Internal Pressures on the Costa Rican Health Care System.....................82
Demographic Changes in Costa Rica..........................................82
Threats to the Cajas Financial Stability..................................83
Unnecessary Patient Referrals to the Caja..................................86
National Management of Human Resources.....................................88
The Contrato de Aprendizaje..............................................90
Deteriorating Conditions in the Caja.........................................93
vi


Working in Both Sectors..................................................96
Passive Privatization....................................................98
CHAPTER 5: NEOLIBERAL PRESSURES ON THE HEALTH CARE SYSTEM
..........................................................................101
The Principles of Neoliberalism.........................................101
Impacts of Structural Adjustment Programs on Public Health.............103
SAPs in Latin America.................................................103
SAPs in Costa Rica....................................................105
Impacts of Trade Agreements on Public Health............................108
The Central American Free Trade Agreement.............................Ill
Global Impacts of Neoliberalism.........................................117
Individual Impacts of Neoliberalism.....................................119
The LoveHate Relationship with the State...............................125
CHAPTER 6: LOCAL EXPERIENCES OF MEDICAL TOURISM............................127
National Actors and the Health Care Cluster.............................127
Emerging Industry Actors as Gatekeepers...............................131
Creating Special Spaces for Medical Tourists............................134
The State of the Medical Tourism Industry in Costa Rica.................138
Local Hopes for Medical Tourism.........................................140
Local Anxieties about Medical Tourism...................................143
Competition...........................................................143
Capacity..............................................................147
Medical Tourism Development in Guanacaste.............................148
Medical Tourism and Inequities in Costa Rica............................150
Financial Resources...................................................151
Internal Brain Drain..................................................153
CHAPTER 7: MEDICAL TOURISM AND COSTA RICAS CONTRADICTING
VISIONS....................................................................159
Costa Ricas Contradictions.............................................159
Medical Tourism and Opposing Ideological Values.......................160
Competing Visions of Health Nationalism...............................163
Medical Tourism Under a Social System...................................166
Medical Tourism, Distributive Justice and Moral Pluralism...............168
The Shifting Role of Social Responsibility..............................172
Regulating Medical Tourism..............................................175
CONCLUSION.................................................................178
WORKS CITED................................................................181
APPENDIX A: EXAMPLE INTERVIEW GUIDE........................................196
APPENDIX B: SURVEY GUIDE...................................................201
APPENDIX C: PARTICIPANT LIST...............................................205
vii


LIST OF FIGURES
Figure 1: Break down of interview participants by primary profession.............8
Figure 2: Break down of physicians interviewed by employment sector..............9
Figure 3: Medical tourism ads featuring beaches and other tourist attractions....20
Figure 4: Map of popular medical tourism destinations............................29
Figure 5: Bumrungrad Hospital lobby and a patient room...........................31
Figure 6: A medical tourism blogger shows that Bumrungrad Hospital in Thailand is
U.S. Approved!.............................................................36
Figure 7: A model of the global medical tourism industry.........................41
Figure 8: Slogan of the Costa Rican Tourism Board: Aqui se cura todo (Here we cure
all).........................................................................73
Figure 9: Idyllic images of Costa Rica: waterfalls, volcanoes and beaches........74
Figure 10: Hospital San Juan de Dios, and an EBAIS primary care clinic...........96
Figure 11: Election Day, February 2010. Costa Ricans supporting their candidates.112
Figure 12: Resistance to CAFTA/TLC...............................................116
Figure 13: The Costa Rican health care cluster...................................129
Figure 14: The role of the government in supporting the medical tourism industry.130
Figure 15: The special spaces of medical tourists................................137
viii


LIST OF TABLES
Table 1: Cost comparison of medical tourism procedures by country...................24
Table 2: Common surgical treatments promoted by medical tourism agencies............28
Table 3: Health and equity indicators for Costa Rica, the United States, and Mexico.58
IX


ACRONYMS
AMA American Medical Association
APEC Asia-Pacific Economic Cooperation
ART Anti-Retroviral Therapy
ASEMECO Asociacion de Servicios Medicos Costariccenses (Association for Costa Rican Medical Services)
CAFTA Central American Free Trade Agreement
CCSS Caja Costarricense de Seguro Social (Costa Rican Social Security System)
CENDEISSS Centro de Desarrollo Estrategico e Informacion en Saludy Seguridad Social (Center for Strategic Development and Information in Health and Social Security)
CONARE
CRMHC Costa Rican Medical Holding Company
EBAIS Equipos Basicos de Atencion Integral de Salud (Primary Health Care Teams)
EMTC European Medical Travel Conference
EU European Union
FDA Food and Drug Administration
FTA Free Trade Agreement
GATS General Agreement on Trade in Services
GATT General Agreement on Tariffs and Trade
GDP Gross Domestic Product
HTI Health Care Tourism International
ICT Instituto Costariccense de Turismo (Costa Rican Tourism Institute)
IMF International Monetary Fund
IMTA International Medical Travel Association
IMTJ International Medical Travel Journal
INS Instituto Nacional de Seguros (National Institute of Insurance)
ISAPRE Instituciones de Salud Previsional (Health Insurance Institutions)
JCI Joint Commission International
MTA Medical Tourism Association
NAFTA North American Free Trade Agreement
OPEC Organization of the Petroleum Exporting Countries
PAC Partico Accion Cuidana (Citizens Action Party)
PLN Partido Liberacion Nacional (National Liberation Party)
PROMED Council for the Promotion of Costa Rican Medicine
PUSC Partido Unidad Social Cristiana (Social Christian Unity Party)
Sala IV Sala Constitucional de la Corte Suprema de Justicia (Constitutional Chamber of the Supreme Court)
SAP Structural Adjustment Program
TLC Tratado Libre Commercio (Central American Free Trade Agreement)
TRIPS Agreement on Trade-Related Intellectual Property Rights
UCR University of Costa Rica
x


UFC United Fruit Company
WB World Bank
WHO World Health Organization
WMTGHC World Medical Tourism and Global Health Congress
WTO World Trade Organization
XI


CHAPTER 1: INTRODUCTION
Very early one morning, I head out of my San Pedro apartment
building to begin my trek up the steep neighborhood hill to the main road
to catch my almost daily 40-cent bus ride into the city. Miguel, the guard
to my buildingwhich also is gated and surrounded by wrought iron
barsdoes not like that I am out while it still dark; he reminds me again
this morning to be careful. But I have an 8am appointment at CIMA
Hospital, in the suburb of Escazu, which will take me a long time to get to
by bus.
At the top of the hill, I brace myself for my daily perila sprint across
four lanes of speeding traffic, interrupted by a quick climb over a median,
and then another dash across two more lanes of traffic. I arrive in one
piece today, out of breath, and swiftly board my bus.
When I reach the city, San Jose is just starting to come to life. Fruit
sellers are out on the corners, shop owners raise their bars, business people
make their way into office buildings, and illegal street vendors lay out
tarps to display the various pirated movies and cheap goods they will try
to sell today.
To catch my next bus, I must walk about a mile through the center of
San Jose to the Coca Cola bus terminal on the west end of the city. The
area around the terminal is crowded and dirty, and I often must step into
the street to maneuver around busy commuters, beggars, and trash that
obstructs the sidewalk. This is a dangerous proposition, as a never-ending
line of swerving, honking cars tries to make its way through the congested
area as well. This district is particularly known as being unsafe, especially
for tourists; I keep my head down and walk briskly to my bus stop, trying
to go unnoticed. I am mostly successful, though I do hear a couple of
Hola machal [Hey blondie!] shouts, followed by the characteristic lip-
smacking sound that accompanies such a shout.
As the bus makes its way out of San Jose and into Escazu, I am struck
by shifting landscape, as the dirty, narrow, crowded streets of San Jose
give way to an expansive highway surrounded by lush green hills. This is
my first time visiting Escazu, though I have been told that it is where all of
the American expatriates live, and that there is a large upscale mall here
where I could go if I wanted American things.
I think of my earlier street-crossing adventure as the bus pulls up to a
raised walkway, which valiantly traverses the highway below, and leaves
me standing in front of the CIMA Hospital complex. It is positively
gleaming in the bright morning sun, which reflects off of the modern glass
facade, giving it a truly radiant appearance. Even though I am early, upon
entry, I am greeted by a uniformed attendant, who takes me directly to
Ophelia, the international patient coordinator, who would be happy to give
me a tour of the complex before she escorts me to the office of the
physician whom I will speak with.
1


This is a sharp contrast to my experience just one day earlier at a
public hospital, San Juan de Dios in downtown San Jose. I arrived early
then, as well, but spent about 15 minutes roaming through a maze of
unmarked hallways asking hurried nurses where I might find the particular
doctor I was looking for. After three failed attempts at finding him, a
sympathetic nurse finally sat me down on an orange plastic chair in a
narrow hallway and told me to just wait.
I was seated in front of a giant laundry bin that contained an absolutely
enormous pile of scrubs. Hospital staff rushed through my little area,
grabbing mismatched pairs of wrinkled scrubs from the bin, and then
quickly hurried off again. Unconscious patients were wheeled by on
gurneys; a nurse walked by carrying vials of blood; in an adjacent room, a
child cried loudly as he received a shot, in full view of the packed waiting
area.
The doctor who I am meeting arrives to retrieve me 35 minutes after
our scheduled appointment. Sorry, I had to check on patients, he
apologizes, as he ushers me into a cluttered room lined with mismatched
communal desks, where at least five others are working. Welcome to my
office, he laughs, holding his hands out, while we search for an
available area to talk. I have to check in for surgery in 20 minutes, he
says, so we should get started.
-Adapted from field notes February 25th and 26th, 2010
These marked differences between public and private spaces of health care
consumption are indicative of the mounting contradictions of the national political project
in Costa Rica. A divergence is occurring, as past visions of health carebased on social
solidarity and state-sponsored medicinegive way to future visions of health care based
on privatization and global wealth accumulation. The emerging practice of medical
tourism, which takes place within new private spaces like CIMA, is illustrative of the
ideological shift that is currently underway in Costa Rica. Though it is entrenched in
larger political and economic forces, many of which are external to Costa Rica, the way
that Costa Rica incorporates medical tourism into the national political project is colored
by the nations successful social health care system.
This dissertation explores medical tourism within the particular context of the
Costa Rican health system. As a novel configuration of health care provision in an
2


increasingly global world, this practice of crossing borders for health care facilitates new
ideological encounters, as national systems of health care collide with the global health
care economy. Within Costa Rica, this clash occurs between a national health care model
based on principles of social medicine, and a model of neoliberal health care that
continues to spread, despite its failings within the developed nations of the world. Costa
Ricas historical orientation towards public health care provision, positioned alongside
the neoliberal model of medical tourism, provides fertile terrain for analyzing the
paradoxes of globalization. This research attempts to make visible the contradictions of
this practice, through following the fault lines out (Nordstrom 2007). This study began
in the United States with research in, and on, the medical tourism industry and followed
the connections to Costa Rica, a very popular medical tourism destination for Americans.
To date, there is little scholarly research on the effects of medical tourism in
destination countries. Though recent academic studies have begun to examine the topic
more critically, there are very few firsthand accounts that assess the impacts of medical
tourism within a particular context. This research takes a step towards filling this gap by
critically engaging with the practice of medical tourism, and its situation within larger
power relations, in the Costa Rican context.
Research Questions
This research set out to answer the overarching research question: How does
medical tourism impact health care in Costa Rica? To do this, it focused on the following
five sub-questions:
(RQ1) How is the medical tourism industry integrated within the state-
dominated Costa Rican health system?
(RQ2) What are the differences- organizationally, structurally, and
with regard to patient population- between public hospitals that serve
3


mainly local and poorer populations and private hospitals that serve
medical tourists and wealthier Costa Ricans?
(RQ3) Where do the profits from the medical tourism industry go?
(RQ4) Does medical tourism draw resources and physicians away
from public health care?
(RQ5) How does medical tourism impact the way that Costa Ricans
think about health care?
Theoretical Approaches and Organization of Text
Anthropology, with its sensitivity to the actors point of view and the
ways these contradict or clash, combined with its capacity for
problematizing the taken for granted ... is particularly suited to analyzing
how ideologies infiltrate the institutions of practices of everyday life.
(Shore and Wright 1997)
To draw connections between global industry and local health care in Costa Rica,
I utilize critical anthropological perspectives that enable a shift of scope from macro to
micro-processes and back again. In particular, this research offers a political economy of
the medical tourism industry.
Political economy of health perspectives are particularly adept at examining the
complex and nuanced problems of globalization, and the processes by which individual
lives and local communities are affected by political, economic and cultural forces that
operate worldwide (Appadurai 1991). These perspectives are concerned, as this project is,
with the distribution of global resources and how global power structures influence
health. Rather than creating a separate section to discuss theory as it relates to the study
of medical tourism, theoretical perspectives are incpororated throughout the dissertation,
connected to the particular themes of each chapter.
In Chapter One, I discuss the changing patterns of global medical travel, offer an
overview of the medical tourism industry, and analyze the various arguments both for and
against medical tourism within the existing literature. The fundamental assumptions of
the industry, rooted in neoliberal principles, are introduced in this chapter. I argue here
4


that the medical tourism industry has developed a blueprint for destination countries,
that lays out specific criteria for what comprises a good destination, and the careful lines
that participating nations must toe in order to participate.
In Chapter Two, the lens is shifted to the specific context of Costa Rica, and I
trace the development of social medicine here and discuss its role in health nationalism.
Costa Rica has had notable successes in health care indicators, uncharacteristic of a
developing nation with such a small GDP. However, the way that Costa Rica has come to
fit the blueprint for the medical tourism industrythrough a public system based on
solidarity, equity, and universal coverageis in sharp contrast to the underlying
principles that medical tourism represents. Ironically, it is the successes of its social
system that have allowed Costa Rica to emerge as a medical tourism destination.
In Chapter Three, I trace the historical role of the private sector in health care
provision within Costa Rica. The private sector is very small in Costa Rica, and it has
relied on the much larger public system for its own survival and expansion, over time.
This relationship has become increasingly parasitic, however, and today, the public sector
is left caring for the poorest and sickest Costa Ricans while the private sector focuses on
profitable forms of health care. Within popular discourse, the public and private sectors
are viewed as disconnected. I argue in this chapter that they are not, and that the
maintenance of this division in public consciousness leaves the public system vulnerable
to passive privatization.
In Chapter Four, I outline the external pressures on the social medicine system,
focusing on the ill effects of neoliberal reform programs and free trade agreements, on
health care provision, as well as the way that neoliberalism, as a global hegemonic
5


system, is changing the way that locals think about health care. These outside pressures
have resulted in further contraction of the public system, and impacted the ability of the
state to to provide health care to its citizens.
In Chapter Five, I focus on local experiences of the medical tourism industry
within Costa Rica, outlining the current state of the industry, local hopes and anxieties
around its expansion, and the impacts that it has on the public system. I argue here that
medical tourism entails a shift of economic and human resources out of the public sector,
which cares for the large majority of citizens, and into the private sector, which cares for
the wealthy few.
In Chapter Six, I summarize the current contradictions of the political project in
Costa Rica, and the competing visions of health nationalism that define the particular
moment. In this chapter, I highlight the overarching ideological impacts that medical
tourism has in a context like Costa Rica, and its impacts on the way that locals
conceptualize health and health care provision.
Research Methods
According to Appadurai (1991), globalization is characterized by the movement
of people, technology, money, images, and ideaswhich now follow increasingly
complex trajectories, moving at different speeds across the globe. Medical tourism, as it
adeptly crosses national boundaries, touches on all of these flows. Because the object of
study is a global industry that is not situated in one place, this research is multi-sited
(Marcus 1995). It utilizes a research framework that both captures local perceptions of
global processes and analyzes the systems that connect them. Ethnographic methods are
well suited for assessing these interrelations, and, in many ways, the focus of this
6


ethnography is on these systemic connections.
From October of 2009 to October of 2010,1 lived just outside the San Jose city
center, in a neighborhood near the University of Costa Rica (UCR). To address the
research questions of this project, this dissertation relied on several foundational methods
of anthropology, including participant-observation, interviews, surveys, archival research,
and review of popular media.1
Though classic participant-observation may be impossible in certain settings
(Gille and ORiain 2002 ), it was used to the extent possible throughout the research
period. This a non-traditional ethnographyin that it largely took place within
institutional settings and through scheduled appointments with participants at their places
of employment or study. At times, I was obliged to rely more heavily on observation than
participation, particularly when conducting fieldwork within hospitals and government
agencies. Living in Costa Rica for a year, however, did allow me ample opportunity for
participation in Costa Rican life, and I took part in several events, including lectures,
protests, discussion groups, films, and conferences. Outside of Costa Rica, I attended two
(rather dissimilar) medical tourism conferencesthe World Medical Tourism Congress,
a trade conference for the industry, in 2008, and the International Conference on Ethics in
Medical Tourism, in 2010.
While participant-observation is the quintessential method of anthropological
fieldwork, it presents a theoretical problem in that it tends to miss the implications of
structures of power and of historical context, because these forces are not immediately
visible in every day observations of individuals (Brotherton 2003). Supplementary
1 See Appendices A and B for interview and survey guides.
7


ethnographic methods help to gain a more nuanced understanding of complex global
processes to address the shortcomings of static methodologies.
Throughout this project, I conducted individual (48) and group (2) interviews with
stakeholders at various levels of the medical tourism industry. In total, I conducted 50
semi-structured interviews with participantsthe majority of whom were physicians
(29), and male (39). Of physicians interviewed, there was nearly an even split between
physicians who worked exclusively in the private sector (12) and those who worked
exclusively in the public sector (11), although, of these physicians, only one had never
practiced in the public sector. (The reason for the high proportion of private sector
physicians in relation to the small size of the private sector is likely because of a site-
access issue, which will be discussed in the Challenges section.) The general composition
of participants is illustrated in the following two figures:
Interview Participants
by Profession
B Physicians
5
B Nurses
7
2
29
Academics
B Medical Tourism
Facilitators
Government Officials
Figure 1: Break down of interview participants by primary profession.
8


Physcian Interviews by
Employment Sector
6
11
n Public Sector Only
B Private Sector Only
Work in Both Sectors
12
Figure 2: Break down of physicians interviewed by employment sector.
Interviews began in the United States prior to my arrival in Costa Rica. I
conducted two phone interviews with representatives of international medical tourism
agencies that worked with hospitals in Costa Rica. From there, I refined my interview
guides based on information received, and obtained referrals for connections within the
industry in Costa Rica whom I could contact upon my arrival to the country. Once in
Costa Rica, I used a purposive snowball sampling strategy to find individuals at various
levels within the industry, the health care system, and the government. When I felt that I
was reaching saturation with responses among stakeholders in the private sector, I started
another snowball to better include the public sector, and to elicit a wider range of
responses and opinions.
Interviews were tape-recorded and either verbal or written consent was obtained
from participants, who are kept anonymous. Throughout the fieldwork process, I refined
9


interview questions to reflect the position of the person I was interviewing, and to learn
more about new themes that emerged as the research progressed.
Over the course of the fieldwork period, I conducted over 200 surveys with
patients in private hospitals and public-private cooperatives. These surveys included both
closed and open-ended questions about access to public and private health care facilities,
patterns of use and opinions of each, and opinions of medical tourism within Costa Rica.
This project relied, too, on archival research and regular scans of popular press
and media coverage around medical tourism and health care in Costa Rica. Prior to
embarking on my fieldwork trip to Costa Rica, I spent the summer of 2009 conducting
archival research on the global medical tourism industry, thanks to a fellowship at an
International Institute in Austria. Because medical tourism is a relatively new topic
within the academic literature, I found reviews of popular press and media particularly
helpful, including newspapers, websites, online videos, blogs, and magazines.
Research Assistant
Vitally important to the success of this research project was the fortunate meeting
of my research assistant, Karina, who I initially met in a yoga class. She heard about my
research project through emails I sent to the UCR prior to my arrival, and was drawn to
the project because of previous research that she conducted on the privatization of health
care in Costa Rica. Karina was instrumental in helping me navigate the health care
system. She also served as a cultural and geographical guide, helping me to understand
cultural nuances, locate people and resources that would further the research, and
navigate the bus system. She attended all interviews conducted in Spanish to ensure that I
10


was gaining accurate information, and to help me to see what I was missing or did not yet
understand.
In gaining access to certain facilities to conduct this research, we quickly
discovered that we made a good teamI had a remarkably easy time gaining access to
private facilities (because private sector stakeholders were eager to promote medical
tourism to an American researcher)while Karina, as a Tica,2 had much better luck
steering through the complex bureaucracy of the public sector to find participants. She
was invaluable in moving this research forward.
Challenges to the Research
My status as an outsider, and an American, sometimes opened doors for me, and
sometimes closed them. While my nationality allowed me access to medical tourism
stakeholders quite frequently, this turned out to be a disadvantage as well. Early in the
fieldwork process, I grew frustrated with what came to be known as the spiel. Because
my sampling strategy started with actors within the medical tourism industry, I began to
hear the same rhetoric about the benefits of medical tourism over and over. When
participants started to repeat the exact same words and phrases verbatim, I came to
understand that there were heavy marketing and messaging tactics at play hereand that
1 would have to be more innovative in order to get past the spiel. Slowly, I became
more adept at using some personal strategies to gain deeper information. In particular, I
feigned ignorance in certain situations, appearing merely inquisitive in order to ask about
touchy subjects such as biombos (bribes) or tax evasion. My non-threatening demeanor
seemed to work to my advantage in these settings. Without trying to alter or censor
2 Tico (male) and Tica (female) are slang terms for Costa Ricans that are popularly used.
11


participant responses, in situations where I felt that they were giving me the spiel, I had
to use my own common sense and other sources of information to get at the underlying
truths. Ethnographic methods are particularly adept at this, and allowed me to conduct the
research in a flexible and creative way.
About half way through my fieldwork, I hit a snag in my research plan when, the
week before Costa Rica was to host an international conference on medical tourism, I
was told by a high-ranking official whom I was interviewing that my research was too
political. He demanded to know who had given me permission to study such a topic,
and, as there is no International Review Board within Costa Rica to approve research
projects by foreigners, I did not have a good answer for him. The next month entailed
several meetings with different institutions to try and figure out who exactly could, and
would, endorse my research.
Academics at the UCR, while fond of my research topic, did not have the
authority to sponsor students who were not enrolled at the university. The Ministry of
Health told me that my project was social in nature and that they did not sponsor such
things. They wondered why I was asking for permission, and suggested that I just do the
research and not tell anyone about it.
Finally, the bioethics department of the Caja3 agreed to review my proposal.
During this time, I learned rather intimately how frustrating the bureaucratic processes of
the Caja could be. After submitting six hard copies of my proposal, I was told that I
would have to wait a month for the proposal to be reviewed. Six weeks later, I heard back
that my proposal was rejected. The reviewers did not understand why I should want to
3 The Caja is short for the Caja Costarricense de Seguro Social, or the CCSS. It is the Costa
Rican Social Security System, which provides health services to the population.
12


study medical tourism, a private industry, within the Caja. If I want to study plastic
surgery, they wrote, why dont I go into the private hospitals? After several months of
back-and-forth communications and revisions, I was finally able to make the bioethics
committee understand the social nature of my research. But with a limited fieldwork
period, I had, in the meantime, drawn on one of the researchers most important
methodological toolsflexibility. Despite the best-laid plans, fieldwork, especially in a
foreign country, sometimes just doesnt go the way it was hoped. In this case, I had to
reassess my project and what was necessary to successfully complete the researchand
then adapt.
Because the majority of private sector physicians work within the public system
as well, I began to search for public sector physicians who operated private offices part-
time, and met with them in their private spaces in order to circumvent my pending
permission to conduct research within Caja facilities. While this proved an effective
strategy, it did skew my participants toward the private sector side more than is
representative of the health care system at large (90% of the nations physicians work
within the Caja, though not all do so exclusively). Eventually I gained official permission
by the Caja to conduct fieldwork in one of their public-private cooperatives, which I did
during the last month of my fieldwork period.
Another challenge of the research, though to a much lesser degree, was the use of
informed consent. Though consent forms did not seem to inhibit participation in the
project, I was told many times that the forms were very American, formal, and
bureaucratic. In general, however, Costa Ricans were very amenable to participating in
this research, and did so without incentive, other than contributing to a topic that they felt
13


was important. Having worked in health care settings here in the United States, it was
especially surprising to me that physicians were so willing to give their time, as this is a
historically difficult group to recruit.
Data Sources and Analysis
Several methods were used to analyze data collected for this study. Interviews
were transcribed by two students, Alan and Silvia, who worked within the Institute for
Social Research at the UCR. Silvia, who had lived for many years in the United States,
translated Spanish transcripts into English, and helped to translate surveys, forms, and
interview guides to ensure their accuracy.
Survey data was entered and analyzed in Excel. Other data sources included field
notes, site descriptions, and background research, which I conducted on certain topics
that arose in interviews (for example CAFTA implementation and provisions, contracts
between medical residents and the Caja, etc.). These sources were typed into Word
documents, and loaded into Atlas.ti, for thematic analysis. A combination of inductive
and deductive coding was used to analyze all narrative data, and codes were reviewed
and organized for writing.
Field sites
This research took place in and around the Costa Rican capital of San Jose,
located in the Central Valley. With a population of over 365,000, San Jose is home to
government institutions, and the majority of the nations health care facilities and
universities.
14


I conducted fieldwork at three private hospitalsHospital Clinica Biblica,
Hospital Hotel La Catolica, and CIMA4all of which are accredited hospitals that try to
attract medical tourists; I also conducted fieldwork in two of the Cajas national hospitals
in San JoseHospital San Juan de Dios and Hospital Calderon Guardiaas well as in
one mixed medicine cooperative, Coopesalud, in Pavas, a district of San Jose. Lastly, I
conducted interviews with students and professors from the UCR, and participated in
events through the university. Throughout the dissertation, I offer some more detail about
these field sites, as it relates to themes around medical tourism.
Reflection on Fieldwork
Though it is somewhat difficult to recall now, my initial decision to study medical
tourism in Costa Rica had at least something to do with the idyllic image of the country
that is portrayed in the media and popular imaginationand, as a medical anthropologist,
its successful social health care system. It is very easy to get caught up in this image.
Studying Costa Ricas health system, I am often solicited to engage in discussion over the
merits of social medicinedeclaring it either good or bad, and either a success or a
failure. While I may have been more amenable to making such a declaration prior to
working in Costa Rica, I now have a much more nuanced appreciation of both the
positive and negative aspects of the Costa Rican health care system. I have tried in this
dissertation to avoid reducing this topic to moral absolutes. I offer a critical perspective
of the medical tourism industry and its founding assumptions, but hope to have painted a
4 Throughout the dissertation, I refer to these three hospitals often as the big three private
hospitals for simplicitys sake. They are not the only private hospitals in the nation, but they are
the largest, and most well-known.
15


sufficiently complex picture of the Costa Rican health system that captures the intricacies
of the current political moment.
Within Costa Rica, too, many whom I met had an agenda that they thought
matched minewhether this was supporting the medical tourism industry, or exposing
the faults of either public or private health care. Understandably, as a researcher, I would
like to satisfy all of those whom I imposed upon to participate in this study, and not to
betray any of them. It is one of the difficulties of ethnographic research that I cannot
make this promise. I can only offer here an account of medical tourism filtered through
my own experiences, research and interpretations.
16


CHAPTER 2: AN OVERVIEW OF THE GLOBAL MEDICAL TOURISM
INDUSTRY
Set to soft Spanish folk music, slow motion scenes of Costa Rica
appear one by onea church...a time-worn statue of two angels...an
elderly Costa Rican man...school children in uniform playing jump rope
outside. Words slowly appear on the screen Different Cultures...a
butterfly... providing new hope... a sunset.
The scene shifts to Bob, bearded, dressed in a red plaid flannel shirt
standing next to his wife Linda. Bob is a middle-aged American, family
man, and construction worker, whose deteriorating knees have left him
worried that he will not be able to support his family. Every morning,
Bob opens his eyes and wonders how much he is going to hurt that day,
reads the female narrator, even playing with his dog hurts too much. He
is insured, but his insurance will only cover a tenth of the cost of knee
replacement surgery, and he cannot afford the remainder of the cost
without going into debt. He is aggravated and depressed; his lifestyle and
personality are affected, the narrator tells us.
That is, until Bob went on the internet and found out about medical
tourism. He has decided to undergo a double knee replacement in Costa
Rica, where he can save $80,000,5 and receive exceptional services. His
trip to Costa Rica will be his first time out of the country, but he did some
research and found out that Costa Rica has a health system that performs
better than the U.S. health care system.
Bob arrives in Costa Rica to find that he is treated better than he ever
has been within the U.S. system. The hospital is expecting him, and staff
is ready for pre-surgical tests upon his arrival. A doctor is waiting on me
he exclaims, Thats a first!
His surgeon, Dr. Oeding, is a family man like Bob, and we see scenes
of him eating with his children, taking them to school, playing racquetball
with his friends. This time rejuvenates Dr. Oeding, and makes him a
better doctor, reads the narrator. Bobs wife Linda thinks his nurses are
beautiful, with such lovely smiles... like angels. Clinica Biblica, the
hospital where Bob will receive his surgery, and the technology that is
used, is state-of-the-art, and accredited by U.S. standards. The medicines
are FDA approved.
Bob and Linda stay at an InterContinental Hotel. After taking a
rainforest canopy tour, Bob undergoes his surgery, and it is a great
success. His physical therapist, Nazarene, is focused and competent,
giving Bob the emotional and physical support he needs to recover from
his surgery. His surgeon checks on him personally and often during the
recovery phase.
On his last day in Costa Rica, Nazarene takes Bob for a walk outside
the hospital to be sure that he can handle real-life obstacles with his new
5 Throughout the dissertation, all monetary values will be given in U.S. dollars, unless specified
otherwise.
17


knees before he boards a plane to go home. They cross pot-holed streets
and dirty, crowded sidewalks, through a construction site. This is real-life
stuff, Nazarene says.
Bob returns home to Florida a new man, with a new outlook on life.
The future looks very good, he says, as uplifting music plays in the
background, each week gets better and better, and better.
- From Angels Overseas, a Medical Tourism
Documentary (MTA 2009)
This is the story presented by the medical tourism industry of what medical
tourism looks like in Costa Ricadesperate middle-class Americans who travel overseas
to be healed by caring angels, who not only offer medical care that is comparable to the
United States, but also truly care about the health and wellbeing of the patient.
Although the documentary tells us that Bob was in Costa Rica two weeks to
undergo and recover from his surgery, he rarely steps outside of the hospital or hotel
except for his quick trip to the rainforest, a popular tourist destination. He is protected
from the real-life of San Jose that takes place outside of these purified spaces.
While the images in the passage above represent the face of medical tourism
presented by the industry, they obscure the reality of medical tourism within destination
countries. The emergence and development of medical tourism as a global industry and
the primary concernsethical, social, and economicthat arise along with the growth of
the medical tourism industry, are the focus of this chapter.
From Individual to Industry: The Global Growth of Medical Tourism
Defining Medical Tourism
The term medical tourism is a controversial concept. Recent anthropological
literature has critiqued the term for failing to account for the diverse types of medical
travel that people undertake, for suggesting leisure or frivolity, and for disregarding the
suffering and lived experiences of patients (Inhom and Patrizio 2009; Kangas 2010; Song
18


2010). Other terms, thought to more accurately reflect the practice, have been suggested
to replace medical tourism, such as medical migrations, medical exile (Matorras 2005 ),
medical refugees (Milstein and Smith 2006), biomedical or biotech pilgrimages,
transnational therapeutic itineraries (Kangas 2010), medical or therapeutic journeys.
Some use terms that are more broad, like health tourism, or less value-laden, like
international or transnational medical travel, medical care abroad, treatment abroad, or
just medical travel.
It may be a useful exercise to debate the relative worth of these terms, but it is not
the aim of the research presented here. The focus of this ethnography is the formal
medical tourism industry that has developed over the past decade; this industry named
itself medical tourism, and in fact has gone to great lengths to protect this name. In the
interest of drawing critical attention to the power relations at play within this emerging
industry and to avoid linguistic de-politicization of this work (Ormond 2011), I use
medical tourism throughout the dissertation.
Additionally, while it is important to note that there are patients who cross borders
out of necessity or desperation, it is equally important to note that there are many who do
not. It has been estimated by some that 80 percent of the medical tourism industry is
centered around cosmetic surgery (Tatko-Peterson 2006). The formal medical tourism
industry formed itself around a population seeking elective surgeries, especially plastic
surgery, at an affordable cost. The industry markets to this population, particularly within
the United Statesa group of people who are healthy enough to travel, but not so healthy
that they do not need care, and a group of people that have enough money to travel to a
foreign country, but not so much money that they can pay the high price for care within
19


the United States without being strained financially. Although it was clear from those
with whom I spoke that the tourism part of medical tourism was outweighed by the
medical part, ads within the industry nonetheless play up this sense of adventure, travel
and leisure in their promotion of destination countries. Even those patients recovering
from elective surgeries rarely do a lot of traveling because they are either too weak, or
too visibly bruised and scarred to seek these pursuits, but most medical tourists do bring
companions with them, who tend to partake in tourist activities.
Figure 3: Medical tourism ads featuring beaches and other tourist attractions.
(Sources, clockwise from top left: Thai Travel News 2011; Escape from America 2011;
Medical Tourism Panama 2010; Your Medical Travel 2008; Johnny Foreigner 2010;
Surgeon & Safari 2009)
Medical tourism today is an industry with an incredible aggregate potential for
growth. Within anthropology, it is valuable to examine the special cases of medical
travel, but it is equally necessary to examine the most widespread forms of medical
tourism. This ethnography aims to study up and to study power (Nader 1974) by
critically examining the formal medical tourism industry.
20


Changing Patterns of Medical Travel
Globalization is not new to health care; people have sought healing in foreign
lands for thousands of years. However, this travel now takes a very different pattern than
in the past century, as patients now travel from more developed countries to less
developed countries to take advantage of lower costs, procedures that may not be
available in their home countries, and a relatively high quality of health care. In the past
century, it was the more developed nations of the world, such as the United States and the
nations of the European Union, that were considered popular destinations for medical and
health procedures because these nations had the physicians, facilities, and technology to
provide high quality medical services that may have been unavailable in many
developing nations. Today, this trend has reversed.
As the demographics of these developed nations change and problems with their
health care systems arisesuch as long waiting lists for procedures in Canada and the
United Kingdom, or the extremely high costs of health care and high rates of uninsured
citizens in the United Statespatients from these countries are now seeking high quality,
low cost health care outside of their national borders. In addition to these demographic
and systemic changes, ease of travel, expansion of the internet and global
communication, increasing portability of health insurance, and the retreat of neoliberal
states from the provision of public services have played a role in the expansion of
medical tourism (Kangas 2010; Whittaker 2010b).
In nations that provide public health services to their citizens, like the United
Kingdom or Canada, the prime motivation for citizens to engage in medical tourism is to
avoid long wait lists for procedures in their own countries. Some medical tourists have
also traveled to protect their privacy, particularly when receiving cosmetic surgeries, or to
21


obtain services for which access was restricted or illegal in their home country (specific
examples of these forms of medical tourism will be discussed in further detail in the next
section). The primary reason for Americans to seek health care abroad, however, is the
lower cost, which in some cases can be as low as 10 percent of the price in the United
States. An inefficient market-based health care system in the United States has led to
inflated costs of health insurance that now leave 47 million Americans uninsured.
Americans who are uninsured, underinsured, and who lack coverage for dental care or
elective procedures are the primary populations seeking care outside of the borders of the
United States. Contrary to the beliefs of many medical tourism proponents, medical
tourism is not a savior for poor, sick, uninsured Americans; the poor do not have the
means to travel out of the country for care, and the very ill cannot travel. Furthermore, it
is not the elite who travel either, because they can afford the high cost of care within the
United States. Rather, it is those who are somewhere in between: middle-class Americans
who are not willing or able to pay the high cost of health care within the United States,
but do have enough expendable income to travel outside of the United States for care and
pay out of pocket. However, as insurance companies begin to consider medical tourism
options to save costs, this profile is changing to include more insured Americans.
Medical tourism facilities in developing countries are able to provide services at
these reduced costs precisely because of their inferior economic status. Lower fixed costs,
wages, and administrative expenses; cheaper pharmaceuticals; and the absence of the
litigious medico-legal climate that exists in the United States all contribute to this cost
differential (Unti 2009). As an example, the professional liability insurance premium for
22


a surgeon in India is only 4 percent of the premium for a comparable practicing surgeon
in New York (Lancaster 2004).
The Procedures Medical Tourists Travel For
Although medical tourism as an industry began with procedures of limited
medical complexity like elective procedures or dental care, which are not covered on
most insurance plans, it has now expanded into more complex procedures. Today,
medical tourists travel for a wide array of procedures, from heart valve replacements to
joint replacements to brain and spinal surgeries. The popular press within the United
States most often chooses to focus on these more critical procedures undertaken in
foreign countries, highlighting the reduced cost. This not only serves as a marketing tool
for medical tourism, but also as a reflection on the high costs within the U.S. health
system as compared to other countries. This was exemplified with the highly publicized
case of Howard Staab, who traveled to India for a heart valve replacement and sparked
lively debate about the benefits and dangers of medical tourism and its potential impacts
on the U.S. health care system.6
Patients most commonly travel for procedures that are available in their home
country but that they have prohibited or limited access to (e.g., because of cost or wait
time), but there are those who travel to access procedures that are unavailable in their
home country as well. This might be because of limited infrastructure, technology, or
6 Howard Staab, in many ways, is patient zero within the medical tourism industry. In 2004,
Staab, 53, uninsured and self-employed, found out that he needed a mitral valve replacement,
which cost upwards of $200,000 in the United States. He traveled to India and had the procedure
done for $10,000. His partner and travel companion, Maggi Ann Grace, wrote a book about his
lifesaving surgery in India entitled State of the Heart. The two received a flood of press
coverage that spurred subsequent discussions about medical tourism.
23


Table 1: Cost Comparison of Common Medical Tourism Procedures by Country
(Medical Tourism Association 20 JO)
Cert.::; Vi I- :d J 1 . Ko-V: T'-j uid V CT1.V- : io o',: o \ co r,:.q
$144,000 $14,802 $25,000 $5,200 $14,400 $28,900 527,000 $27,500 $15,121 Not Provided $10,000 $11,430 Not Provided
T!7 $57,000 $4,500 $13,000 $3,300 $5,000 $15,200 $12,500 $8,000 $3,788 Not Provided $8,000 $5,430 Not Provided
->{T ri'7 ' ?: $170,000 $18,000 $30,000 $5300 $14,400 $43300 $18,030 $29,712 $21,212 Not Provided $10,130 $10,530 Not Provided
- c =: a :e $50,000 $6,500 $12,500 $7,000 $8,000 $14,120 $13,000 $25,250 $7,879 $3,250 $10,840 $7 500 $S,700
- -:C $50,000 $10,500 $12,500 $7,000 $10,000 $15,600 $15,000 $20,000 $15,152 Not Provided $7,640 $12,350 Not Provided
-:.e: c^' t : $50,000 $6,500 $11,500 $6,200 $8,000 $19,800 $12,000 $24,850 $12,297 $3300 Not Provided $7,000 $S,200
Spinal Fusion $100,000 Not Provided $11,500 $6,500 $10,000 $15,400 $12,000 $35,000 $9,091 $5,150 Not Provided $6,000 Not Provided
i!.! :... .! $2,800 $1,750 $900 $1,000 $1,000 $4,200 $1,800 S2 150 $5,636 Not Provided S5.340 $354 Not Provided
- r $28,700 $7,200 $10,500 $5,000 Not Provided Mot Provided $9,995 $11,500 $13,636 Not Provided SB,770 NotProvided $8,000
$32,927 $9,900 $12,500 $5,000 Not Provided Not Provided 510,950 $11,500 $16,667 Not Provided $3,935 $9340 $8,000
= =1 1 $30,000 $9,900 $8,500 $3,000 $7,000 Not Provided $6300 SI. 000 $11,515 Not Provided Not Provided Mot Provided $8,000
.. t ^:: : - $9,000 $2,500 $3,900 $2,800 $4,000 Not Provided $2,800 $7,242 $2,303 $2,850 SS060 $2,299 Not Provided
3*r3i: ! : a-:? $9,750 $3,500 $5,300 $3,000 $4,000 Not Provided $4,025 511.000 $5,000 $3,850 S2.533 NcrProvirfed Not Provided
$10,000 $1,500 $3,800 $3,500 $3,500 $12300 $3,500 $21,000 $2,727 $3,850 52.930 Mot Provided $4,400
$8,000 $2300 $4,500 $4,000 $3,000 $5,000 $3300 59300 $5,091 $2,200 53.935 $1,293 $2,400
$15,000 $5,000 $6,000 $4,000 $4,400 $15,300 $4,900 $16,000 $3,697 $4,150 $4,520 $3,440
$15,000 Not Provided $5,700 $2,500 $6,000 $11,000 $5,800 $14,000 $2,727 S3.270 $5,250 $3,000
$4,400 $2,000 $1,800 $500 $5,000 $6,000 $1,995 $1,815 $1,640 S4.200 $477 Mot Provided
Mot Provided Not Provided $4,200 Not Provided Not Provided $7,000 Not Provided $16,700 $1,800 Not Provided $6,450 Not Provided Not Provided
Re:' -?. Not Provided Not Provided $4,500 $850 Not Provided $10,200 $3,500 $13,000 $4,242 Not Provided S33/0 $3,000 Not Provided
.V:; -a'. .j $14,500 Not Provided $2,800 $3,250 $2,700 $2,180 $3,950 52,300 $9,091 Not Provided S5,520 $3,819 Not Provided
Transplants when
India Jordan Korea Mexico Thailand Africa
Not Provided Not Provided Mot Provided $135,000 $45,455 Mot Provided
$8,000 $25,000 $45,600 $45,000 $21,212 $15,450
$13,000 $100,000 $170,000 $115,000 $36,364 mt Provided
* ".T-: V Not Provided Not Provided Mot Provided Not Provided $51,515 Mot Provided
K>
4^


expertise, or because a procedure is controversial, experimental, or illegal.7 Prominent
examples of these include stem cell, organ transplant, reproductive, abortion, or gender
reassignment procedures.
In the case of stem cell tourism, patients travel abroad for stem cell treatments
that are not approved within their home countries. This form of medical tourism is likely
not as related to cost as other forms, but rather it represents hope for patients seeking a
cure for terminal illness (e.g., Parke, et al. 2010; Song 2010). Liberation therapy, also
known as venoplasty or vein opening, for the treatment of multiple sclerosis is another
example of an experimental procedure for which patients travel. Another example,
though significantly less controversial, is hip resurfacing, which is now an accepted
alternative to full hip replacement, but was not approved by the Food and Drug
Administration (FDA) in the United States until 2006. Indian doctors had been
performing hip resurfacing for over a decade by the time FDA approval came through
(Neely 2009). Because ethical debates and legislative processes can take a significant
period of time and regulatory structures are more stringent in developed countries,
medical tourists might choose to seek these procedures elsewhere.
In addition to experimental procedures, there are medical tourists who travel for
illegal or highly stigmatized procedures, such as abortion (e.g., Sethna and Doull 2010)
or gender reassignment surgeries (e.g., Aizura 2010; Wilson 2010). While not always
illegal in their home country, these procedures are often so stigmatized that patients
might choose to leave their home country to ensure privacy or anonymity.
7 See Kangas 2010 for an account of Yemeni travelers seeking treatments not available in Yemen
for chronic illness, following a more traditional pattern of medical travel from less developed to
more developed countries.
25


An illegal and highly controversial form of medical tourism that has been gaining
attention among researchers and the popular press is transplant tourism. Shortages of
donor organs for transplants have created commercial opportunities abroad in the global
organ trade. Patients in search of organs can now purchase them on the black market (it is
illegal to pay for organs in the United States). This is a way for desperate patients to
circumvent the regulatory framework of their countries, but it raises serious bioethical
concerns. In developing countries, the poor sometimes sell a kidney for as little as
$1,000-3,000; the same organ is then sold to a wealthy patient in a developed country for
upwards of $40,000. Especially among the poor, this practice can have very detrimental
effects on the health of the organ seller (e.g., Cohen 2003; Cohen 2005 ; Scheper-Hughes
2002). The medical tourism industry has struggled with this issue, and although most
medical tourism associations now say that patients must bring their own donor, there is
virtually no regulation of this practice.
Reproductive tourism is another form of medical tourism that has become
extremely popular in recent years, sometimes called procreation vacations in the press.
Due to the high cost of fertility treatments, limited insurance coverage, and legal and
policy implications in some countries, women and couples travel abroad for in vitro
fertilization (IVF) treatments (e.g., Blyth and Farrand 2005 ; Inhorn and Patrizio 2009;
Speier 2011; Whittaker 2010a). While this practice in itself might not be viewed as
ethically questionable, in some cases, the couple may choose the genetic characteristics
of the fertilized egg that are most desirable, or have another woman act as a surrogate
mother. This surrogacy practice occurs frequently in India (e.g., Kumar 2008;
Venkatachalan, et al. 2010), wherein an Indian woman is implanted with a fertilized egg
26


and carries the pregnancy to term for a couple. The genetic parents can even shop
around, looking through photos of potential surrogates, even in cases where the
surrogate mothers genetic material is not used in the process. Potential surrogates must
first prove their fertility by having one child of their own, and then may act as a paid
surrogate up to five times. The rate of cesarean sections among these surrogates is nearly
100 percent. While cesarean sections protect the health of the baby, they are much more
dangerous to the health of the surrogate mother, especially when some women undergo
the procedure multiple times throughout their productive years (Venkatachalan, et al.
2010).
As Meghani (2010) notes, different kinds of medical tourism procedures, such as
reproductive, transplant and cosmetic, raise different ethical issues. The forms of
medical tourism discussed above raise several significant ethical and moral issues, from
eugenic concerns to the post-colonial value of third world bodies that are now being
used in the service of keeping first world bodies healthy. These ethical impacts of
medical tourism, as well as the socio-cultural and economic impacts, will be discussed in
more detail in Chapter Six. While it is imperative that these controversial gray areas of
medical tourism continue to be exposed and critically examined, it is also important to
keep in mind, again, that although medical tourism can take place in pursuit of urgent,
controversial, or illegal procedures, in its current state, the majority of procedures are
elective or non-urgent.
27


Table 2: Common surgical treatments promoted by medical tourism agencies (Unti 2009)
Specialty Procedure
Cardiac and vascular surgery Aortic aneurysm repair Atrial septic defect repair Cardiac valve replacements: aortic and mitral Carotid endarterectomy Coronary artery bypass grafting Femoropopliteal bypass surgery Varicose vein treatments
Cosmetic and plastic surgery Abdominoplasty Blepharoplasty Breast augmentation/reduction Cosmetic skin refinishing and body contouring Face lifts and implant surgery Liposuction Rhinoplasty
Dentistry and oral surgery Bridges and implants Endodontic procedures; root canal surgery General dentistry procedures Orthodontic procedures Tooth veneers
Ear, nose, and throat surgery Bronchoscopy Cochlear implants Nasal septoplasty and reconstruction Sinus surgery Tonsillectomy and adenoidectomy Tympanoplasty and tube insertion
General, colorectal, and oncologic surgery Bariatric surgery; banding and bypass Bowel surgery: colectomy and other procedures Breast surgery: biopsy, lumpectomy, mastectomy Cholecystectomy Gastrointestinal endoscopy: upper and lower Hemorrhoidectomy Herniorrhaphy Laparoscopic surgery
Neurosurgery Treatment of brain tumors Treatment of spine disorders Skull base surgery
Obstetrics and gynecology Gynecologic laparoscopy Hysterectomy: abdominal and vaginal In vitro fertilization and intrauterine insemination Tubal ligation and reversal
Ophthalmologic surgery Cataract surgery Cornea alteration procedures Glaucoma treatments
28


Table 2 (continued)
Orthopedic surgery Ankle fusion Arthroscopic and arthroplasty procedures Carpal tunnel release Back procedures: diskectomy, laminectomy, spinal fusion Hip replacement and resurfacing Knee replacement Shoulder surgery
Transplant surgery Organ transplantation: heart, kidney, liver, lung
Urologic surgery Cystoscopy Genitourinary prosthetic implant surgery Prostatectomy Testicular cancer surgery
Medical Tourism Destination Countries
About 20 nations are consistently identified as legitimate medical tourist
destinations by the popular press and medical tourism companies. Some estimate that as
many as 50 countries may be currently promoting medical tourism.
Figure 4: Map of popular medical tourism destinations.
29


From an industry perspective, there is a certain blueprint for destination
countries that must be met before medical tourism is promoted there. These include an
existing tourism infrastructure, high quality medical care and technology, accredited
facilities, a pool of skilled, English-speaking workers and physicians, and capacity within
the private sector to promote and develop this industry. These criteria automatically leave
out the poorest of nations. Most medical tourism destinations are lower-middle income
countries that already have an active tourism industry.
Additionally while quality medical care is essential, these places must also match
the tourist imagination for such a trip. They must be considered beautiful, exotic and
adventurousbut not so exotic or adventurous that they lack modern amenities. Medical
tourists are also shielded from the undesirable third world characteristics of the
destination, such as poverty, violence, or unsanitary conditions.
In addition to high quality medical services, medical tourists also expect to
receive VIP treatment when they obtain health care abroadpersonal medical attention,
luxury accommodations, door-to-door transportation services, personal care during the
recovery period and high quality meals (Turner 2007). Many facilities provide
international patients with a hospital suite comparable to a five star hotel, complete with
flat-screen TVs, wireless internet access, guest suites and side trips to local tourist sites.
Bumrungrad International Hospital in Bangkok, Thailand is the largest private hospital in
Southeast Asia and serves over 400,000 foreigners each year (Bumrungrad International
Hospital 2012). It is the first, and most well-known medical tourism facility, and is an
example of a facility that offers these amenities; it also contains a Starbucks, Au Bon
Pain, and McDonalds in its lobby.
30


Figure 5: Bumrungrad Hospital lobby and a patient room.
(Medical Travel Site 2007; Bloomberg.com 2011)
It is not always the modern amenities and concierge services that most appeal to
medical tourists. Medical tourists often imagine themselves refugees, escaping an
inequitable, unjust, uncaring health care system that does not care about their needs. They
are drawn to the notion that warm and caring nurses and physicians in destination
countries will spend time with them to assuage their fears, and give them the personalized
care that they desire. In Costa Rica, foreign patients who were recovering from plastic
surgery felt that health care personnel had a different mindset around health care
provision and a concern for the total wellbeing of the patient (Ackerman 2010). This is
ironic, because, at the same time, medical tourism is contingent on intensified
commercialization and Westernization of medical services in Costa Rica, as well as the
expansion of a neoliberal model of health care. At the same time that Costa Rica is seen
as peaceful, green, natural and different from the United States, it must be perceived as
having advanced Western biomedical technology, physicians and standards of care.
It is imperative, then, that destination countries walk these lines. They must be
exotic enough, but not so exotic that patients feel uncomfortable traveling there; they
must be poor enough for there to be a cost differential in care, but not so poor that they
31


are unable to provide quality health care and infrastructure; and they must be seen as
fundamentally different from Western notions of biomedicine, while at the same time
offering Western biomedical care.
The Current State of the Medical Tourism Industry
Whereas the practice of medical tourism began at an individual level, a powerful
industry has formed around this practice within the past decade, and the numbers of
medical tourists have increased dramatically. A report by the Deloitte Center for Health
Solutions (2008) estimated that 750,000 Americans traveled abroad for medical care in
2007 and projected an increase to more than 1.6 million by 2012, with sustainable annual
growth of 35 percent. They further estimated that the worldwide market for medical
travel was worth $60 billion, and expected that it would grow to $100 billion by 2020.
Data Challenges and Questionable statistics
These figures are likely the most quoted statistics on global medical tourism, but
even these are questionable, and it is not clear how these figures were determined.
Inconsistent definitions and methods for collecting and reporting medical tourism data
make it extremely difficult to provide an accurate estimate of the number of medical
tourists traveling for health care. A researcher who publishes on medical tourism
criticized the data collection of major research firms, stating, Accurate figures on
medical tourism are not easy to come by... by definition, almost every official figure is
flawed. They are often badly collected, imperfectly collated and spun to infinity
(Youngman 2009).
One of the primary challenges of collecting data is determining how medical
tourism is defined. While medical tourism as a global industry has been widely defined as
32


patients who travel for the specific purpose of receiving medical treatment, this definition
does not always translate into attempts to measure the flow of patients, which sometimes
include tourists who have an accident while traveling, or expatriates who live in the
country and receive regular health care there, as medical tourists. Desires for privacy of
traveling patients also results in underreporting of procedures by patients. Additionally,
medical tourism statistics seem to change depending on the particular agenda of the
reporting agency or facility. For example, when trying to promote the medical tourism
industry to patients or investors, numbers of medical tourists tend to be greatly
exaggerated by reporting agencies to give the impression that medical tourism is more
mainstream and less risky. Some hospitals also inflate their figures by counting the
number of patient visits instead of the number of visiting patients. Youngman says that
agencies, experts, politicians, and hospitals often make ludicrous estimates of actual or
potential numbers and gives an example of an Asian minister who said his country had
100,000 medical tourists, while the next week another minister claimed it was 200,000
(2009). On the other hand, when reporting patient numbers to the government for tax
purposes, especially within smaller clinics, numbers tend to be under-reported.
After sorting through the data and picking out what he deemed the more reliable
sources, Youngman estimated that the number of medical tourists, excluding emergency
cases, expatriates, those who travel for wellness or spas, and internal travel, a
conservative estimate would be in the range of 5 million medical tourists globally.
Despite a scarcity of accurate data, there is no question that medical tourism has
increased significantly as a practice, and continues to do so. What is noteworthy is its
shift from a very small niche market to a boom in a very short period of time, as the
33


practice shifts from an individual to an aggregate form.
Global Actors in the Medical Tourism Industry
The remarkable potential of medical tourism and its rapid expansion has resulted in a
dramatic increase in the number of actors with stakes in this new industry. In addition to the
rise in number of associations or facilitator companies that act as intermediaries, the number
of insurance companies exploring medical tourism as an option and the number of accredited
health care facilities that cater to foreigners have been on the rise. These actors, who serve to
oversee and regulate the industry, promote quality services and protect the reputation of the
industry, as well as to profit from it, are discussed in the section that follows.
Medical Tourism Facilitator Companies
Medical tourism is often part of a package in which all arrangements, medical and
otherwise from obtaining a passport or visa, to flight, ground transportation, hotel stay,
meals, and tourism or vacation plans are taken care of by a single medical tourism
facilitator company. Facilitators, formerly called brokerages, take the legwork out of
arranging care abroad by working with reputable private hospitals, physicians, travel, and
accommodation providers. The number of medical tourism facilitators has expanded
exponentially in the past five years. Currently, there are more than 100 U.S.-based
facilitators; four facilitator companies have opened in Colorado since 2007. These
companies are private, for-profit, and typically owned and operated by American CEOs.
They charge fees to traveling patients (or companies who send patients) for arranging
these services, as well as a fee to foreign hospitals for providing them with patients,
usually a percentage of the total cost of the procedure performed. Although the United
34


States has a very high number of facilitator companies, these companies do exist in
several other countries (both sending and receiving) as well.
International Accreditations & Branding
Turner (2007) discusses the ways that the medical tourism industry signals
quality, meaning that in order to be successful, the industry must present itself as safe,
well-regulated, and possessing the same standards for health care as in the United States.
One of the primary ways that medical tourism facilitators and international hospitals
signal quality is through international accreditation. U.S.-based Joint Commission
International (JCI) is one of several geographically specific accrediting organizations,
and the most recognized accrediting body for U.S. patients traveling abroad for care.8 It
was established in 1997 and accredited its first hospital (in Brazil) in 1999. Since then,
JCI has accredited over 300 public and private health care organizations in 39 countries
(Joint Commission International 2011). Smaller facilities are accredited by separate
organizations, such as the Accreditation Association for Ambulatory Health Care
(AAAHC), which accredits clinics.
8 Other accrediting agencies include the International Society for Quality in Health Care Inc.
(ISQua), Trent Accreditation Scheme (TAS) out of the UK, Accreditation Canada, Australian
Council on Health Care Standards (ACHSI), and Irish Health Services Accreditation Board,
among others.


71 Joint Commission
] fjspTERN AT IO N A L
United States of America
Ittch lias-cvaiurttei-l Jiis bospiral
amUuund il lo meal the
inwmutional health care qualnv
~ sraudai ds tor puticni care
and ortwnittilion munagemetii
Jr^ a ~ T
Figure 6: A medical tourism blogger shows that Bum run grad Hospital in Thailand is
U.S. Approved! (Anti-Aging and Longevity Project 2009)
Another way that quality is signaled is through co-branding with well-known,
medical facilities within the United States and Europe. Respected medical centers in the
United States, such as the Cleveland Clinic, Harvard Medicine International, Johns
Hopkins Hospital, Duke Medicine, Cornell Medical School, and Columbia University
Medical Center, have partnered with hospitals abroad to promote quality services at
lower costs (e.g., Deloitte Center for Health Solutions 2008; Milstein and Smith 2007;
Sobo, et al. 2011). It must be noted that these U.S. hospital chains retain a portion of the
profits made by their international affiliates.
In addition to the highlighting of accreditation and co-branding with Western
affiliates, studies of how medical tourism associations and companies market to potential
medical tourists have shown that the Western education and training of physicians in
destination countries is played up as well (e.g., Johnston, et al. 2010; Sobo, et al. 2011).
Ads typically state that most of their physicians are educated in U.K. or U.S. and are
board certified (Sobo, et al. 2011). State of the art facilities and cutting edge
technology are also advertised very prominently to signal quality.
36


International Insurance Companies
Although insurance companies have been slow to adopt medical tourism options,
there are several that are piloting programs within their existing health benefit plans.
Anthem Blue Cross and Blue Shield of Wisconsin, United Group Program of Florida,
Blue Shield and Health Net of California, and Blue Cross Blue Shield of South Carolina
are all testing the waters with pilot medical tourism plans, and some third party groups,
like United Health Care, have started to reimburse patients for procedures undertaken
outside of the United States (Deloitte Center for Health Solutions 2009). In 2006, the
United States Senate Special Committee on Aging held a hearing on medical tourism,
calling a task force of experts to explore the impact and safety of this practice. In
addition, state legislative bills were introduced in both Colorado and West Virginia in
2007 to incentivize state employees to cross borders for health care (Assembly 2007;
West Virginia General Assembly 2007). Although neither bill passed, and the Special
Committee hearing never amounted to much, these actions were notable in that state and
federal legislators were noticing the potential cost savings of medical tourism at an
aggregate level.9
The guidelines for medical tourism released by the American Medical Association
(AMA) (2008) stated that travelling abroad for care must be voluntary and that domestic
alternatives should not be inappropriately limited. While there were no cases of
companies requiring that patients travel abroad for care, it is clear that, to date, most
insured patients choose not to. Aetna Inc. offered coverage abroad for 27,000 employees
9 Both bills were viewed as aggressive in the provision of financial incentives, and this may have
been a primary reason why they were rejected.
37


of Hannaford Bros, supermarket chain in the northeast, and two years later, not one
employee had chosen this option (Bajgrowicz 2010).
Medical Tourism Associations
Medical tourism associations, such as California-based Healthcare Tourism
International (HTI), which opened in 2006, and the Florida-based Medical Tourism
Association (MTA), which opened in 2007 have been established to promote the industry
and protect its reputation. The MTA, in particular, has tried to establish itself as the
leading trade association for medical tourism internationally and promotes itself as
objective resource for transparency, communication, and education within the industry.
The association, made up of international hospitals, insurers, agencies, educational
institutions, and other affiliated companies whose purpose is to increase the awareness
and utilization of overseas hospitals for medical care, targets U.S. consumers in
particular. When launched, the stated goals of the MTA were to promote use of their
hospital and clinic affiliates by patients and insurers, to control the growth and standards
of the industry (standards based on U.S. criteria), to protect the reputation of medical
tourism through quality assurance measure, to act as the representative for dealing with
the governments of U.S. and destination countries, and to create a comprehensive website
for people to learn about medical tourism (2007).
Although legally a non-profit, the MTA, owned and run by a couple, Jonathan
Edelheit and Renee Marie Stephano (both attorneys) has drawn much criticism for using
the organizations non-profit status as a shield to run profitable activities (Ratner 2009)
and for legally and ethically questionable activities within the sector. Stephano set up a
very profitable conference and event business that runs the annual World Medical
38


Tourism and Global Health Congress (WMTGHC) for the MTA, now in its fifth year,
which links medical tourist companies, large-scale employers, insurance companies, and
international hospitals into business networks. The registration fee for the congress is
$1,200, and priority is given to speakers who sponsor the event (Ratner 2009). Congress
sponsors pay anywhere from $500 to $100,000, depending on their level of sponsorship,
with higher levels of sponsorship yielding more advertising exposure and other benefits.
The MTA also publishes two trade magazines on medical and health tourism, which sell
ad space to members and feature destinations that are paying members of the association.
To join the MTA, fees are anywhere from $500 (for an individual) up to $5,000 (for
medical or pharmaceutical suppliers). Hospitals pay $3,000 for membership, and
governments pay $2,000. Additionally, the MTA has a string of trademarked certification
programs that members can pay to go through.10 Critics of the MTA have suggested that
the non-profit MTA is merely a shell company for these profitable activities.
Adding to these concerns over the activities and transparency of the MTA, in
2009, the MTA sued another association, Singapore-based International Medical Travel
Association (IMTA) over service mark infringement and unfair competition, despite the
fact that the two associations have very different agendas and geographic service areas.
One commenter wrote, It is deplorable that the two lawyers who own an association that
has only been in the industry since May of 2007 believe they own the words medical
tourism association, which describes a concept used regularly by the media, the public,
and is not unique in any way (Ratner 2009). Discussion over who owns medical
10 These include International Patient Services Certification for Hospitals and Clinics,
International Patient Center Training (which must be received prior to the International Patient
Services Certification, Certified International Patient Specialist, and a Medical Tourism
Facilitator Certification.
39


tourism heated up again in 2011 when a writer for International Medical Travel Journal
(IMTJ) found that Edelheit had registered 370 web domain names of potential medical
tourism websites, including domain names that should belong to competitor conferences
and companies, such as the annual European Medical Travel Conference (EMTC) and the
Trent Accreditation Scheme (an alternate accrediting body to the Joint Commission
International which is more popular in Europe). Additionally, Edelheit registered a
domain for a common misspelling of the leading international medical tourism hospital
Bumrungrad Hospital in Thailand (Edelheit registered Brumrungrad.com) so that any
users who misspelled the hospitals name would be redirected to the MTA website
(Ratner 2009).
Though the accusations discussed above have not been resolved yet, the point must be
made that medical tourism is not a benign industry that exists only to provide health care to
those in need. Especially as medical tourism continues to shift from an activity of individual
patients to an activity covered by health insurance plans, the aggregate potential of the
industry is drastically increasing. It has become a big business, with many competing
interests and powerful actors involved. There is much profit to be made in this industry.
40


Figure 7: A model of the global medical tourism industry (created by author).
The Role of Governments in Destination Countries
The level of involvement and role of governments in destination countries varies,
though within the industry blueprint, there is a plan for how this should work. The
MTA promotes what it calls a health care cluster in member countries. A health care
cluster is generally an independent organization of hospitals, clinics, medical
professionals, supporting businesses (i.e., accommodations, transportation, aftercare, and
tours) and the government, which all come together to support the medical tourism
industry (Cook 2008; Medical Tourism Association 2012). The cluster is funded by all
participants and may be supported by government funding. It is meant to represent the
interests of all of its members, to promote the members of the cluster, and to build the
reputation of the country for medical tourism. The MTA suggests that advertising and
41


marketing goals be established and that these tie in with the Ministry of Tourism and the
Ministry of Health for governmental support. The cluster is to promote the image of
country above all else, and regulate who should be able to promote medical tourism
within the country (Edelheit and Stephano 2008). According to the MTA materials on
developing a healthcare cluster,
Forming a healthcare cluster is probably the most important single step in
establishing a medical tourism destination and to enhance the locations
chances of success as a destination for medical tourists and increasing
patient flow. All the medical tourism stakeholders, such as hospitals,
doctors, Ministry of Health, Tourism, Economic Development, Tourism
Operators, Hotels and more must work together to promote this image of
high quality of healthcare to establish a brand name for the location
throughout the world (Medical Tourism Association 2012).
It further states that over 40 governments are involved in supporting medical
tourism, a number that is growing, and that government entities should work together
with the private sector on medical tourism initiatives. What is not clear is whether these
governments receive any benefits from the industry, or what those benefits might be.
Global Impacts of Medical Tourism
Thus far, most discussion of the impacts of medical tourism has been around how
this practice will affect the U.S. health care system. Reports within the United States
contend that this growth holds important implications for U.S. health care providers,
health plans, consumers, and the government, (Unti 2009) and may result in a $16
billion loss in revenue for U.S. health care providers (Deloitte Center for Health
Solutions 2009). Many health care providers within the United States express animosity
towards payers that send patients away and patients who choose to go abroad, therefore
eliminating domestic revenues, but expect physicians to provide follow-up care for
patients returning home (which has lower compensation). A Costa Rican physician whom
42


I spoke with told me the story of one of his patients, a woman who came to him for a
facelift, for which he charged $3,000. She needed four sutures removed when she
returned home to the United States, and her U.S. physician, upset that she had gone to a
foreign country, told her that he would charge her $3,000 to remove the sutures. On the
other hand, some argue that medical tourism will act as a relief valve for the U.S. health
care system, reducing some of the burden, and allowing those who cannot afford care to
find it elsewhere. Rather than a solution to the problems of the U.S. health care system,
medical tourism is a symptom of its malaise.
Although impacts on the U.S. health care system are prominent in discussions of
medical tourisms growth, very few questions have been asked about what this growth
could mean for the destination countries to which patients are traveling. Because the rise
of medical tourism is a relatively recent phenomenon, and because accurate data is hard
to come by, many of its purported impacts are speculative. Until very recently, critique of
medical tourism from the social sciences has been almost nonexistent. Meanwhile,
powerful global industry actors have been fervently preaching the benefits of the
industryat home and abroadsince its inception. Their considerable ideological and
financial investments in medical tourism have translated into media inundation with
upbeat, optimistic accounts of medical tourism and its benefits, and muted criticisms. The
following section lays out the proposed benefits of medical tourism on destination
country health systems, as well as the potential negative impacts and concerns about this
expanding industry at a global level.
43


The Potential Benefits of Medical Tourism for Destination Countries
The arguments supporting medical tourism are primarily economic. Medical
tourism embodies the promises of a neoliberal health care economy and is viewed as a
progressive economic strategy by many industry actors, as well as government actors in
destination countries.11 It boosts revenue within the tourism sector, and does so at a rate
estimated to be at least four times higher than conventional tourism (Taborda 2011). It is
reported that these revenues do not just stay within the health sector, but impact auxiliary
industries as well, stimulating ripple effects at recovery retreats, hotels, tour operators,
transportation services and at the government level (Cook 2008). Medical tourism is
also an important area of growth for foreign investment in destination countries.
The underlying assumption is that increased national revenue translates into
improved health care for the citizens of destination countries. Advocates of medical
tourism claim that revenue earned through performing medical procedures for foreigners
will support the public sector and complement public health efforts, with these effects
trickling down to the poor. It is also asserted that medical tourism will create jobs for
locals (both within and outside of the medical field), promising to have important
knock-on effects that may benefit even the poor (Economist 2008, emphasis mine).
Proponents also argue that medical tourism will reverse brain drain by keeping
professionals practicing in their home nations rather than emigrating to practice in foreign
countries where pay is higher. The head of Wockhardt hospitals, a large medical tourist
hospital group in India, reported that two dozen Indian doctors returned from the United
States and the United Kingdom to work in his facilities (Madden 2008).
11 Neoliberal discourse and its role in the expansion of medical tourism globally and within Costa
Rica will be discussed in detail in Chapter Four.
44


Many within the industry claim that medical tourism actually increases quality of
care within both the public and private sectors in destination countries by improving
standards of care, infrastructure, technology and training. Stephano, of the MTA, states
that it raises healthcare standards and increases competition, which raises the bar even in
the public sector (Murray 2009). Others claim that medical tourism is good use of the
excess capacity of private hospitals, and increases the availability of diverse specialists
for the whole population (Bookman and Bookman 2007).
Medical tourism can also serve as source of national pride. Song (2010) discusses
the inversion of core and periphery within biomedical research that medical tourism
represents, highlighting the story of a Chinese physician who provides stem cell
treatments to paralyzed patients who travel from countries conventionally thought to be
technologically superior to China to receive this care. The physician justifies his decision
to treat foreigners over Chinese patients as a way to assert Chinas new dominance and
superiority in the field of regenerative medicine (Song 2010). The intersection of medical
tourism with national rhetoric in Costa Rica will be discussed in greater detail in
subsequent chapters.
The Potential Harms of Medical Tourism for Destination Countries
Are we in the wealthy world really so blind and selfish that it does not
even occur to us to ask to what extent medical tourism, in the end, boils
down to poor countries subsidizing the cost of health care for rich
countries? (Reader comment in Milstein 2009)
Critiques of medical tourism, like this one, increasingly suggest that economic
and other conjectured benefits disproportionately favor the sending nations and
negatively impact local access to health care in destination countries in a number of
45


ways. In short, the costs of medical tourism to public health provision may outweigh the
benefits.
First, as previously mentioned, in order for medical tourism to present a cost
differential attractive enough for foreigners to travel, inequities between the sending and
receiving nations must remain relatively stable. This means that if destinations countries
receive significant boosts in tourism revenue that translate into increased wages for
medical tourist physicians, or higher fixed costs or administrative expenses that push the
price of medical tourism up, the demand for medical tourism will decline, and the
industry will likely shift its focus to other countries that can maintain a better price
differential. Medical tourism may also contribute to higher costs of health care within the
private sector to create local free zones (Blyth and Farrand 2005 ) in the private sector,
as prices increase to levels that are inaccessible to locals.
Similarly, the profits from medical tourism that are supposedly going towards
improvements in public health seem to remain almost exclusively within the private
sector. Medical tourism contributes to the development of a two-tiered health system
where elite, technologically sophisticated hospitals cater to wealthy foreigners, while the
impoverished majority must use poorly resourced public hospitals. Although medical
tourism did not create these problems, it represents the manifestation of inequitable and
inefficient health care systems, and has the potential to worsen existing conditions in
developing countries. There is currently no mechanism in place to ensure that medical
tourism supports public health care systems in destination countries in a way that helps to
alleviate these inequities.
46


Much of the profit generated by medical tourism remains with foreigners rather
than with destination countries. Medical tourism associations, facilitator companies,
accreditation schemes, recovery homes, as well as private hospitals and hospital groups in
destination countries are often foreign-owned. In addition, many of the physicians that
work within medical tourism receive at least some of their medical training in the United
States and Europe and hold memberships in medical organization there. Much of the
state-of-the-art technology that is used within the medical tourism industry is also
imported from more developed countries, further diverting revenues. The privileging of
Western biomedicine and technology within the industry means more profits stay within
the Western world.
Beyond economic ramifications, medical tourism also has implications for the
quality of health care within destination countries, as human resources may be siphoned
from the public to the private sector. External brain drainwherein health care personnel
leave developing countries to practice in more developed countries where they earn a
higher salaryin the presence of medical tourism is being replaced by internal brain
drain, as health care personnel leave the public health care sector to work in private
hospitals that treat wealthy medical tourists.
Medical tourism was recently cited in Thailands physician shortage, as
physicians opt to practice at hospitals like Bumrungrad, where remuneration is higher
(NaRanong and NaRanong 2011). Many of these destination countries are already
plagued with human resource shortages. Between 1990 and 2004, India had only 60
physicians per 100,000 people, while the United States had 256 physicians per 100,000 of
its population, and yet Thailand and India are the leading destinations for medical tourism
47


(Meghani 2010). Physicians often choose, as well, to specialize in procedures that cater to
foreign demand, rather than preventive or primary health care.
Overarching these more tangible effects of medical tourism on economic and
human resources are impacts at an ideological level. Medical tourism operates from the
fundamental assumptions that health is a commodity subject to the forces of the market,
and that a neoliberal health care model is the most effective way to provide health care.
There is irony in the fact that medical tourism subsists on the failings of this model of
health care in developed nations. The rapidly expanding trade in health care has
implications for the health systems of both sending and receiving countries, but more
fundamentally on the view of health as a commodity rather than a right and global public
good.
The Research Project
There are significant gaps in our understandings of this new configuration of
health care mobility and its implications. This research critically investigates these
potential and actual impacts of medical tourism on the health systems of destination
countries. Medical tourism, as a global industry, represents a new form of health care in
an increasingly interconnected world. It raises many questions about the shifting role of
the state in health care provision, global governance for this emerging industry, and the
effects that neoliberal models of health care have on destination countries with very
disparate health care systems. Among destination countries, Costa Rica stands out
because of its successful socialized health care system and the principles on which it was
founded. It provides a unique case study to examine the effects of this emerging health
care economy and its ideological contradictions. In the chapters that follow, both global
48


and local aspects of the medical tourism industry, as well as its implications, are
examined within the specific Costa Rican context.
49


CHAPTER 3: HEALTH WITHOUT WEALTH THE COSTA RICAN
CONTEXT
To understand local impacts on health systems, it is important to first situate the
research within the Latin American and Costa Rican contexts. Although global medical
tourism is becoming more standardized on the side of the industry with the emergence of
international actors and standards, it cannot be assumed to have a homogenous effect
across destination countries that are very different politically, culturally, socially,
historically, and economically.
This chapter briefly discusses health systems in Latin America, before shifting to
an in-depth discussion of the Costa Rican context. It includes an overview of national and
health system history and development, the complementary role of medical education,
and local opinions of the health system. I argue in this chapter that Costa Rica very much
fits the blueprint criteria of the global medical tourism industry, but that its national
health achievements are based on very different ideologies than the medical tourism
industry. On one hand, Costa Ricas successes have been the result of a strong welfare
state and progressive social policies that view health care as a right to which all are
entitled, while on the other hand, medical tourism is based on neoliberal principles that
view health as a commodity, to be purchased by those who have the ability to pay. This
chapter will serve as an introduction to several of the themes that will be expanded upon
in later chapters.
Social Medicine in Latin America
While nations in the Latin American region developed along different trajectories,
general similarities among their health systems do exist, primarily an orientation towards
50


social medicine. Though defining social medicine can be complicatedand politically
loadedsocial medicine most generally refers to a state-supported system of health care
delivery. This means that the government could fully control the delivery and financing of
health care, though in practice, socialized medicine represents a range of strategies, from
complete government ownership of facilities and employment of health care providers, to
public financing of private insurance and providers. In Latin America, the principles
underlying social medicinebeliefs that social and economic conditions impact health,
that the health of the population should be a matter of social concern, and that society
should promote health and provide health care serviceshave played prominently in
health system development (Waitzkin, et al. 2001). Because of this, Latin American
countries historically have placed high priority on social welfare programs, particularly
education and health, and these programs have often focused on the poor. These nations
have seen remarkable improvements in health indicators over time, with the average life
expectancy for Latin America and the Caribbean increasing from 57 years in 1960 to 70
years in the year 2000. Nonetheless, there remain significant intraregional differences in
health indicators and achievements. For example, in the year 2000, Costa Rica and Cuba
had the highest life expectancies in the region, at 78 and 77 years, respectively, while
Bolivia and Guyana had the lowest at 63 yearsa striking 15-year gap (Soares 2009).
Despite very different state orientations in Cuba and Costa Rica, both have been
lauded as examples within Latin America of the power of political will, over economic
wealth, and a message to the world that positive health indicators and developing
countries are not mutually exclusive (Morgan 1989). In Costa Rica, the shaping of health
care priorities was tied strongly to political rhetoric around its longstanding democratic
51


values, whereas in Cuba, it was tied to rhetoric around Communist values. The key
components of political will, described by Rosenfield (In Morgan 1989), are a historical
commitment to health as a social goal, a social welfare orientation to development,
widespread participation in the political process, equity, and inter-sectoral linkages for
health, which, combined, can overcome political, economic, or technical obstacles.
Discussion of political will was spurred by the Alma Ata Declaration of 1978,12 which
promoted political will as an essential element of primary health programs that
governments of less developed countries had a responsibility to provide for their
underserved populations.
Although a commitment to social medicine worked better in Costa Rica and Cuba
than in some other countries in Latin America, Morgan (1989) critiques the idea of
political will as diverting attention from global power relationships. Attributing health
care successes to political will puts attention on the nations themselves, instead of outside
global forces and international agencies that often shape health care policies. This, then,
shifts the blame for inequitable health care systems to a lack of national will, instead of on
inequitable global conditionsa blame the victim mentality. Indeed, the message of
state responsibility for health care put forth by Alma Ata became convoluted, with the
spread of neoliberal health reforms in the 1980s by international agencies (particularly the
International Monetary Fund and the World Bank). The impacts of these reforms in
shaping health care policies in Costa Rica will be discussed in Chapter Four.
12 The Alma Ata Declaration adopted the 1948 World Health Organization definition of health as
a state of complete physical, mental and social well-being and not merely the absence of disease
or infirmity, recognized the gross inequity in health status between the developed and
developing world, and set the goal of Health for All by the year 2000, which would be reached
through the development of participatory primary care initiatives by governments.
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In any event, historically, the nations of Latin America all adopted social medicine
to varying degrees, and though they had different visions for how health care would be
provided, they shared an underlying philosophy that health care would be provided to all
citizens, as a human right and a social good to which all citizens must have access.
Costa Rica as a Case Study
Costa Rica's successful socialized health care system makes it an interesting case
study for examining the interaction between medical tourism, a global private industry,
and local health care delivery, which is almost exclusively state-sponsored. Bordered by
the Pacific Ocean to the west and Caribbean Sea to the east, Costa Rica is about 19,700
square miles in size (it could fit inside of West Virginia) with a population of just over
4.5 million people. It is a standout in Central America, with very high education and
health indicators, and no standing military. It is one of the worlds longest standing
democracies and has one of the most successful universal health care systems in the
world, covering over 90 percent of its citizens. Tourism is the number one industry in
Costa Rica, and it is particularly known for ecotourism because of its progressive national
environmental policies and biodiversity. In recent years, Costa Rica has become a
popular medical tourist destination as well, attracting many Americans in search of high
quality, low cost health care.
Colonial History
Although Costa Rica certainly shares cultural and historical similarities with its
neighbors, it is also unique within Central America. Costa Ricans trace their democratic
roots to colonialism (Biesanz, et al. 1998). Though Costa Rica, like the rest of Central
America, was colonized by Spain, Spanish colonizers found a very different situation
53


when they arrived in 1502. Whereas other Central American nations had large indigenous
populations and a great deal of gold or silver to be exploited, Costa Rica did not. Thus it
became a lower priority colony to the Spanish, and was largely ignored by colonizers.
This lack of attention and interest seems to have had a profound effect on its course of
development.
Without human labor or mineral wealth to be exploited, very few Spanish settled
in Costa Rica. Those who did, having no indigenous labor to set up feudal colonies,
became subsistence farmers. Because there was no exploitation of local peoples, relations
between the Spanish farmers and the very small indigenous population were relatively
peaceful; there were no class divisions. This rural classless democracy is the
foundation of the country. From these small subsistence farmers rose the coffee elite,
who would form the first governmenta government that was egalitarian and
accommodating towards the indigenous population (Biesanz, et al. 1998).
This, anyway, is the highly romanticized, and often told, myth of Costa Rican
development. This idyllic picture of the colonial encounter has been all but debunked
though it is true that the violence between settlers and the indigenous in Costa Rica
occurred to a much lesser degree than in other Central American nations with high
indigenous populations. In neighboring nations, ethnic and class conflict played an
enormous role in national development, which was marred by extensive periods of
violence. In Costa Rica, the democratic origin of the nation was interrupted only a brief
period of violencethe 44-day civil war of 1948, which ended in the 1949 abolition of
the military. During the war, the United States supported the social democratic Partido
Liberation National (PLN, or National Liberation Party), opening the door to U.S.
54


intervention in Costa Rica. While the U.S. has a long history of intervention in Costa
Rica, it pales in comparison to the rest of Central America, which experienced far more
invasive U.S. action through the 1980s. Most notably, the United States led political and
military counter-insurgencies in El Salvador, Guatemala, Nicaragua, Panama and
Honduras, which left hundreds of thousands dead (e.g., Manz 2004; Robinson 2003).
American imperial intervention in the region began in the 19th century, and continued
through the 1980s, with many detrimental consequences. In many ways, this imperialism
defined the development of the region. The contemporary expansion of industry into the
Central American region is, in many ways, a manifestation of this legacy.
The colonial history of Costa Rica has impacted the way that Costa Ricans
imagine themselves. The comparative lack of ethnic conflict in Costa Rica allowed the
nation to develop in what they consider a very European way. Today, less than one
percent of the Costa Rican population is indigenous, compared to 30 percent in Mexico
and 40 percent in Guatemala. Costa Ricans think of themselves as both whiter and
smarter than other Central Americans because of their (supposedly) pure European
ancestry and adoption of European education systems. Biesanz et al. (1998) calls this the
Costa Rican leyenda blanca (white legend).
The egalitarian myth of national development also remains prominent in the
national identity of Costa Rica, and it is considered to have been the impetus for the
natural emergence of democracy and peace in Costa Rica. Costa Rica is often referred
to as the Switzerland of Central America, because of its global neutrality and lack of
military. These unifying myths, as well as its standout accomplishments as compared to
the rest of Latin America, contribute to the notion of Costa Rican exceptionalism that
55


Costa Ricans are whiter, smarter, more peaceful, democratic, and egalitarian than their
neighbors (Robinson 2003). These idyllic images have been appropriated globally,
contributing to Costa Ricas development as a tourism destination generally, and, more
specifically, a popular ecotourism and medical tourism destination.
Health System Successes
This legacy contributed to the successful development of the Costa Rican welfare
state, and particularly its universal public health system. Although its national gross
domestic product (GDP) is far eclipsed by the industrialized nations of the world, Costa
Rica's health indices are the best in Latin America, with the exception of Cuba, and rival
those in many of the world's most developed nations. These outcomes are the result of a
well-developed, publicly funded, comprehensive health care system built on principles of
solidarity, universality, and equity. This Central American success story has often been
lauded as a potential role model for other developing nations seeking to achieve health
without wealth (Morgan 1987; Morgan 1989).
The countrys per capita income is one fourth that of the United States, and
approximately the same as that of Mexico; however, Costa Rica's health and equity
indicators are more comparable to the United States' and well above Mexico's (Unger, et
al. 2007). In 2009, Costa Rica spent 10.5 percent of its GDP on health care and was
ranked 36th in the World Health Organizations rankings of health systems, while the
United States spent 16.2 percent and was ranked 37th (World Health Organization 2000).
Costa Ricans are deservedly proud of their health care system, and it is a prominent part of
national identity. Those who I spoke with did not hesitate to tell me that the health
indicators in Costa Rica are better than those in the United States. One physician beamed,
56


Did you know that we are ranked better than the United States for our
national health system? Yes, we are number 36 in the world, and the
United States is number 37. And we are the size of state... no, maybe
one county in the States. Costa Rica is Costa Rica thanks to its national
health system.... Without any doubt it is the best thing that we have in
Costa Rica. We have some problems, like any country hasdeveloped
or developingwhen you talk about public health...but generally
speaking, we are really lucky to be in this country. (16)13
There is particular pride in being considered more successful than the U.S. health
system, which is viewed as unfair and inequitable because of its orientation to
approaching health care as a business rather than a social responsibility. I spoke with a
retired physician from the public health system who told me,
The public system in Costa Ricawhat it does is it protects the
population. And if there is profit in public programs, they are
reinvested for more public benefit. However in the private sector, the
benefit goes to shareholdersto distributing dividends. There is not
much reinvestment, and any reinvestment that there is goes to
increasing profits, so the gain is not for the majority, but for the
owners of the private service. In the United States, this is very clear. In
the United States, 25% of the population does not have medical
coverage of any kind because they do not have health insurance.
[Shakes his head, pauses for a moment then smiles]... There is this
program on the television called Emergency Room or something
like that. That program is such a fraud! Because there they are [U.S.
doctors] running around with the patient, shouting that they are going
to do a scan, give him a transfusion, and whatever else. None of that is
going to happen if the companion [who came in with the patient] cant
demonstrate that he has health insurance. If he does not have
insurance, they take him out through the back door without doing
anything at all to him! (8)
The U.S. health care system was often criticized by participants as having a great
deal more money than the Costa Rican system and yet still failing to provide care to its
citizens. This failure is, after all, the reason why medical tourists come to Costa Rica in
13 Participants in the study are anonymous, but I assigned participant numbers for reference.
Throughout the dissertation, when I directly quote a participant, I reference their participant
number in parenthesis after the quote. A list of general individual characteristics can be found in
Appendix C.
57


the first place. The blame for the shortcomings of the U.S. system was placed most often
on its neoliberal principles that viewed health as a commodity rather than a right. In Costa
Rica, it is implied that they have the right idea about health care, since they have been
able to achieve such successes spending roughly one-fourth less per capita than in the
United States. Ironically, in March of 2010, even conservative talk show host Rush
Limbaugh famously said that he would go to Costa Rica for his health care if the proposed
reforms to the U.S. health care system passedan odd choice for someone so fervently
against universal health care (Long 2010b). In Costa Rica, everyoneeven resident
foreignersis required to pay into the government-run health system, whether they use it
or not.
Table 3: Health and Equity Indicators for Costa Rica, the United States, and Mexico.
(Unger, et al. 2007)
Costa Rica United States Mexico
GDP per capita (a) Health expenditure $9,460 34,320 8,430
per capita, $ 562 4,887 544
Infant mortality (b) 9 7 24
Life expectancy at birth (c) 78.0 77.0 73.3
Gini index (d) 46.5 40.8 54.6
Note. GDP = gross domestic product.
All data are for 2001 with the exception of the Gini index, which reflects 2000 figures.
Data were derived from the United Nations Development Programme.
(a) Purchasing power parity.
(b) Probability of dying between birth and exactly 1 year of age, expressed per 1000 live births.
(c) Number of years a newborn infant would live if prevailing patterns of age-specific mortality at
the time of the infants birth were to stay the same throughout his or her life.
(d) Measurement of inequality in the distribution of income or consumption within a country on a
scale of 1-100.14
14 These figures are from 2000, but I mention in a later chapter that Costa Ricas Gini index has
risen to 50.31.
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History and Development of the Health System
Costa Rica developed its public health system gradually. Before 1941, the Costa
Rican system was disjointed, made up of private or charitable medical care without central
organization. In 1941, President Rafael Angel Calderon Guardia created Costa Ricas
Social Security Administration (Caja Costarricense de Seguro Social, or the CCSS),
popularly referred to as La Caja.15 The Caja began as a system for wage earners that
gradually expanded to cover to the rest of the population over the next 50 years. At the
time, there was extraordinarily strong opposition to the formation of a social insurance
system. The majority of the nations physicians, as well as the Union Medica Nacional
(National Medical Union)the first union of its kind within Latin Americaadamantly
opposed a social security system because of the impact that it would have on private
medical practice. In fact, union statutes stated that its primary function would be to oppose
the development of a social insurance system.
However, Calderon Guardia and his followers enjoyed a great deal of political
power at the time, and when the social security system gained support from both the
Catholic Church and the Communist Party, it eventually won out. The leader of the
Catholic Church in Costa Rica at this time was Monsignor Sanabria, whose education in
Europe had convinced him that the Church had a social function in worker employer
relations. The Communist Party, established in Costa Rica in 1934, held as one of their
main tenets that social insurances to protect health must exist. Although the Catholic
Church and Communist party were not aligned ideologically, they both believed strongly
15 Throughout the dissertation I refer to the CCSS by its popular name, the Caja, which literally
translates to the box. Costa Ricans and the popular press refer to the CCSS as the Caja and all
of my participants referred to it in this way.
59


in the labor movement, and were willing to briefly join forces to ensure that it succeeded
(Cruz 1992).
It is important to note that the development of the public social security system
was tightly linked to increasing work productivity and economic development, as it
originally covered the productive workforce only. In fact, the private health care system
that preceded the Caja is often said to have been influenced by the United Fruit
Companys (UFC) presence in Central America and their desire to both civilize their
native employees and keep them healthy to protect the companys productivity (Aliano
2007).16 The UFC, a U.S.-based company that established banana republics in Central
America to sell fruit to the United States and Europe, is often called the archetypal multi-
national corporation. It was known throughout the region for its imperial practices, worker
exploitation, and poor working conditions. The legacy of the UFCs presence can still be
seen today in Costa Ricas two major exportswhile coffee is viewed as the darling of
the nation and part of the egalitarian and organic roots of the nation, bananas are often
vilified as representative of imperialism and outside influence.
In 1949, after the brief civil war, Costa Rica ratified a constitution that abolished
the national army, enabling funding to flow toward social programs such as education and
health. With these new social investments, steady health sector improvement continued,
and in 1973, the General Health Law placed all health treatment services, including
primary care facilities and hospitals, under the control of the Caja. This legislation also set
16 The United Fruit Company (UFC) was also complicit in the Guatemalan civil war when heads
of the UFC, who had underreported their land-holdings to the Guatemalan government, feared
that the newly elected Guatemalan president, Jacobo Arbenz, was going to redistribute their land
to the poor. UFC accused Arbenz of being a communist and, in response, the CIA engineered a
coup of the Arbenz government. A 36-year civil war resulted, which left 200,000 dead, mostly
indigenous people, ft was declared a genocide by the U.N. (Manz 2004, Robinson 2003).
60


provisions for the continued expansion of the Caja until it eventually became a universal
health insurance system. In Costa Rica, the right to health is written into the constitution,
and the country has authorities both inside and outside the health sector to oversee and
safeguard this right: the Sala Constitutional de la Corte Suprema de Justicia
(Constitutional Chamber of the Supreme Court, popularly referred to as the Sala IV), an
ombudsmens office called Defensorla de los Habitantes (the Peoples Defender) which
exercises oversight on the timeliness and quality of health care, and the Ministerio de
Salud (Ministry of Health) which oversees the rights and duties of health system users,
both public and private.
Within Costa Rica, and globally, this era from the 1930s to the 1970s is seen as a
golden age of social programs and welfare states, in which stable development and
economic growth allowed for the expansion of social policies and a greater role of the
state in promoting these social rights (Waitzkin, et al. 2001). It was during this time that
the institutionalization of medical practice in Costa Rica began, when the countrys first
medical school became linked to the Caja, and newly-graduated physicians began entering
the health system through the social security system. This joining of education and health
care further entrenched the nation within a framework of social medicine.
In Costa Rica, the social security system was widely embraced as a project of
nation-building, modernization and social equalization (Ackerman 2009) and the
production of physicians, patients, and healthy citizens all became the business of the
state. The nation embraced the path to modernization through biomedicine, and the health
of citizensmediated through access to biomedical servicesbecame linked to the social,
political and economic well-being of the nation. Individual health became symbolic to the
61


health of the nation, or to the body politic (Scheper-Hughes and Lock 1987). Under this
system, physicians became the most important civil servants in the nation, and held a
prominent symbolic role in national identity (Palmer 2003). The development of the social
security system in Costa Rica not only came to define what it meant to be Costa Rican,
but also institutionalized the states role in the everyday lives of its citizens.
Medical Education and the Institutionalization of Medical Practice
As mentioned in Chapter One, a major concern about the effects of medical
tourism in destination countries has to do with the management of human resources, and
the potential brain drain of health care personnel from public to private care within
these countries. In Costa Rica this is of particular concern, as health care is not only
provided almost exclusively through the public sector, but medical education and training
of physicians are subsidized through the public sector as well. Public universities,
particularly the University of Costa Rica (UCR), are inextricably linked to the Caja. The
institutionalization of medical practice within the public sector makes the following
discussion of medical tourism more complicated, as it is nearly impossible to think of the
nations physicians, including those who treat medical tourists, as separate from the public
system that formed them.
According to the Costa Rican constitution, primary education is compulsory. By
law, public expenditure on education, including higher education, must be at or above 16
percent of the annual gross domestic product. Although not the case for primary and
secondary schools, public universities in Costa Rica are considered of much higher quality
than private universities, and private universities in Costa Rica are often dismissed as
second rate. A recent study by CONARE (a consortium of the countrys public
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universities) showed that 85 percent of final year high school students want to pursue a
degree at a public university (Long 2010a). Costa Rica currently has five public
universitiesthe oldest, largest and most prestigious being the UCR. Approximately
39,000 students attend the UCR, which is located in San Pedro, just outside of San Joses
city center. Admission is very selective; applicants must take a test for entry and have
good high school grades. In 2009, of the 31,042 students that completed the admission
test, only 16,593 scored highly enough to be admitted to the university. Even then, this
does not ensure that they will be admitted to their chosen department or major. In 2007,
60 percent of admitted students were accepted into their desired major (University of
Costa Rica 2012). Once students are accepted into the UCR, their education is highly
subsidized, and even those students who do pay tuition (many do not) pay negligible
tuition fees of roughly $80-$250 per semester. In contrast, private universities have no
such admission requirements and essentially accept any student who can pay the tuition,
which might cost up anywhere from $500 to $4,000 per semester, depending on the
degree program and the university (Long 2010a).
A Ministry of Health Official whom I spoke with, said, The UCR has prestige
equal to that of the Caja; nobody can take it away from Costa Rica (12). The UCR is
internationally recognized for its high quality of education and is considered the most
important research university in Central America. Many of the nations past and current
leaders attended the UCR. It defines itself as a highly democratic, humanistic institution in
contrast to technocratic government that ignores citizens. Community participation is
expected of students, and forms of social commentary including protests and social
movements are accepted, and even encouraged, by the university and its faculty.
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In April of 2010,1 co-presented a paper at the UCR with Karina. The conference
was called Nuevas Voces en Ciencias Socialies (New Voices in the Social Sciences) and it
took place in the Institute de Investigaciones Sociales (Institute for Social Research), an
institute formed to voice critical perspectives within the fields of the social sciences. The
conference was entirely student-organized and lasted two days. I was feeling particularly
frustrated with the way that the fieldwork had been going at this time; just the week before
I had been told that my work was too political and started negotiations with the Caja to
endorse my project, and, more generally, I was becoming discouraged with my interviews
in the private sector, where I was hearing the spiel a little too frequently. In my field
notes that week, I wrote:
The conference took place in a small, very basic classroom in the Institute.
It is stark white, outfitted only with orderly rows of wooden tables and
some chairs. There are outdated posters on the wall, tearing at the corners.
About 30 or so people are present for the opening of the conference, even
though it is only 8 am. Though it is early, it is already hot and humid. The
windows are open, and the waking sounds of university life can be heard.
As the day goes on, yells from a nearby soccer game float in through the
open windows and snippets of passerby conversations are heard.
Occasionally, it rains, hard. The microphones go in and out during the
presentations but no one seems to mind. They are fully engaged, and the
atmosphere feels informal, but important.
It is a relief for me to be here. After spending so much time among
those with high stakes in the medical tourism industry, who tout its praises
without forethought or without concern, I feel at home in this university
environment. People are interested in what we have to say, and have
thoughtful comments. In our discussion after the presentation, we find that
many are critical of medical tourism, and a few are even enraged at the
practice. They are concerned, as I am, about the consequences of medical
tourism for Costa Rica. There is a sense of solidarity here in this room,
about what it means to be Costa Rican.
-Excerpt from Field Notes April 27, 2010
There is a strong spirit of social activism at the UCR; I witnessed many instances
of this, including public marches for or against presidential candidates during the February
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2010 election, performances and documentaries produced by students and faculty, and
protests over social and political issues. I arrived at the campus one day to conduct an
interview only to find that the university had been shut down without notice, so that
students and university employees could have the opportunity to protest the governments
proposed financial commitment to the Special Fund for Higher Education (FEES), which
was to be cut, and demand an increase in education funding.
Medical Schools
The number of medical schools has grown significantly in recent years; there are
now eight in the country. Like universities in general, there are both public and private
medical schools in Costa Rica, but the public ones are known as being much better in
every field. The UCR has the most respected medical school in the nation, and likely in
Central America.
The UCR was created in 1940, alongside the Caja, during the reformist
administration of President Rafael Angel Calderon Guardia and it grew in tandem with the
Caja. Like the Caja, it is considered a foundational institution and plays a prominent role
in Costa Rican national identity. A retired physician and professor who was instrumental
in the development of both the Caja and the UCR had this to say about the intertwined
history of these institutions:
It was a parallel development. We organized and opened the
medical school because there was no medical school in the country
and it was absurd to think that we could have a national health
system if we did not have a factory to create the workers for the
systemthe doctors. So, parallel to the political project, I
developed the academic project... organizing the commission to
open the medical school, developing the first courses and I was one
of the first university professors that the medical school had in the
country. (8)
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The special relationship that the UCR shares with the Caja is often criticized by
other universities, particularly private ones, who feel that the preferential treatment given
to UCR students puts their own students at a disadvantage in receiving medical training,
and in finding work post-graduation. Despite this criticism, however, receiving a
residency position has become more political over the years, and private university
students are now able to get positions based on money or personal connections more often
than in the past. UCR medical students and residents whom I interviewed felt that this was
unfair, and that they were much better prepared to become a physician than their peers
from private universities whom they sometimes had residencies alongside. The tension
between public and private institutions has been increasing as the private sector begins to
take a more prominent position in Costa Rican society, a topic that will be explored
further in the next chapter.
Medical Residencies
By virtue of graduating with a medical degree from an undergraduate university,
which typically takes four to five years, graduates become general physicians. Only those
who continue on to become specialists receive residency training in Costa Rica, and only
the Caja provides this training. The time of residency varies depending on the specialty; a
residency in pediatrics is four years, while a residency in neurology takes ten. During the
residency period, residents work as a general doctor and are paid as one (about 2-3 million
colones, or $4,000-$6,000 per year), but complete shifts within their specialty, which
supplements this base income substantially. Upon completion of the residency, specialists
receive placements within Caja facilities, their salary increases, and they are expected to
work fewer shifts.
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Because there are a limited number of residency slots open in the Caja, getting a
residency is not only somewhat political, but it is very competitive as well. About 450
medical students each year graduate from all 8 medical schools in the country, with about
80 of those coming from the UCR. Of 1,300 graduates who would like to pursue
specialties, about 250 pass the first test to become a specialist. Those who pass then have
to take a second test for the particular specialty they wish to apply for. Most physicians
whom I spoke with had taken the specialist test more than once. In the neurosurgery
specialty, which is considered one of the most difficult, there were four openings in 2009.
Only three physicians took the test, and none passed. In this case, the four positions were
not filled and remained open for the next year. Furthermore, even if the applicants do pass
the extremely difficult examinations, they are not guaranteed a residency. The number of
spots available depends the number of residents needed within that particular specialty, a
figure that is calculated by CENDEISSS (Centro de Desarrollo Estrategico e Information
en Salud y Seguridad Social, or the Center for Strategic Development and Information in
Health and Social Security). So, there might be ten spots open in a particular specialty and
twenty applicants who have passed the two tests, in which case only the top ten will get a
residency position. Within general surgery, 100-150 people sometimes compete for 4-6
spots. It is not unheard of for some physicians to apply up to 20 times without getting a
residency.
Those who cannot get a residency position must choose to either keep applying
(possibly in a different specialty), work as a general physician, or change careers
altogether. Some who cannot obtain a residency move to the private sector and open
medical offices there. The problem with this is that, up until recent years, patient volume
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in the private sector has been so low that it is difficult for an unspecialized physician to
make a living solely with a private practice. However, political changes and the promotion
of medical tourism have opened more opportunities for physicians in the private sector.
Some of these unspecialized physicians advertise themselves to medical tourists as being
able to perform procedures at a lower cost, even though they might not be licensed in the
area of specialty. Specialists who work in more legitimate medical tourism facilities
caution against using these physicians, who can tarnish the reputation of the industry, and
are a danger to patientsthey are peligroso bruto (a dangerous brute), according to one
participant (28).
In sum, the medical residency within the Caja is extremely important because it is
the only place where the nations specialists are trained. The special relationship between
the UCR and the Caja continues during the residency period, as almost all medical
residents are concurrently UCR students and Caja employees, where they not only earn a
salary, but also begin to accrue seniority, and receive all the bonuses, incentives, and
benefits of other Caja employees. Once employed by the Caja, health care personnel
move up the ranks based on their years of experience working in the public system. They
are able to accrue higher salaries and more employment benefits as tenure continues. A
career within the Caja is considered to be very stable; it is nearly impossible to get fired.
Some criticize this tenure system, however, as being poor incentive to increase work
performance (a topic that comes up again in later discussion of neoliberal actors).
Quality of Care in the Caja
The Caja subsidizes medical education and trains the nations physicians with the
expectation that they will remain in the public sector serving Costa Ricans. After
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residency training is complete, physicians typically do remain in the Caja because it is
where they gain experience. The sheer number of patients and pathologies within the
public sector allows physicians to gain skills very quickly. The medical director of a
private hospital, who had worked in the Caja earlier in his career, said:
If you did not work in the Caja you do not have experience. Because the
patient volume that you see in the private sector is very little compared to
the volume which you see in the public sector, and the majority of rare
diseases or complicated diseases you do not see it here [in the private
sector.] The private hospitals are light hospitals, as we would say. They
are hospitals that do liposuction, remove a vein, operate on a knee... but
when a piece of the colon has to be removed, a very big tumor, etc.,
everything like that is in the Caja. So if you have not worked in the Caja,
what experience are you going to have? (12)
The Caja provides excellent training for physicians, and almost all of the nations
physicians work, or have worked, in the public sector. Despite my sampling method of
locating Caja physicians within their private practices, discussed in the Introduction, only
one physician that I interviewed had never practiced in the Caja at all (in this particular
case, he decided to go back to medical school later in his life and was happy with a small
practice as a general physician in the private sector.)
Partly due to the rigorous training and vast experience that physicians gain in the
public system, both patients and health care personnel consider the Caja to provide
extremely high quality health care. The Caja is where patients go for complex, chronic, or
emergency medical services, not only because they do not have to pay (beyond their
wage contributions), but because the public system is considered the best equipped to
handle these problems. The one physician I interviewed who had not worked in the Caja
at all said,
In the Caja, those are people who have been trained in the public system
and the system has paid for them to be trained. These people are the best
69


of the best that we have in the country. They have gained their experience
in the public sector. Its not the same thing if you do an open-heart surgery
in the private sector, where you do one a year. You do one a day in the
Caja. So you become really, really good. (34)
The great majority of Costa Rican physicians and patients work in, and use the
Caja, but it has been faced a number of challenges in recent years, which will be the topic
of the next chapter. These are not around its technical capabilities, but rather its
administration, wait times, and high volumes of patients, which leave little time for
physicians to spend with each patient. These constraints have led a growing number of
physicians and patients to migrate to the private sector. Although it is rare for a physician
to forego training in the Caja altogether, it becoming more and more common as a career
trajectory for a physician to work for a number of years in the Caja, gaining experience
and expertise, and then move to a private sector practice after they have gained enough
experience and established a client base.
Solidarity as Ideology: Principles of the Caja
Despite its restrictions, Costa Ricans love the Caja, consider it to be of high
quality, and are deservedly proud of its achievements. Participants across this research
uniformly praised the Cajas founding social principles and the underlying belief of the
health systemthat health is a rightis not questioned. When asked what the best things
about the Costa Rican health care system are, almost all participants referenced its social
principles:
At the Caja, it doesnt matter if you are the President, if you are a
homeless person. If they need to do a surgery, theyll use everything.
They wont say, oh no, he doesnt have money... no, no. Well do the
surgery. People do not die in the Caja because they dont have
insurance. Thats the thing I love. (38)
In addition to belief in health care as a right, not one person I spoke with
70


complained about the fact that wealthier Costa Ricans subsidize health care for the poor.
The motto of the Hospital San Juan de Dios, one of the most beloved Caja institutions in
the country is el bien que le haceis a los pobres lo haceis a vosotros mismos (the good
that you do for the poor is good that you do for yourself). Some proudly referred to the
Caja as a Robin Hood system, saying:
The focus of health should always be directed to equity, solidarity,
universality, and the focus should be on attending to the person who
needs it the most and who has fewer resources. Because we have seen
that economic issues are related to healththe less I have, the more
probability I have of getting sick. So there will be many more problems
in the larger population when we dont take care of the poor. The health
system cant favor, or lean towards, the elite population. It should work
in favor of the simpler population that is in need of services. Those for
me are the principles that should always govern us. (22)
The Caja is hailed as the great success of Costa Rica. I heard it called the pillar of
the nation, and the mother of Costa Rica, and credited with keeping the social peace,
and, preventing war. A Caja administrator said about the Caja,
This institution makes the difference between us and other countries in
Latin America. It gives peace to the country. The wars in other
countriesguerilla warsare because of their social circumstances...
they fight because they dont have health, because they dont have
education. Someone told me that Guatemala spends 30 percent of their
PIB [GDP]30 percent of the income of the countryfor the army. Why
do you do that? In Costa Rica we spend the 7 percent on health. To give
health to the people; and we dont have war. (45)
Although many had complaints about the deterioration of the social system,
citizens still have great confidence in the Caja. A 2004 poll conducted by the UCR asked
Costa Ricans about their pride and confidence in state institutions and national values.
Those polled said they had more confidence in the Caja than in the justice system, the
police, the national government, or the Catholic church (Ackerman 2009). The
achievements of the social security system play a prominent role in the story of Costa
71


Rican exceptionalism. It is an enormous part of Costa Rican national identity and what it
means to be Costa Rican.
Today, the Caja continues to dominate health insurance, employment, and health
care provision, operating 29 hospitals (compared to 6 hospitals in the private sector) and
940 primary health care teams called EBAIS (Equipos Basicos de Atencion Integral de
Salud)an extensive network of clinics located throughout the country. It has more than
48,000 employees, including the large majority of the nations physicians (CCSS 2010).
Funding for the system comes from mandatory taxation on wages from employers
(9.25%), employees (5.5%) and the state (0.25%), and the Caja currently covers about 90
percent of the population (Muiser, et al. 2008).
The Costa Rican Image and the Medical Tourism Blueprint
Our education system, our health care systemthey give a certain
condition to the country. Sure, you can go somewhere else, to a
neighboring country and you can find some good surgeons, but they are
not surrounded by the correct system. So if you have unplanned
complications, heart problems, or something else, you benefit from the
[public] well-developed system of medicine around you. So I think our
system is what makes it a safe place for medical tourism. Its not just
about the nice buildings with a lot of luxury, and transportation and
hotels... the health system is what makes the difference. (15)
The above quote outlines what a plastic surgeon who frequently works with
medical tourists explained to me. It is the successes of the health system that have opened
the door for the development of medical tourism in Costa Rica. Costa Rica fits the
blueprint of the medical tourism industry quite well. It has high quality health care, a
skilled workforce, and a large English-speaking population. Since the 1970s, it has grown
into a very popular tourist destination, largely due to its image as peaceful, healthy, and
natural. It is home to one of five blue zones in the world, wherein people live
72


measurably longer lives, and was named the happiest place on earth in a New York
Times op-ed piece in 2010 (Kristof).
Costa Rica is particularly well known as an ecotourism destination due to
progressive environmental policies and its ownership of a disproportionate percentage of
the worlds biodiversity (five percent of the worlds animal and plant species are found in
Costa Rica). The national slogan for the Instituto Costariccense de Turismo, (ICT, or the
Costa Rican Tourism Board) is Sin ingredientes artificiales (No artificial ingredients) and
a more recent slogan focuses on medical tourism, Aqui se cura todo (Here we cure all).
These idyllic images of Costa Rica ignore much of the poverty, increasing violent crimes,
and unsanitary conditions that exist, but fit perfectly with the ideal archetype of a medical
tourist destination.
CosnteA Tct
Sin Inqredienles Artificiales
^Inicio Conozca ICT ^Enlaces ^Contactenos ^HTi j nh4BEIHKun^n£l
PWMB£fcT**-v**
Figure 8: Slogan of the Costa Rican Tourism Board: Aqui se cura todo (Here we cure
all). (Instituto Costariccense de Turismo 2011)
73


Figure 9: Idyllic images of Costa Rica: waterfalls, volcanoes and beaches
(Photos by author).
It is ironic that the Costa Rican system that invited medical tourism clashes so
dramatically with the neoliberal principles of medical tourism. A private hospital
administrator thought that the Caja helps to brand the country, making an analogy to
grocery shopping:
You are not going to go to a supermarket to buy meat if you know
beforehand that the meat that they sell in that Automercado [a national
supermarket chain] is a product of cattle that suffers from mad cow
disease. But when you have a country that shows good health indicators, a
well-maintained public hospital network, presents a well-defined face, or
brand, when it comes to health treatmentthen the public sector
complements the private sector in the sale of health services. It is not that
the public sector goes out to sell services and provides services to health
tourists themselves, but it is about the face that the Costa Rican state
presents and it is a face that complements the [medical tourism] activity
that is being developed. (18)
The face that Costa Rica presents to the world, and its exceptionalism within the
region, has helped it to become a very popular medical tourist destination, particularly for
Americans. However, the health system developments that have allowed Costa Rica to fit
the medical tourism blueprint, and emerge as a destination, have been achieved in a very
different way than the neoliberal model on which the medical tourism industry is
founded. The socialized health care system in Costa Rican system makes it a standout
74


compared to other medical tourism destinations, which might already be more oriented to
private health care provision, or that already have inequitable health care systems.
75


CHAPTER 4: PRIVATIZATION OF THE HEALTH CARE SYSTEM
Just as the Caja has contributed to the rise in medical tourism, the shift in national
priorities towards privatization and global economic development has meant a
contraction of the public system that, in many ways, is accountable for this global
recognition in the first place. In recent years, there have been significant internal and
external challenges to the hegemony of the public system, and private health care is on
the rise.
Demographic changes, misuse and corruption within the public system,
challenges in managing human resources, and financial burdensoften intensified by the
private health care sectorhave all contributed to internal strain on the health care
system and have affected the ability of the Caja to take care of its citizens. These
pressures, along with enhanced opportunities in the private sectorspurred by
privatization and medical tourismhave led physicians and other health care personnel
to seek employment outside of the Caja, exacerbating the difficulties of health care
provision through the public sector.
The Relationship between the Public and Private Health Care Sectors
Multiple times during the course of my research, I was asked why I should be so
concerned with the public health care system when I was studying medical tourism, which
is wholly in the private sector. I was told that there is no relationship between one and the
other; the public and private health care sectors function totally separately. When I asked a
medical student about whether medical tourism has any negative impacts for the Caja, he
responded sharply:
76


Private is private. If a tourist comes to have surgery here, it doesnt have to affect
a Costa Rican citizen. He is in a private hospital, he is paying for his surgery, it is
income for the doctors, it creates more jobs and that helps the growth of the
country. Besides, most of the surgeries are aesthetic, thats what I understand; so
public hospitals wont get involved in that anyway. It is just private. (37)
Though the relationship between the public and private health care sectors is not a
simple one, and may not be readily apparent, I argue in this chapter that this relationship
not only exists, but that the two sectors are intricately connected. The physicians and
personnel who practice in the public and private sectors are the same; the patients who
seek care in the public and private sectors are the same; sometimes even the equipment
and facilities used in each sector are the same. Since the inception of the Caja, the private
sectors survival has come to depend on its relationship to the public sector in varying
capacities over time. Their relationship is, at best, symbiotic, and, at worst, parasitic
with the private sector benefitting from its position as the Caja shoulders the burden of
providing health care to an increasing Costa Rican population with decreasing funds to do
so. Privatization in Costa Rica has been more passive than in other Latin American
countries (Clark 2010), but it has been occurring nonetheless.
The Role of the Private Sector in Health Care Provision
Contrary to the prominent place that state-sponsored medicine holds in Costa
Rican national identity, the role of the private sector in the national health care system has
been more limited, home grown, and pragmatic (Homedes and Ugalde 2002). This is
not to say that the private sector has not had a notable role in the health system
historically. There have been several attempts to promote mixed-medicine models, which
have been entangled with the Cajas development. The overt justification for these mixed-
medicine programs is to relieve strain on the public system and reduce waitlist times for
77


patients, though this rationale has been questioned by critics of privatization, suggesting
that the true intent is more politically and economically driven (Salas 2009). In particular,
pressures by international agencies such as IMF and World Bank, and the inclination of
Oscar Arias government17 towards privatization, are cited as some of the actual reasons
behind increased privatization within the health care arena.
The first of these mixed medicine models occurred in the 1970s when the Caja
piloted a medicina de empresa program (company doctor program), under which
companies agreed to pay the salary of a Caja physician and provide office space, while the
Caja provided all necessary testing and medications. Though still used on a small scale
today, the programs impact has been limited. Then, in the late 1970s, the Caja piloted
another mixed medicine model wherein patients insured by the Caja paid out of pocket to
go see a private sector physician, with the Caja providing any necessary tests or
medications. This program is also still used to a limited degree today, but it never really
took hold because it both offends a strong anti-privatization current within the Caja and,
because it is based on fee-for-service payments, is too expensive to expand (Clark 2010).
A more successful venture occurred in 1988, when the executive president of the
Caja, Dr. Guido Miranda, under pressure by President Arias, piloted a cooperative model
of health care. It was imperative to Dr. Miranda that the Caja not be privatized and that it
maintain control over the cooperative. He successfully set up the first health care
cooperative in the San Jose suburb of Pavas, called Coopesalud, which was publicly
17 Oscar Arias was the president of Costa Rica from 1986 1990, and, after a Costa Rican law
changed concerning re-election, again from 2006 2010. He won the Nobel Peace Prize in 1987
for promoting peace within Central America, which was steeped in warfare at the time. He called
for more integration in the region and proposed a Central American Parliament during his first
administration. During his second, however, he declared that Costa Rica would not join this
Parliament. He is regarded as a neoliberal, though he belongs to the social democratic party, PLN.
78


funded and privately managed. This model was deemed a success, and the Caja continued
expanding it until the existing six cooperatives were operating in Costa Rica. Four are true
cooperatives, one is operated by the UCR Medical School, and one is run by a for-profit
doctors group called Asociacion de ServiciosMedicos Costariccenses (ASEMECO,
Association for Costa Rican Medical Services), which owns one of the big three private
hospitals, Clinica Biblica.
The cooperatives are all located in populous suburbs of San Jose and serve
upwards of half a million users (Diaz 2009). Though obligated by the Caja to provide a
package of essential services to the population, they are otherwise free from public laws
regarding health care purchasing and management. There is debate about whether or not
the cooperatives are more efficient than Caja facilities, and many have claimed that they
actually are more expensive to operate than other public facilities. When this issue came
to light a few years ago, cooperatives became obligated to undergo a public bidding
process in order to gain the Cajas business. Reports suggest not only that the cooperative
model is less efficient than the Caja, but that they refer patients to Caja facilities more
than is necessary, creating an undue strain on public facilities (Homedes and Ugalde
2005).
In the early 1990s, another mixed medicine model, the free choice medical
program, was established allowing users to seek care from a private physician of their
choosing (within the Caja, patients cannot choose their physicians) with economic
assistance from the Caja. The public sector also began contracting out complex diagnostic
testing to Clinica Biblica, with the official reason of avoiding technological risk. This
contract has been critiqued as a result of political pressure to create a space for private
79


medicine within the country and for personal financial gain (Salas 2009). The contract
became, in a matter of years, a purchase of millions of dollars on medical equipment that
benefitted the private sector. The Clinica Biblica director told me in an interview that over
20 percent of his hospitals sales are currently to the Caja (8).
There are many suspicions about the nature of these public-private relationships,
and the way that private sector entities like ASEMECO, and Clinica Biblica win these
bids. This became national news when Rafael Angel Calderon Fournier, ex-President and,
ironically, son of the Cajas founder, was convicted in 2004 for his involvement in the
largest corruption scandal in the Cajas history. He awarded a multi-million dollar Caja
contract to a private pharmacy chain, the Fischel Corporation, then dispersed nearly $8
million in payoffs to highly ranked Caja officials (Arbol 2009). This notorious Caja
scandal is fresh in the national memory, and it has caused other doubts around who wins
private sector bids for Caja contracts.
It is apparent that, in spite of the national orientation to public health care in Costa
Rica, the private sector has always intervened to some degree in the management and
provision of health care, and several policy decisions have allowed for greater private
participation over time. In reality, the private sector is sustained by the Caja and public
sector contracts to provide services to Caja users. This is an important point to keep in
mind as we further discuss Costa Ricas shift toward passive privatization, the burden that
private medicine creates for the social security system, and how medical tourism impacts
the public sector. The public-private relationship in Costa Rica is complex, but the two
sectors are undeniably connected.
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The Private Sector Today
As compared to the 29 Caja hospitals in Costa Rica, there are only 6 private
hospitals, the newest of which, Hospital Metropolitano, opened in late 2011. The big
three hospitals where I conducted fieldwork Hospital Clinica Biblica, CIMA, and
Hospital Hotel La Catolica, are popular among American expatriates and medical tourists,
and all three have gained JCI accreditation since 2006. CIMA (highlighted in the field note
excerpt that began this dissertation) opened in 2000 and advertises itself as ultramodern
and designed and organized for Americans, with foreigners comprising over 25 percent
of its patients (CIMA Hospital 2012).
Two more private hospitals are slated to open by 2013 in the San Jose
metropolitan area (Arce 201 la), as well as two satellite hospitals of Cltnica Btblica and
CIMA in the Guanacaste area, the most popular tourist area in the country. If these
openings go as planned, the number of private hospitals in the country will have doubled
since 2011, a shockingly fast growth for such a small country. This does not include
smaller clinics, which have been on the rise as well.
Despite this unprecedented private sector growth, the Caja covers over 90 percent
of Costa Ricans, and those who are not covered (mostly those who work in the informal
economy, the self-employed, or undocumented immigrants) are still eligible to use its
services even though they do not pay into the system.
Most locals who access private facilities do so as a limited health care strategy.
The low number of private sector users is primarily cost-related, but the Caja is also
widely acknowledged as providing the best care available for illnesses and injuries
because it will perform every test required and take all necessary medical measures to
treat patients, regardless of the cost. For the majority of Costa Ricans, the cost of private
81


care is too high and the private sector remains out of reach. However, long wait times in
the public sector have led patients with financial means to seek care in the private sector,
and studies have shown that up to 30 percent of the population now uses private health
care in some capacity (e.g., Connolly 2002; Herrero 2001; University of Costa Rica 2006).
Only upper class Costa Ricans and foreigners can afford to regularly receive their
health care within the private health care system, but middle class patients use the private
sector in a limited capacityfor example, they might get diagnosed within the private
sector to avoid a long wait time in a public facility, but upon diagnosis, return to the Caja
for treatment and medicines, especially for complicated or expensive care. This results not
only in double expenditures for Costa Rican families (who pay for the Caja from their
wages, and out of pocket for care in the private sector), but also in a strain on the public
health care sector, which performs the most costly procedures.
Internal Pressures on the Costa Rican Health Care System
Demographic Changes in Costa Rica
There are demographic changes occurring in Costa Rica that contribute to a strain
on the Caja as well. The population has been growing at a steady rate, while, at the same
time, people are living longer. Life expectancy today is nearly 20 years longer than it was
in 1960 (Index Mundi 2009). This demographic shift towards an aged population
(common to developing and developed nations alike) means an increased demand for
health services related to treating chronic conditions, which are often the most expensive.
A growing immigrant population in Costa Rica, mostly Nicaraguans, has also
increased the costs of health care. According to the 2000 census, there were 226,374
Nicaraguans residing permanently in Costa Rica, nearly six percent of the total
82


population (Muiser, et al. 2008). This figure does not include short-term migrant workers
from Nicaragua, or those not captured by the census for lack of a fixed address.
Nicaraguan immigrants are perceived as a threat because they use the Caja without
paying into it. It has been found, despite these anti-immigrant sentiments, that immigrants
often do pay into the system more than popular opinion suggests (Tellez 2011), and that it
is often their employers who fail to pay into the system (Salas 2009). Immigrants tend to
work the lowest paying jobs within Costa Rica, as coffee pickers, banana plantation
workers, maids, or guards, and often there take place in the informal economy, or bosses
flatly refuse to pay the obligatory 9.25 percent contribution for their workers.
Intensifying violence and poverty within Costa Rica, as well as patterns of global
neoliberal consumption (such as an affinity for fast food) have also led to increasingly
expensive treatments within the Caja, as obesity, cardiovascular disease, cancers, and
other diseases of affluence have made their way to Costa Rica (Tellez 2011). Though
this consumption takes place in the private sector, the associated medical costs are
absorbed by the public sector. In lieu of preventive care, these problems have translated
to an increased emphasis on high-tech and intensive medical interventions, which are
very expensive for the Caja.
Threats to the Cajas Financial Stability
The Caja is facing serious problems of financial sustainability. All residents of
Costa Rica, regardless of their enrollment in the public system or immigration status, are
entitled to use Caja services, and anyone who enters a public facility for emergency
services will not be turned away, even if they lack the required insurance. The Caja also
offers several options for medical coverage. While salaried workers and their employers
83


pay a portion of their monthly wages into the Caja, if a household income depends on
that single worker, then the entire family receives insurance from these contributed fees.
Contract workers are free to enroll in the Caja, paying a monthly flat fee that varies
according to the workers income. The government pays for students and those living in
extreme poverty.
These enrollment options comply with universal health coverage under the
constitution, but make the system difficult to regulate, and it is quite easy to get around
paying the enrollment fees. The Caja has had difficulty collecting mandated fees,
particularly from the self-employed or those not employed in the legitimate economy,
and audits of the Caja collection system showed significant problems of contribution
evasion and delinquent payments. In 1998, it was estimated that about 30 percent of the
Cajas annual income was lost due to evasion, which does not take into account the
growing problem of late payments (Muiser, et al. 2008). A medical student told me,
They [the Caja] should make everybody pay, but they cannot. Before,
everybody paid into the Caja, so that made health care available for those
who couldnt pay for it. But now, a lot of people dodge the system and
dont pay the Caja. So the poor people who use the most resources cant
pay, and the wealthy people arent paying into the system either, and we
end up with a system that has no money and still has to cover a big part of
the population. (43)
In addition to many citizens not paying into the system at all, it is not uncommon
to find instances wherein someone will wait until they are diagnosed with a serious or
chronic illness and then enroll in the Caja to receive expensive treatments. The system is
structured in such a way that if a citizen begins paying for Caja insurance today, he or she
can begin receiving services tomorrow, regardless of health status or cost of the services.
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Patients and physicians alike occasionally find ways to manipulate the long
waitlists for procedures that impact the system. Patients might put themselves on more
than one waitlist for the same procedurewhich is possible because there is no
centralized tracking system to monitor the liststhus decreasing the efficiency of the
system.
Physicians, especially specialists, who manage their own patients waitlists,
sometimes abuse the system too. For example, they might take patients out of turn
because of personal relationships, or accept bribes, known as biombos (this literally
translates into a folding screen), in exchange for moving a patient to the top of the list.
Biombos occur across public and private sectors due to the fact that many physicians
work in both sectors. For instance, a physician in the private sphere might accept a
biombo from a private patient to push them to the top of the waitlist in a Caja facility. In
these cases, the patient benefits by not having to pay for expensive private services and
avoids the long wait times for treatment in the Caja, while the physician makes extra
money off the books. Occasionally, a reverse strategy might be used, wherein
physicians harvest the patients from the public sector, and bring them into their private
office where they can charge them (34). These tactics work because, as one economist I
interviewed pointed out, it is not only the doctors who move between sectors, but the
patients too:
As a physician, you are hired by the Caja, but at 3:00 when you finish
your day [in the public sector], you go across the street to your private
office. And your patients in one sphere could be the same patients as in the
other. And then...well only angels will keep good accounting of the
situation. (14)
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Caja physicians have occasionally been known to use another strategy to increase
their public salaries wherein they perform fewer surgeries during their scheduled 7am to
3pm work day and then schedule procedures after hours, during which time they receive
overtime pay.
Unnecessary Patient Referrals to the Caja
Within the Caja, access to the health care system should theoretically be through
the primary level of care; however, users of Caja services may, and often do, opt to go
straight to a Caja hospital rather than use a primary care facility first. In addition, the
EBAIS primary care clinics and the public-private cooperatives tend to refer patients to
Caja hospitals more than is necessary (i.e., when they could instead be treated on an
outpatient basis or within the clinic). This contributes to extremely high patient volumes
in the Caja hospitals. A private sector physician said,
Here, everybody tries to get to the hospitals. There are three Class A
hospitals, and in these hospitals, everybody comes in with just a cold...
the structurethe system of EBAIS that we have nowthat doesnt work.
All the doctors end up sending the patients to the hospitals. I mean they
dont have resources to work with at the EBAIS. The resources should be
with the EBAIS, in the primary care clinics. So they have everything they
need to solve problems. And the big hospitals should dedicate to more
serious illnesses. But thats not the way it works here. Here, if you are in
the emergency room at a hospital, youll see diarrhea, toothaches, colds,
everything. So the emergency rooms get saturated and then the hospital
collapses because it doesnt have the capacity. (33)
Often, the municipality pays for the provision of primary health care while the
state government pays for hospital care. There is a tendency among first level physicians
to unnecessarily refer patients to the second level of care to diminish their own workload
and reduce the expenditures of the municipal unit. More than 43 percent of the services
86


provided in the public health sector are hospital services, compared with 11.1 percent in
the private sector (Herrero 2001).
Evaluations of the public-private cooperatives have suggested that this model is
actually less efficient than the Caja, and more costly without evidence of improved
quality (Homedes and Ugalde 2005). The cooperatives receive a capitation payment from
the Caja for their services, but the Caja provides all necessary tests, specialty care,
hospitalization and medicines. Residents in the selected geographical areas join the
cooperatives at no cost, but continue to use the Caja for all non-primary health services
and emergencies. The evaluations also indicate that there are more referrals to public
hospitals, not because of medical need, but as a way to reduce the cooperatives
expenditures and physician workloads (Homedes and Ugalde 2005). This increases costs
and workloads of the Caja, and reduces the overall efficiency of the Costa Rican health
system. Surplus profits of these non-profit cooperatives are distributed mostly among
physicians and other staff members (Homedes and Ugalde 2005), rather than supporting
the Caja.
Private hospitals, too, often refer patients to the Caja for the most complicated or
critical surgeries. Private providers typically make these referrals because a patient can't
afford to pay for the treatment, the procedure is not considered profitable, or because they
want to avoid high death or complication rates that might put off the rich patients and
foreigners they are targeting for business.
Beyond these referrals, patients (even the wealthy) also just prefer to use the Caja
for chronic illness and for complicated procedures. A professor at UCR said,
Except for the waiting lists, public health care is good. It is even
sometimes better than private care. Its recognized across the continent,
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and the specialized care is fantastic. Even the rich people will stay with the
Caja because of that. You know, they might go to the private ambulatory
services for a delivery [birth] or a cesarean section, or something cheap,
like a small operationa knee thing or something that is not a huge
thingthey will do it in the private sector... but if they really have cancer
or something serious they go to the public sector, to the Caja. (22)
This means that the highest number of patients and the most expensive procedures
and treatments all remain within public hospitals, placing a heavy burden on the system.
As a result of all of these factors, revenues entering the Caja tend to be less than the
benefits paid out. This is a problem that has become more severe over the past decade. As
of February 2010, the Caja, had accrued an $82 million deficit (the annual budget totals
$1.8 billion) and owed $46 million in overdue payments to service providers and medical
equipment suppliers (Tellez 2011). Ironically, the central government itself is
consistently in arrears on the quotas that it owes to the Caja (0.25 percent of salary per
worker plus 9.25 percent for its own employees) and, in 2011, it owed the Caja $220
million (Tellez 2011).
National Management of Human Resources
The management of human resources has also been a challenge for the Caja in
recent years. In 2004, to address the mismatch between the high numbers of graduating
physicians and the low number of residency spots, the government signed an agreement
to gradually double the number of residency spots, increasing available positions by 50
per year from 350 in 2004 to 700 in 2007 (Clark 2010), which remains the current
number. This occurred under the Arias administration, which, like the current
administration, is known for an inclination towards privatization and promoting global
industry. This agreement was intended not only to better fill the needs of the Caja, but
also to produce physicians for the private sector to bolster its capacity. Despite this
88


relatively sharp increase in positions, medical students and residents with whom I spoke
still criticized the Cajas long-term management of residencies, saying that it often goes
to extremes, with Caja opening several positions at once when they see a need in a
particular specialty, and then not opening any at all the next year (43).
The difficulty in getting a residency and dearth of available positions is
paradoxical because within particular specialty areas there are extreme shortages within
the Caja. One explanation for this could found in the example mentioned in the previous
chapter, wherein four neurosurgery positions were not filled because no one passed both
tests to become a neurosurgery resident. But another reason for these shortages is because
the planning area of CENDEISS, which calculates the annual needs of the different
specialty areas for the Caja, makes the assumption that upon completing their residency,
the specialists trained in the Caja will stay there to practice medicine. While this was the
case for many years, and is still the case for many specialties, the number of physicians
who migrate to the private sector shortly after their residency has increased sharply over
the past decade or so. The most notable example of this was anesthesiologists, who left
in droves for the private sector (23). In 2009, the extreme shortage of anesthesiologists
stopped operations within the Caja. Though this is the most widely used example of a
specialty shortage due to flight to the private sector, there are more specialties that are
beginning to show signs of a similar pattern, especially plastic and aesthetic surgery
(though these are still private-sector-dominated specialties). Sarah Ackerman (2009), in
her study of plastic surgery tourism within Costa Rica, noted that most of CIMAs mid-
career plastic surgeons resigned from state employment shortly after completing their
training in reconstructive surgery, to the disappointment of their mentors. Private sector
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HEALTHCAREATACROSSROADS:MEDICALTOURISMANDTHE DISMANTLINGOFCOSTARICANEXCEPTIONALISM by CourtneyA.Lee B.A.,SkidmoreCollege,2001 M.A.,UniversityofColoradoatBoulder,2006 Athesissubmittedtothe FacultyoftheGraduateSchoolofthe UniversityofColoradoinpartialfulfillment oftherequirementsforthedegreeof DoctorofPhilosophy HealthandBehavioralSciencesDepartment 2012

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ii ThisthesisfortheDoctorofPhilosophydegreeby CourtneyA.Lee hasbeenapprovedforthe HealthandBehavioralSciencesDepartment by StephenKoester,ChairandAdvisor JeanScandlyn SarahHorton SaraYeatman DateApril20,2012

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iii CourtneyA.Lee(Ph.D.,HealthandBehavioralSciencesDepartment) HealthCareataCrossroads:MedicalTourismandtheDismantlingofCostaRican Exceptionalism ThesisdirectedbyProfessorStephenKoester ABSTRACT Basedonayearofethnographicfieldwork,thisdissertationexploresthedevelopmentof theglobalmedicaltourismindustryinCostaRicaandthesocial,ethical,andideological implicationsthatitsgrowthmayhavefortheexistingsocializedhealthcaresystem.This studyseekstounderstandthewaysinwhichmedicaltourism,asamodelofglobal neoliberalhealthcare,affectshowCostaRicansthinkaboutdeliveryofandstate responsibilityforhealthcare.Theresearchdrawsdeeplyonthesocial,economic, political,andculturalcontextsinwhichmedicaltourismisunfolding.Itaddressesthe ideologicaltensionsandcontradictionsthatsurroundmedicaltourism,asthelinebetween conceptionsofhealthcareaslocalandglobal,socialistandcapitalist,publicandprivate, blurstoaccommodatethisemergingindustry.Ratherthanemphasizingtheviewof medicaltourismfromthetop,thefocusisonlocalperceptions,understandingsand engagementswithmedicaltourism.GroundedintheexperiencesofCostaRicanhealth careproviders,educators,policymakersandcitizens,thispapertellsthestoryofa systeminflux. Theformandcontentofthisabstractareapproved.Irecommenditspublication. Approved:StephenKoester

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iv ACKNOWLEDGMENTS Thoughwritingadissertationcanbealonelyprocess,itisnotasolitaryone,andI amgratefulforthesupportandencouragementofmanypeopleandinstitutions.First,I wouldliketoexpressmythankstothemanyCostaRicanswhoparticipatedinthis researchprojectandletmeintotheirverybusylives.Theyweredoctors,nurses, administrators,teachers,parents,andstudents,whonotonlymadetimeformeintheir hecticdays,butoftenthanked me fortalkingabouttopicsthatwereofimportanceto them;theirrespectforsocialresearchistrulyinspirational.IwouldliketothanktheCaja, thehospitalswhereIconductedmyfieldworkandtheUniversityofCostaRicafor allowingmeaccesstotheirfacilitiesandinstitutions.TheUniversityofCostaRica,in particular,providedawelcomingandintellectuallystimulatingenvironmenttothink aboutthisresearch,andIfoundmyselfalwaysgoingbacktherewhenIfeltstuck. Ioweanenormousdebtofgratitudetomywonderfulresearchassistantand friend,KarinaValverdeSalas,abrilliantsocialresearcherwhoflawlesslyguidedme throughtheculture,geographyandlanguageofCostaRica.Duringmyfirstmonthin CostaRica,ImetKarinabychanceonthreeseparateoccasions,whichiswhenIknew ourworkingtogethermusthavebeenfate.IdontknowwhatIwouldhavedonewithout her.Thisresearchisasmuchhersasitismine. Averyspecialthankyoutomycommitteeandacademicadvisers,SteveKoester, JeanScandlyn,SarahHortonandSaraYeatman,whoseinsightfulcommentsand conversationhelpedimprovethisdissertationtremendously.JeanandSteve,especially, haveheardendlessversionsofthisprojectsinceIcameupwiththeideatostudymedical tourismwhiletakingtheirGlobalHealthandQualitativeMethodsclassesin2005.They encouragedmyveryroughideaandtactfullyhelpedmetoshapeitintoarespectable researchproject.Throughoutthislongprocess,theyhavebeenwholeheartedlyonboard-duringthetimeswhenIlovedthisprojectandthetimeswhenIhatedit--guidingmewith theirexpertise,kindnessandhumor.Icannotsayhowmuchthishasmeanttome. IwouldalsoliketothanktheHealthandBehavioralSciencesDepartment,where Ihavefeltathomeduringtheseyears.Ihavebeenaffordedeveryopportunitybymy departmentandhavefeltsupportedandvaluedasaresearcher,teacher,studentand person.AbbyFitchhasbeenanever-patientandhelpfulguidethroughthebureaucratic processesofgraduateschoolandamuchneededearwheneverIwalkintoheroffice unannouncedandseatmyselfinthechairacrossfromher.Theenthusiasm,support,and positiveoutlookofourChair,DebbiMain,alwaysmademefeellikeIwasdoing interestingwork,evenonthedayswhenIwasjustnotconvinced.Iwouldliketothank aswellPaulShankman,adviserfrommymastersprograminanthropology,whose encouragementhelpedmetofindwhatIwaslookingforwithinmedicalandapplied anthropology.Thankyoutothegroupofbrilliantandinspirationalanthropologists, researchersandteacherswhohavehelpedmetothinkcriticallyabouttheworldandseek outitscontradictions.Ihavelearnedsomuchalongtheway. IwouldliketoacknowledgethegenerousfundingfromtheNationalScience Foundation(DissertationImprovementGrant#0852414),theWennerGrenFoundation (DissertationFieldworkGrant),theUniversityofColoradoDenverHealthand BehavioralSciencesDepartment(DissertationGrant)andtheInternationalInstitutefor AppliedSystemsAnalysis(YSSPsummerfellowship),thatsupportedmydissertation

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v researchandallowedmetoliveabroadfor15monthsandcompletethisresearchinthe waythatIenvisioned.Iamsoappreciative. Finally,athankyoutomyfriendsandfamily.Evenmyfriendswhohavenoidea exactlywhatitisthatI do havekeptmegoingwiththeirunderstanding,companionship andmuchneededlaughter.JessicaLee,inparticular,hasbeenrighttherewithmealong thislong,bumpyroad.Herideas,input,senseofhumor,andclosefriendshiphavebeen soimportanttomethroughouttheprogram.Myparentsandbrotherhavebeenpatient andsupportive,andalwayskeepmegrounded.MyNanaismyinspirationtokeepgoing andaccomplishwhatIsetouttodo.MyhusbandStevenhasputmebacktogethermore timesthanIcaretoadmit.Hehassupportedmeunquestioningly;evenwhenhehadno ideawhatkindofcrazyhedbefacedwithfromonedaytothenext.Iamsogratefuland fortunatetohavethesepeopleinmylifeandIcouldnothavedonethiswithoutthem. WhenIreturnedfrommyfieldwork,IsatdowninSteveKoestersofficeina frenzyaboutthemanysnagsIhit,andallthethingsthatdidntgoasIhadhoped.He patientlyletmefinishmyexasperatedrant,leanedbackinhischairandsaidImso happytohearyousaythat!WhenIlookedathimalittlefunny,heclarified,Wellif youcamebackandtoldmethateverythingwentsmoothlyandexactlyasyouplannedit, thatswhenIwouldhaveknownthatyoudidntreallydothework.Thisjourneyhasnot alwaysbeensmoothorevenclosetoperfectbutIdiddothework.

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vi TABLEOFCONTENTS CHAPTER1:INTRODUCTION....................................................................................1 ResearchQuestions...............................................................................................................3 TheoreticalApproachesandOrganizationofText.............................................................4 ResearchMethods.................................................................................................................6 ResearchAssistant............................................................................................................10 ChallengestotheResearch...............................................................................................11 DataSourcesandAnalysis................................................................................................14 Fieldsites.........................................................................................................................14 ReflectiononFieldwork...................................................................................................15 CHAPTER2:ANOVERVIEWOFTHEGLOBALMEDICALTOURISM INDUSTRY......................................................................................................................17 FromIndividualtoIndustry:TheGlobalGrowthofMedicalTourism...........................18 DefiningMedicalTourism................................................................................................18 ChangingPatternsofMedicalTravel................................................................................21 TheProceduresMedicalTouristsTravelFor.....................................................................23 MedicalTourismDestinationCountries............................................................................29 TheCurrentStateoftheMedicalTourismIndustry.........................................................32 DataChallengesandQuestionablestatistics......................................................................32 GlobalActorsintheMedicalTourismIndustry.................................................................34 TheRoleofGovernmentsinDestinationCountries..........................................................41 GlobalImpactsofMedicalTourism..................................................................................42 ThePotentialBenefitsofMedicalTourismforDestinationCountries...............................44 ThePotentialHarmsofMedicalTourismforDestinationCountries..................................45 TheResearchProject..........................................................................................................48 CHAPTER3:HEALTHWITHOUTWEALTHTHECOSTARICAN CONTEXT.......................................................................................................................50 SocialMedicineinLatinAmerica......................................................................................50 CostaRicaasaCaseStudy.................................................................................................53 ColonialHistory...............................................................................................................53 HealthSystemSuccesses..................................................................................................56 HistoryandDevelopmentoftheHealthSystem................................................................59 MedicalEducationandtheInstitutionalizationofMedicalPractice...................................62 QualityofCareintheCaja................................................................................................68 SolidarityasIdeology:PrinciplesoftheCaja....................................................................70 TheCostaRicanImageandtheMedicalTourismBlueprint............................................72 CHAPTER4:PRIVATIZATIONOFTHEHEALTHCARESYSTEM.................76 TheRelationshipbetweenthePublicandPrivateHealthCareSectors...........................76 TheRoleofthePrivateSectorinHealthCareProvision...................................................77 ThePrivateSectorToday..................................................................................................81 InternalPressuresontheCostaRicanHealthCareSystem.............................................82 DemographicChangesinCostaRica................................................................................82 ThreatstotheCajasFinancialStability............................................................................83 UnnecessaryPatientReferralstotheCaja.........................................................................86 NationalManagementofHumanResources......................................................................88 TheContratodeAprendizaje..........................................................................................90 DeterioratingConditionsintheCaja.................................................................................93

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vii WorkinginBothSectors....................................................................................................96 PassivePrivatization...........................................................................................................98 CHAPTER5:NEOLIBERALPRESSURESONTHEHEALTHCARESYSTEM .........................................................................................................................................101 ThePrinciplesofNeoliberalism.......................................................................................101 ImpactsofStructuralAdjustmentProgramsonPublicHealth......................................103 SAPsinLatinAmerica...................................................................................................103 SAPsinCostaRica.........................................................................................................105 ImpactsofTradeAgreementsonPublicHealth..............................................................108 TheCentralAmericanFreeTradeAgreement.................................................................111 GlobalImpactsofNeoliberalism......................................................................................117 IndividualImpactsofNeoliberalism................................................................................119 TheLoveHateRelationshipwiththeState...................................................................125 CHAPTER6:LOCALEXPERIENCESOFMEDICALTOURISM.....................127 NationalActorsandtheHealthCareCluster..................................................................127 EmergingIndustryActorsasGatekeepers.......................................................................131 CreatingSpecialSpacesforMedicalTourists.................................................................134 TheStateoftheMedicalTourismIndustryinCostaRica..............................................138 LocalHopesforMedicalTourism....................................................................................140 LocalAnxietiesaboutMedicalTourism..........................................................................143 Competition....................................................................................................................143 Capacity.........................................................................................................................147 MedicalTourismDevelopmentinGuanacaste................................................................148 MedicalTourismandInequitiesinCostaRica................................................................150 FinancialResources........................................................................................................151 InternalBrainDrain........................................................................................................153 CHAPTER7:MEDICALTOURISMANDCOSTARICASCONTRADICTING VISIONS........................................................................................................................159 CostaRicasContradictions.............................................................................................159 MedicalTourismandOpposingIdeologicalValues........................................................160 CompetingVisionsofHealthNationalism......................................................................163 MedicalTourismUnderaSocialSystem.........................................................................166 MedicalTourism,DistributiveJusticeandMoralPluralism..........................................168 TheShiftingRoleofSocialResponsibility.......................................................................172 RegulatingMedicalTourism............................................................................................175 CONCLUSION.............................................................................................................178 WORKSCITED............................................................................................................181 APPENDIXA:EXAMPLEINTERVIEWGUIDE...................................................196 APPENDIXB:SURVEYGUIDE...............................................................................201 APPENDIXC:PARTICIPANTLIST........................................................................205

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viii LISTOFFIGURES Figure1:Breakdownofinterviewparticipantsbyprimaryprofession.............................8 Figure2:Breakdownofphysiciansinterviewedbyemploymentsector...........................9 Figure3:Medicaltourismadsfeaturingbeachesandothertouristattractions................20 Figure4:Mapofpopularmedicaltourismdestinations...................................................29 Figure5:BumrungradHospitallobbyandapatientroom...............................................31 Figure6:AmedicaltourismbloggershowsthatBumrungradHospitalinThailandis U.S.Approved!......................................................................................................36 Figure7:Amodeloftheglobalmedicaltourismindustry...............................................41 Figure8:SloganoftheCostaRicanTourismBoard:Aqusecuratodo(Herewecure all).............................................................................................................................73 Figure9:IdyllicimagesofCostaRica:waterfalls,volcanoesandbeaches.....................74 Figure10:HospitalSanJuandeDios,andanEBAISprimarycareclinic......................96 Figure11:ElectionDay,February2010.CostaRicanssupportingtheircandidates.....112 Figure12:ResistancetoCAFTA/TLC...........................................................................116 Figure13:TheCostaRicanhealthcarecluster..............................................................129 Figure14:Theroleofthegovernmentinsupportingthemedicaltourismindustry......130 Figure15:Thespecialspacesofmedicaltourists..........................................................137

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ix LISTOFTABLES Table1:Costcomparisonofmedicaltourismproceduresbycountry.............................24 Table2:Commonsurgicaltreatmentspromotedbymedicaltourismagencies...............28 Table3:HealthandequityindicatorsforCostaRica,theUnitedStates,andMexico.....58

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x ACRONYMS AMAAmericanMedicalAssociation APECAsia-PacificEconomicCooperation ARTAnti-RetroviralTherapy ASEMECO AsociacindeServiciosMdicosCostariccenses (Associationfor CostaRicanMedicalServices) CAFTACentralAmericanFreeTradeAgreement CCSS CajaCostarricensedeSeguroSocial (CostaRicanSocialSecurity System) CENDEISSS CentrodeDesarrolloEstratgicoeInformacinenSaludy SeguridadSocial (CenterforStrategicDevelopmentandInformation inHealthandSocialSecurity) CONARE CRMHCCostaRicanMedicalHoldingCompany EBAIS EquiposBsicosdeAtencinIntegraldeSalud (PrimaryHealthCare Teams) EMTCEuropeanMedicalTravelConference EUEuropeanUnion FDAFoodandDrugAdministration FTAFreeTradeAgreement GATSGeneralAgreementonTradeinServices GATTGeneralAgreementonTariffsandTrade GDPGrossDomesticProduct HTIHealthCareTourismInternational ICT InstitutoCostariccensedeTurismo (CostaRicanTourismInstitute) IMFInternationalMonetaryFund IMTAInternationalMedicalTravelAssociation IMTJInternationalMedicalTravelJournal INS InstitutoNacionaldeSeguros (NationalInstituteofInsurance) ISAPRE InstitucionesdeSaludPrevisional (HealthInsuranceInstitutions) JCIJointCommissionInternational MTAMedicalTourismAssociation NAFTANorthAmericanFreeTradeAgreement OPECOrganizationofthePetroleumExportingCountries PAC ParticoAccinCuidana (CitizensActionParty) PLN PartidoLiberacinNacional (NationalLiberationParty) PROMEDCouncilforthePromotionofCostaRicanMedicine PUSC PartidoUnidadSocialCristiana (SocialChristianUnityParty) SalaIV SalaConstitucionaldelaCorteSupremadeJusticia (Constitutional ChamberoftheSupremeCourt) SAPStructuralAdjustmentProgram TLC TratadoLibreCommercio (CentralAmericanFreeTradeAgreement) TRIPSAgreementonTrade-RelatedIntellectualPropertyRights UCRUniversityofCostaRica

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xi UFCUnitedFruitCompany WBWorldBank WHOWorldHealthOrganization WMTGHCWorldMedicalTourismandGlobalHealthCongress WTOWorldTradeOrganization

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1 CHAPTER1:INTRODUCTION Veryearlyonemorning,IheadoutofmySanPedroapartment buildingtobeginmytrekupthesteepneighborhoodhilltothemainroad tocatchmyalmostdaily40-centbusrideintothecity.Miguel,theguard tomybuildingwhichalsoisgatedandsurroundedbywroughtiron barsdoesnotlikethatIamoutwhileitstilldark;heremindsmeagain thismorningtobecareful.ButIhavean8amappointmentatCIMA Hospital,inthesuburbofEscazu,whichwilltakemealongtimetogetto bybus. Atthetopofthehill,Ibracemyselfformydailyperilasprintacross fourlanesofspeedingtraffic,interruptedbyaquickclimboveramedian, andthenanotherdashacrosstwomorelanesoftraffic.Iarriveinone piecetoday,outofbreath,andswiftlyboardmybus. WhenIreachthecity,SanJosisjuststartingtocometolife.Fruit sellersareoutonthecorners,shopownersraisetheirbars,businesspeople maketheirwayintoofficebuildings,andillegalstreetvendorslayout tarpstodisplaythevariouspiratedmoviesandcheapgoodstheywilltry toselltoday. Tocatchmynextbus,Imustwalkaboutamilethroughthecenterof SanJostothe CocaCola busterminalonthewestendofthecity.The areaaroundtheterminaliscrowdedanddirty,andIoftenmuststepinto thestreettomaneuveraroundbusycommuters,beggars,andtrashthat obstructsthesidewalk.Thisisadangerousproposition,asanever-ending lineofswerving,honkingcarstriestomakeitswaythroughthecongested areaaswell.Thisdistrictisparticularlyknownasbeingunsafe,especially fortourists;Ikeepmyheaddownandwalkbrisklytomybusstop,trying togounnoticed.Iammostlysuccessful,thoughIdohearacoupleof Holamacha ![Heyblondie!]shouts,followedbythecharacteristiclipsmackingsoundthataccompaniessuchashout. AsthebusmakesitswayoutofSanJosandintoEscazu,Iamstruck byshiftinglandscape,asthedirty,narrow,crowdedstreetsofSanJos givewaytoanexpansivehighwaysurroundedbylushgreenhills.Thisis myfirsttimevisitingEscazu,thoughIhavebeentoldthatitiswhereallof theAmericanexpatriateslive,andthatthereisalargeupscalemallhere whereIcouldgoifIwantedAmericanthings. Ithinkofmyearlierstreet-crossingadventureasthebuspullsuptoa raisedwalkway,whichvaliantlytraversesthehighwaybelow,andleaves mestandinginfrontoftheCIMAHospitalcomplex.Itispositively gleaminginthebrightmorningsun,whichreflectsoffofthemodernglass faade,givingitatrulyradiantappearance.EventhoughIamearly,upon entry,Iamgreetedbyauniformedattendant,whotakesmedirectlyto Ophelia,theinternationalpatientcoordinator,whowouldbehappytogive meatourofthecomplexbeforesheescortsmetotheofficeofthe physicianwhomIwillspeakwith.

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2 Thisisasharpcontrasttomyexperiencejustonedayearlierata publichospital, SanJuandeDios indowntownSanJos.Iarrivedearly then,aswell,butspentabout15minutesroamingthroughamazeof unmarkedhallwaysaskinghurriednurseswhereImightfindtheparticular doctorIwaslookingfor.Afterthreefailedattemptsatfindinghim,a sympatheticnursefinallysatmedownonanorangeplasticchairina narrowhallwayandtoldmetojustwait. Iwasseatedinfrontofagiantlaundrybinthatcontainedanabsolutely enormouspileofscrubs.Hospitalstaffrushedthroughmylittlearea, grabbingmismatchedpairsofwrinkledscrubsfromthebin,andthen quicklyhurriedoffagain.Unconsciouspatientswerewheeledbyon gurneys;anursewalkedbycarryingvialsofblood;inanadjacentroom,a childcriedloudlyashereceivedashot,infullviewofthepackedwaiting area. ThedoctorwhoIammeetingarrivestoretrieveme35minutesafter ourscheduledappointment.Sorry,Ihadtocheckonpatients,he apologizes,asheushersmeintoaclutteredroomlinedwithmismatched communaldesks,whereatleastfiveothersareworking.Welcometomy office,helaughs,holdinghishandsout,whilewesearchforan availableareatotalk.Ihavetocheckinforsurgeryin20minutes,he says,soweshouldgetstarted. AdaptedfromfieldnotesFebruary25 th and26 th ,2010 Thesemarkeddifferencesbetweenpublicandprivatespacesofhealthcare consumptionareindicativeofthemountingcontradictionsofthenationalpoliticalproject inCostaRica.Adivergenceisoccurring,aspastvisionsofhealthcarebasedonsocial solidarityandstate-sponsoredmedicinegivewaytofuturevisionsofhealthcarebased onprivatizationandglobalwealthaccumulation.Theemergingpracticeofmedical tourism,whichtakesplacewithinnewprivatespaceslikeCIMA,isillustrativeofthe ideologicalshiftthatiscurrentlyunderwayinCostaRica.Thoughitisentrenchedin largerpoliticalandeconomicforces,manyofwhichareexternaltoCostaRica,theway thatCostaRicaincorporatesmedicaltourismintothenationalpoliticalprojectiscolored bythenationssuccessfulsocialhealthcaresystem. Thisdissertationexploresmedicaltourismwithintheparticularcontextofthe CostaRicanhealthsystem.Asanovelconfigurationofhealthcareprovisioninan

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3 increasinglyglobalworld,thispracticeofcrossingbordersforhealthcarefacilitatesnew ideologicalencounters,asnationalsystemsofhealthcarecollidewiththeglobalhealth careeconomy.WithinCostaRica,thisclashoccursbetweenanationalhealthcaremodel basedonprinciplesofsocialmedicine,andamodelofneoliberalhealthcarethat continuestospread,despiteitsfailingswithinthedevelopednationsoftheworld.Costa Ricashistoricalorientationtowardspublichealthcareprovision,positionedalongside theneoliberalmodelofmedicaltourism,providesfertileterrainforanalyzingthe paradoxesofglobalization.Thisresearchattemptstomakevisiblethecontradictionsof thispractice,throughfollowingthefaultlinesout(Nordstrom2007).Thisstudybegan intheUnitedStateswithresearchin,andon,themedicaltourismindustryandfollowed theconnectionstoCostaRica,averypopularmedicaltourismdestinationforAmericans. Todate,thereislittlescholarlyresearchontheeffectsofmedicaltourismin destinationcountries.Thoughrecentacademicstudieshavebeguntoexaminethetopic morecritically,thereareveryfewfirsthandaccountsthatassesstheimpactsofmedical tourismwithinaparticularcontext.Thisresearchtakesasteptowardsfillingthisgapby criticallyengagingwiththepracticeofmedicaltourism,anditssituationwithinlarger powerrelations,intheCostaRicancontext. ResearchQuestions Thisresearchsetouttoanswertheoverarchingresearchquestion: Howdoes medicaltourismimpacthealthcareinCostaRica? Todothis,itfocusedonthefollowing fivesub-questions: (RQ1)HowisthemedicaltourismindustryintegratedwithinthestatedominatedCostaRicanhealthsystem? (RQ2)Whatarethedifferences-organizationally,structurally,and withregardtopatientpopulation-betweenpublichospitalsthatserve

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4 mainlylocalandpoorerpopulationsandprivatehospitalsthatserve medicaltouristsandwealthierCostaRicans? (RQ3)Wheredotheprofitsfromthemedicaltourismindustrygo? (RQ4)Doesmedicaltourismdrawresourcesandphysiciansaway frompublichealthcare? (RQ5)HowdoesmedicaltourismimpactthewaythatCostaRicans thinkabouthealthcare? TheoreticalApproachesandOrganizationofText Anthropology,withitssensitivitytotheactorspointofviewandthe waysthesecontradictorclash,combinedwithitscapacityfor problematizingthetakenforgrantedisparticularlysuitedtoanalyzing howideologiesinfiltratetheinstitutionsofpracticesofeverydaylife. (ShoreandWright1997) TodrawconnectionsbetweenglobalindustryandlocalhealthcareinCostaRica, Iutilizecriticalanthropologicalperspectivesthatenableashiftofscopefrommacroto micro-processesandbackagain.Inparticular,thisresearchoffersapoliticaleconomyof themedicaltourismindustry. Politicaleconomyofhealthperspectivesareparticularlyadeptatexaminingthe complexandnuancedproblemsofglobalization,andtheprocessesbywhichindividual livesandlocalcommunitiesareaffectedbypolitical,economicandculturalforcesthat operateworldwide(Appadurai1991).Theseperspectivesareconcerned,asthisprojectis, withthedistributionofglobalresourcesandhowglobalpowerstructuresinfluence health.Ratherthancreatingaseparatesectiontodiscusstheoryasitrelatestothestudy ofmedicaltourism,theoreticalperspectivesareincpororatedthroughoutthedissertation, connectedtotheparticularthemesofeachchapter. InChapterOne,Idiscussthechangingpatternsofglobalmedicaltravel,offeran overviewofthemedicaltourismindustry,andanalyzethevariousargumentsbothforand againstmedicaltourismwithintheexistingliterature.Thefundamentalassumptionsof theindustry,rootedinneoliberalprinciples,areintroducedinthischapter.Iarguehere

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5 thatthemedicaltourismindustryhasdevelopedablueprintfordestinationcountries, thatlaysoutspecificcriteriaforwhatcomprisesagooddestination,andthecarefullines thatparticipatingnationsmusttoeinordertoparticipate. InChapterTwo,thelensisshiftedtothespecificcontextofCostaRica,andI tracethedevelopmentofsocialmedicinehereanddiscussitsroleinhealthnationalism. CostaRicahashadnotablesuccessesinhealthcareindicators,uncharacteristicofa developingnationwithsuchasmallGDP.However,thewaythatCostaRicahascometo fittheblueprintforthemedicaltourismindustrythroughapublicsystembasedon solidarity,equity,anduniversalcoverageisinsharpcontrasttotheunderlying principlesthatmedicaltourismrepresents.Ironically,itisthesuccessesofitssocial systemthathaveallowedCostaRicatoemergeasamedicaltourismdestination. InChapterThree,Itracethehistoricalroleoftheprivatesectorinhealthcare provisionwithinCostaRica.TheprivatesectorisverysmallinCostaRica,andithas reliedonthemuchlargerpublicsystemforitsownsurvivalandexpansion,overtime. Thisrelationshiphasbecomeincreasinglyparasitic,however,andtoday,thepublicsector isleftcaringforthepoorestandsickestCostaRicans,whiletheprivatesectorfocuseson profitableformsofhealthcare.Withinpopulardiscourse,thepublicandprivatesectors areviewedasdisconnected.Iargueinthischapterthattheyarenot,andthatthe maintenanceofthisdivisioninpublicconsciousnessleavesthepublicsystemvulnerable topassiveprivatization. InChapterFour,Ioutlinetheexternalpressuresonthesocialmedicinesystem, focusingontheilleffectsofneoliberalreformprogramsandfreetradeagreements,on healthcareprovision,aswellasthewaythatneoliberalism,asaglobalhegemonic

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6 system,ischangingthewaythatlocalsthinkabouthealthcare.Theseoutsidepressures haveresultedinfurthercontractionofthepublicsystem,andimpactedtheabilityofthe statetotoprovidehealthcaretoitscitizens. InChapterFive,Ifocusonlocalexperiencesofthemedicaltourismindustry withinCostaRica,outliningthecurrentstateoftheindustry,localhopesandanxieties arounditsexpansion,andtheimpactsthatithasonthepublicsystem.Iargueherethat medicaltourismentailsashiftofeconomicandhumanresourcesoutofthepublicsector, whichcaresforthelargemajorityofcitizens,andintotheprivatesector,whichcaresfor thewealthyfew. InChapterSix,Isummarizethecurrentcontradictionsofthepoliticalprojectin CostaRica,andthecompetingvisionsofhealthnationalismthatdefinetheparticular moment.Inthischapter,Ihighlighttheoverarchingideologicalimpactsthatmedical tourismhasinacontextlikeCostaRica,anditsimpactsonthewaythatlocals conceptualizehealthandhealthcareprovision. ResearchMethods AccordingtoAppadurai(1991),globalizationischaracterizedbythemovement ofpeople,technology,money,images,andideaswhichnowfollowincreasingly complextrajectories,movingatdifferentspeedsacrosstheglobe.Medicaltourism,asit adeptlycrossesnationalboundaries,touchesonalloftheseflows.Becausetheobjectof studyisaglobalindustrythatisnotsituatedinoneplace,thisresearchismulti-sited (Marcus1995).Itutilizesaresearchframeworkthatbothcaptureslocalperceptionsof globalprocessesandanalyzesthesystemsthatconnectthem.Ethnographicmethodsare wellsuitedforassessingtheseinterrelations,and,inmanyways,thefocusofthis

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7 ethnographyisonthesesystemicconnections. FromOctoberof2009toOctoberof2010,IlivedjustoutsidetheSanJoscity center,inaneighborhoodneartheUniversityofCostaRica(UCR).Toaddressthe researchquestionsofthisproject,thisdissertationreliedonseveralfoundationalmethods ofanthropology,includingparticipant-observation,interviews,surveys,archivalresearch, andreviewofpopularmedia. 1 Thoughclassicparticipant-observationmaybeimpossibleincertainsettings (GilleandORiain2002),itwasusedtotheextentpossiblethroughouttheresearch period.Thisanon-traditionalethnographyinthatitlargelytookplacewithin institutionalsettingsandthroughscheduledappointmentswithparticipantsattheirplaces ofemploymentorstudy.Attimes,Iwasobligedtorelymoreheavilyonobservationthan participation,particularlywhenconductingfieldworkwithinhospitalsandgovernment agencies.LivinginCostaRicaforayear,however,didallowmeampleopportunityfor participationinCostaRicanlife,andItookpartinseveralevents,includinglectures, protests,discussiongroups,films,andconferences.OutsideofCostaRica,Iattendedtwo (ratherdissimilar)medicaltourismconferencestheWorldMedicalTourismCongress, atradeconferencefortheindustry,in2008,andtheInternationalConferenceonEthicsin MedicalTourism,in2010. Whileparticipant-observationisthequintessentialmethodofanthropological fieldwork,itpresentsatheoreticalprobleminthatittendstomisstheimplicationsof structuresofpowerandofhistoricalcontext,becausetheseforcesarenotimmediately visibleineverydayobservationsofindividuals(Brotherton2003).Supplementary 1 SeeAppendicesAandBforinterviewandsurveyguides.

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ethnographicmethodshelptogainamorenuancedunderstandingofcomplexglobal processestoaddress the Throughoutthisproject, stakeholde rsatvariouslevelsofthemedicaltourismindustry.Intotal,Iconducted50 semistructuredinterviews (29), andmale(39).Ofphysiciansinterviewed,therewasnearlyanevensplitbetween physicia nswhoworked exclusively inthepublicsector(11),although practicedinthepublicsector. physicians inrelationtothesmallsizeoftheprivatesector accessissue,whichwillbediscu ofparticipantsisillustratedinthefollowingtwofigures: Figure1 :Breakdownofinterviewparticipantsbyprimaryprofession. 7 ethnographicmethodshelptogainamorenuancedunderstandingofcomplexglobal the shortcomingsofstaticmethodologies. Throughoutthisproject, Iconductedindividual(48)andgroup(2)interviewswith rsatvariouslevelsofthemedicaltourismindustry.Intotal,Iconducted50 structuredinterviews withparticipantsthemajorityof whom andmale(39).Ofphysiciansinterviewed,therewasnearlyanevensplitbetween nswhoworked exclusively intheprivatesector(12)andthosewhoworked inthepublicsector(11),although ofthesephysicians,onlyonehadnever practicedinthepublicsector. ( Thereasonforthehighproportionofprivatesector inrelationtothesmallsizeoftheprivatesector islikelybecauseofasite accessissue,whichwillbediscu ssedintheChallengessection.) Thegeneralcomposition ofparticipantsisillustratedinthefollowingtwofigures: :Breakdownofinterviewparticipantsbyprimaryprofession. 29 2 5 5 InterviewParticipants byProfession Physicians Nurses Academics MedicalTourism Facilitators GovernmentOfficials 8 ethnographicmethodshelptogainamorenuancedunderstandingofcomplexglobal Iconductedindividual(48)andgroup(2)interviewswith rsatvariouslevelsofthemedicaltourismindustry.Intotal,Iconducted50 whom werephysicians andmale(39).Ofphysiciansinterviewed,therewasnearlyanevensplitbetween intheprivatesector(12)andthosewhoworked ofthesephysicians,onlyonehadnever Thereasonforthehighproportionofprivatesector islikelybecauseofasite Thegeneralcomposition :Breakdownofinterviewparticipantsbyprimaryprofession. Physicians Nurses Academics MedicalTourism Facilitators GovernmentOfficials

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Figure2 :Breakdownofphysiciansinterviewedbyemploymentsector. Interviews beganin conductedtwophoneinterviewswithrepresentativesof agenciesthat workedwithhospitalsinCostaRica.Fromthere,Irefinedmyinterview guidesbasedoninformationreceived,andobtainedreferralsforconnections industry inCostaRicawhomIcouldcontact CostaRica,Iuseda purposivesnowballsampling levelswithinthei ndustry,thehealthcaresystem, wasreachingsaturationwithresponsesamongstakeholdersintheprivatesector,I anothersnowball to responsesandopinions. Interviewsweretape fromparticipants,whoare :Breakdownofphysiciansinterviewedbyemploymentsector. beganin theUnitedStatespriortomyarrivalinCostaRica conductedtwophoneinterviewswithrepresentativesof inter nationalmedicaltourism workedwithhospitalsinCostaRica.Fromthere,Irefinedmyinterview guidesbasedoninformationreceived,andobtainedreferralsforconnections inCostaRicawhomIcouldcontact uponmyarrival tothecountry purposivesnowballsampling strategy tofindindividualsatvarious ndustry,thehealthcaresystem, andthegovernment.When wasreachingsaturationwithresponsesamongstakeholdersintheprivatesector,I to betterincludethepublicsector, andtoelicitawiderrangeof responsesandopinions. Interviewsweretape -recordedandeith erverbalorwrittenconsentwasobtained fromparticipants,whoare keptanonymous.Throughoutthefieldworkprocess,Irefined 11 12 6 PhyscianInterviewsby EmploymentSector PublicSectorOnly PrivateSectorOnly WorkinBothSectors 9 :Breakdownofphysiciansinterviewedbyemploymentsector. theUnitedStatespriortomyarrivalinCostaRica .I nationalmedicaltourism workedwithhospitalsinCostaRica.Fromthere,Irefinedmyinterview guidesbasedoninformationreceived,andobtainedreferralsforconnections withinthe tothecountry .Oncein tofindindividualsatvarious andthegovernment.When IfeltthatI wasreachingsaturationwithresponsesamongstakeholdersintheprivatesector,I started andtoelicitawiderrangeof erverbalorwrittenconsentwasobtained keptanonymous.Throughoutthefieldworkprocess,Irefined PublicSectorOnly PrivateSectorOnly WorkinBothSectors

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10 interviewquestionstoreflectthepositionofthepersonIwasinterviewing,andtolearn moreaboutnewthemesthatemergedastheresearchprogressed. Overthecourseofthefieldworkperiod,Iconductedover200surveyswith patientsinprivatehospitalsandpublicprivatecooperatives.Thesesurveysincludedboth closedandopen-endedquestionsaboutaccesstopublicandprivatehealthcarefacilities, patternsofuseandopinionsofeach,andopinionsofmedicaltourismwithinCostaRica. Thisprojectrelied,too,onarchivalresearchandregularscansofpopularpress andmediacoveragearoundmedicaltourismandhealthcareinCostaRica.Priorto embarkingonmyfieldworktriptoCostaRica,Ispentthesummerof2009conducting archivalresearchontheglobalmedicaltourismindustry,thankstoafellowshipatan InternationalInstituteinAustria.Becausemedicaltourismisarelativelynewtopic withintheacademicliterature,Ifoundreviewsofpopularpressandmediaparticularly helpful,includingnewspapers,websites,onlinevideos,blogs,andmagazines. ResearchAssistant Vitallyimportanttothesuccessofthisresearchprojectwasthefortunatemeeting ofmyresearchassistant,Karina,whoIinitiallymetinayogaclass.Sheheardaboutmy researchprojectthroughemailsIsenttotheUCRpriortomyarrival,andwasdrawnto theprojectbecauseofpreviousresearchthatsheconductedontheprivatizationofhealth careinCostaRica.Karinawasinstrumentalinhelpingmenavigatethehealthcare system.Shealsoservedasaculturalandgeographicalguide,helpingmetounderstand culturalnuances,locatepeopleandresourcesthatwouldfurthertheresearch,and navigatethebussystem.SheattendedallinterviewsconductedinSpanishtoensurethatI

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11 wasgainingaccurateinformation,andtohelpmetoseewhatIwasmissingordidnotyet understand. Ingainingaccesstocertainfacilitiestoconductthisresearch,wequickly discoveredthatwemadeagoodteamIhadaremarkablyeasytimegainingaccessto privatefacilities(becauseprivatesectorstakeholderswereeagertopromotemedical tourismtoanAmericanresearcher)whileKarina,asaTica, 2 hadmuchbetterluck steeringthroughthecomplexbureaucracyofthepublicsectortofindparticipants.She wasinvaluableinmovingthisresearchforward. ChallengestotheResearch Mystatusasanoutsider,andanAmerican,sometimesopeneddoorsforme,and sometimesclosedthem.Whilemynationalityallowedmeaccesstomedicaltourism stakeholdersquitefrequently,thisturnedouttobeadisadvantageaswell.Earlyinthe fieldworkprocess,Igrewfrustratedwithwhatcametobeknownasthespiel.Because mysamplingstrategystartedwithactorswithinthemedicaltourismindustry,Ibeganto hearthesamerhetoricaboutthebenefitsofmedicaltourismoverandover.When participantsstartedtorepeattheexactsamewordsandphrasesverbatim,Icameto understandthattherewereheavymarketingandmessagingtacticsatplayhereandthat Iwouldhavetobemoreinnovativeinordertogetpastthespiel.Slowly,Ibecame moreadeptatusingsomepersonalstrategiestogaindeeperinformation.Inparticular,I feignedignoranceincertainsituations,appearingmerelyinquisitiveinordertoaskabout touchysubjectssuchas biombos (bribes)ortaxevasion.Mynon-threateningdemeanor seemedtoworktomyadvantageinthesesettings.Withouttryingtoalterorcensor 2 Tico(male)andTica(female)areslangtermsforCostaRicansthatarepopularlyused.

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12 participantresponses,insituationswhereIfeltthattheyweregivingmethespiel,Ihad tousemyowncommonsenseandothersourcesofinformationtogetattheunderlying truths.Ethnographicmethodsareparticularlyadeptatthis,andallowedmetoconductthe researchinaflexibleandcreativeway. Abouthalfwaythroughmyfieldwork,Ihitasnaginmyresearchplanwhen,the weekbeforeCostaRicawastohostaninternationalconferenceonmedicaltourism,I wastoldbyahigh-rankingofficialwhomIwasinterviewingthatmyresearchwastoo political.Hedemandedtoknowwhohadgivenmepermissiontostudysuchatopic, and,asthereisnoInternationalReviewBoardwithinCostaRicatoapproveresearch projectsbyforeigners,Ididnothaveagoodanswerforhim.Thenextmonthentailed severalmeetingswithdifferentinstitutionstotryandfigureoutwhoexactlycould,and would,endorsemyresearch. AcademicsattheUCR,whilefondofmyresearchtopic,didnothavethe authoritytosponsorstudentswhowerenotenrolledattheuniversity.TheMinistryof Healthtoldmethatmyprojectwassocialinnatureandthattheydidnotsponsorsuch things.TheywonderedwhyIwasaskingforpermission,andsuggestedthatIjustdothe researchandnottellanyoneaboutit. Finally,thebioethicsdepartmentoftheCaja 3 agreedtoreviewmyproposal. Duringthistime,Ilearnedratherintimatelyhowfrustratingthebureaucraticprocessesof theCajacouldbe.Aftersubmittingsixhardcopiesofmyproposal,IwastoldthatI wouldhavetowaitamonthfortheproposaltobereviewed.Sixweekslater,Iheardback thatmyproposalwasrejected.ThereviewersdidnotunderstandwhyIshouldwantto 3 TheCajaisshortfortheCajaCostarricensedeSeguroSocial,ortheCCSS.ItistheCosta RicanSocialSecuritySystem,whichprovideshealthservicestothepopulation.

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13 studymedicaltourism,aprivateindustry,withintheCaja.IfIwanttostudyplastic surgery,theywrote,whydontIgointotheprivatehospitals?Afterseveralmonthsof back-and-forthcommunicationsandrevisions,Iwasfinallyabletomakethebioethics committeeunderstandthesocialnatureofmyresearch.Butwithalimitedfieldwork period,Ihad,inthemeantime,drawnononeoftheresearchersmostimportant methodologicaltoolsflexibility.Despitethebest-laidplans,fieldwork,especiallyina foreigncountry,sometimesjustdoesntgothewayitwashoped.Inthiscase,Ihadto reassessmyprojectandwhatwasnecessarytosuccessfullycompletetheresearchand thenadapt. Becausethemajorityofprivatesectorphysiciansworkwithinthepublicsystem aswell,Ibegantosearchforpublicsectorphysicianswhooperatedprivateofficesparttime,andmetwiththemintheirprivatespacesinordertocircumventmypending permissiontoconductresearchwithinCajafacilities.Whilethisprovedaneffective strategy,itdidskewmyparticipantstowardtheprivatesectorsidemorethanis representativeofthehealthcaresystematlarge(90%ofthenationsphysicianswork withintheCaja,thoughnotalldosoexclusively).EventuallyIgainedofficialpermission bytheCajatoconductfieldworkinoneoftheirpublicprivatecooperatives,whichIdid duringthelastmonthofmyfieldworkperiod. Anotherchallengeoftheresearch,thoughtoamuchlesserdegree,wastheuseof informedconsent.Thoughconsentformsdidnotseemtoinhibitparticipationinthe project,IwastoldmanytimesthattheformswereveryAmerican,formal,and bureaucratic.Ingeneral,however,CostaRicanswereveryamenabletoparticipatingin thisresearch,anddidsowithoutincentive,otherthancontributingtoatopicthattheyfelt

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14 wasimportant.HavingworkedinhealthcaresettingshereintheUnitedStates,itwas especiallysurprisingtomethatphysiciansweresowillingtogivetheirtime,asthisisa historicallydifficultgrouptorecruit. DataSourcesandAnalysis Severalmethodswereusedtoanalyzedatacollectedforthisstudy.Interviews weretranscribedbytwostudents,AlanandSilvia,whoworkedwithintheInstitutefor SocialResearchattheUCR.Silvia,whohadlivedformanyyearsintheUnitedStates, translatedSpanishtranscriptsintoEnglish,andhelpedtotranslatesurveys,forms,and interviewguidestoensuretheiraccuracy. SurveydatawasenteredandanalyzedinExcel.Otherdatasourcesincludedfield notes,sitedescriptions,andbackgroundresearch,whichIconductedoncertaintopics thataroseininterviews(forexampleCAFTAimplementationandprovisions,contracts betweenmedicalresidentsandtheCaja,etc.).ThesesourcesweretypedintoWord documents,andloadedintoAtlas.ti,forthematicanalysis.Acombinationofinductive anddeductivecodingwasusedtoanalyzeallnarrativedata,andcodeswerereviewed andorganizedforwriting. Fieldsites ThisresearchtookplaceinandaroundtheCostaRicancapitalofSanJos, locatedintheCentralValley.Withapopulationofover365,000,SanJosishometo governmentinstitutions,andthemajorityofthenationshealthcarefacilitiesand universities.

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15 Iconductedfieldworkatthreeprivatehospitals HospitalClnicaBblica HospitalHotelLaCatlica ,and CIMA 4 allofwhichareaccreditedhospitalsthattryto attractmedicaltourists;IalsoconductedfieldworkintwooftheCajasnationalhospitals inSanJos HospitalSanJuandeDios and HospitalCalderonGuardia aswellasin onemixedmedicinecooperative, Coopesalud ,inPavas,adistrictofSanJos.Lastly,I conductedinterviewswithstudentsandprofessorsfromtheUCR,andparticipatedin eventsthroughtheuniversity.Throughoutthedissertation,Ioffersomemoredetailabout thesefieldsites,asitrelatestothemesaroundmedicaltourism. ReflectiononFieldwork Thoughitissomewhatdifficulttorecallnow,myinitialdecisiontostudymedical tourisminCostaRicahadatleastsomethingtodowiththeidyllicimageofthecountry thatisportrayedinthemediaandpopularimaginationand,asamedicalanthropologist, itssuccessfulsocialhealthcaresystem.Itisveryeasytogetcaughtupinthisimage. StudyingCostaRicashealthsystem,Iamoftensolicitedtoengageindiscussionoverthe meritsofsocialmedicinedeclaringiteithergoodorbad,andeitherasuccessora failure.WhileImayhavebeenmoreamenabletomakingsuchadeclarationpriorto workinginCostaRica,Inowhaveamuchmorenuancedappreciationofboththe positiveandnegativeaspectsoftheCostaRicanhealthcaresystem.Ihavetriedinthis dissertationtoavoidreducingthistopictomoralabsolutes.Iofferacriticalperspective ofthemedicaltourismindustryanditsfoundingassumptions,buthopetohavepainteda 4 Throughoutthedissertation,Irefertothesethreehospitalsoftenasthebigthreeprivate hospitalsforsimplicityssake.Theyarenottheonlyprivatehospitalsinthenation,buttheyare thelargest,andmostwell-known.

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16 sufficientlycomplexpictureoftheCostaRicanhealthsystemthatcapturestheintricacies ofthecurrentpoliticalmoment. WithinCostaRica,too,manywhomImethadanagendathattheythought matchedminewhetherthiswassupportingthemedicaltourismindustry,orexposing thefaultsofeitherpublicorprivatehealthcare.Understandably,asaresearcher,Iwould liketosatisfyallofthosewhomIimposedupontoparticipateinthisstudy,andnotto betrayanyofthem.ItisoneofthedifficultiesofethnographicresearchthatIcannot makethispromise.Icanonlyofferhereanaccountofmedicaltourismfilteredthrough myownexperiences,researchandinterpretations.

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17 CHAPTER2:ANOVERVIEWOFTHEGLOBALMEDICALTOURISM INDUSTRY SettosoftSpanishfolkmusic,slowmotionscenesofCostaRica appearonebyoneachurchatime-wornstatueoftwoangelsan elderlyCostaRicanmanschoolchildreninuniformplayingjumprope outside.WordsslowlyappearonthescreenDifferentCulturesa butterflyprovidingnewhopeasunset. ThesceneshiftstoBob,bearded,dressedinaredplaidflannelshirt standingnexttohiswifeLinda.Bobisamiddle-agedAmerican,family man,andconstructionworker,whosedeterioratingkneeshavelefthim worriedthathewillnotbeabletosupporthisfamily.Everymorning, Bobopenshiseyesandwondershowmuchheisgoingtohurtthatday, readsthefemalenarrator,evenplayingwithhisdoghurtstoomuch.He isinsured,buthisinsurancewillonlycoveratenthofthecostofknee replacementsurgery,andhecannotaffordtheremainderofthecost withoutgoingintodebt.Heisaggravatedanddepressed;hislifestyleand personalityareaffected,thenarratortellsus. Thatis,untilBobwentontheinternetandfoundoutaboutmedical tourism.HehasdecidedtoundergoadoublekneereplacementinCosta Rica,wherehecansave$80,000, 5 andreceiveexceptionalservices.His triptoCostaRicawillbehisfirsttimeoutofthecountry,buthedidsome researchandfoundoutthatCostaRicahasahealthsystemthatperforms betterthantheU.S.healthcaresystem. BobarrivesinCostaRicatofindthatheistreatedbetterthanheever hasbeenwithintheU.S.system.Thehospitalisexpectinghim,andstaff isreadyforpre-surgicaltestsuponhisarrival.Adoctoriswaitingonme heexclaims,Thatsafirst! Hissurgeon,Dr.Oeding,isafamilymanlikeBob,andweseescenes ofhimeatingwithhischildren,takingthemtoschool,playingracquetball withhisfriends.ThistimerejuvenatesDr.Oeding,andmakeshima betterdoctor,readsthenarrator.BobswifeLindathinkshisnursesare beautiful,withsuchlovelysmileslikeangels. ClinicaBiblica, the hospitalwhereBobwillreceivehissurgery,andthetechnologythatis used,isstate-of-the-art,andaccreditedbyU.S.standards.Themedicines areFDAapproved. BobandLindastayatanInterContinentalHotel.Aftertakinga rainforestcanopytour,Bobundergoeshissurgery,anditisagreat success.Hisphysicaltherapist,Nazarene,isfocusedandcompetent, givingBobtheemotionalandphysicalsupportheneedstorecoverfrom hissurgery.Hissurgeonchecksonhimpersonallyandoftenduringthe recoveryphase. OnhislastdayinCostaRica,NazarenetakesBobforawalkoutside thehospitaltobesurethathecanhandlereal-lifeobstacleswithhisnew 5 Throughoutthedissertation,allmonetaryvalueswillbegiveninU.S.dollars,unlessspecified otherwise.

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18 kneesbeforeheboardsaplanetogohome.Theycrosspot-holedstreets anddirty,crowdedsidewalks,throughaconstructionsite.Thisisreal-life stuff,Nazarenesays. BobreturnshometoFloridaanewman,withanewoutlookonlife. Thefuturelooksverygood,hesays,asupliftingmusicplaysinthe background,eachweekgetsbetterandbetter,andbetter. -From AngelsOverseas,aMedicalTourism Documentary(MTA2009) Thisisthestorypresentedbythemedicaltourismindustryofwhatmedical tourismlookslikeinCostaRicadesperatemiddle-classAmericanswhotraveloverseas tobehealedbycaringangels,whonotonlyoffermedicalcarethatiscomparabletothe UnitedStates,butalsotrulycareaboutthehealthandwellbeingofthepatient. AlthoughthedocumentarytellsusthatBobwasinCostaRicatwoweeksto undergoandrecoverfromhissurgery,herarelystepsoutsideofthehospitalorhotel exceptforhisquicktriptotherainforest,apopulartouristdestination.Heisprotected fromthereal-lifeofSanJosthattakesplaceoutsideofthesepurifiedspaces. Whiletheimagesinthepassageaboverepresentthefaceofmedicaltourism presentedbytheindustry,theyobscuretherealityofmedicaltourismwithindestination countries.Theemergenceanddevelopmentofmedicaltourismasaglobalindustryand theprimaryconcernsethical,social,andeconomicthatarisealongwiththegrowthof themedicaltourismindustry,arethefocusofthischapter. FromIndividualtoIndustry:TheGlobalGrowthofMedicalTourism DefiningMedicalTourism Theterm medicaltourism isacontroversialconcept.Recentanthropological literaturehascritiquedthetermforfailingtoaccountforthediversetypesofmedical travelthatpeopleundertake,forsuggestingleisureorfrivolity,andfordisregardingthe sufferingandlivedexperiencesofpatients(InhornandPatrizio2009;Kangas2010;Song

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19 2010).Otherterms,thoughttomoreaccuratelyreflectthepractice,havebeensuggested toreplacemedicaltourism,suchasmedicalmigrations,medicalexile(Matorras2005), medicalrefugees(MilsteinandSmith2006),biomedicalorbiotechpilgrimages, transnationaltherapeuticitineraries(Kangas2010),medicalortherapeuticjourneys. Someusetermsthataremorebroad,likehealthtourism,orlessvalue-laden,like internationalortransnationalmedicaltravel,medicalcareabroad,treatmentabroad,or justmedicaltravel. Itmaybeausefulexercisetodebatetherelativeworthoftheseterms,butitisnot theaimoftheresearchpresentedhere.Thefocusofthisethnographyistheformal medicaltourismindustrythathasdevelopedoverthepastdecade;thisindustrynamed itselfmedicaltourism,andinfacthasgonetogreatlengthstoprotectthisname.Inthe interestofdrawingcriticalattentiontothepowerrelationsatplaywithinthisemerging industryandtoavoidlinguisticde-politicizationofthiswork(Ormond2011),Iuse medicaltourism throughoutthedissertation. Additionally,whileitisimportanttonotethattherearepatientswhocrossborders outofnecessityordesperation,itisequallyimportanttonotethattherearemanywhodo not.Ithasbeenestimatedbysomethat80percentofthemedicaltourismindustryis centeredaroundcosmeticsurgery(Tatko-Peterson2006).Theformalmedicaltourism industryformeditselfaroundapopulationseekingelectivesurgeries,especiallyplastic surgery,atanaffordablecost.Theindustrymarketstothispopulation,particularlywithin theUnitedStatesagroupofpeoplewhoarehealthyenoughtotravel,butnotsohealthy thattheydonotneedcare,andagroupofpeoplethathaveenoughmoneytotraveltoa foreigncountry,butnotsomuchmoneythattheycanpaythehighpriceforcarewithin

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20 theUnitedStateswithoutbeingstrainedfinancially.Althoughitwasclearfromthose withwhomIspokethatthetourismpartofmedicaltourismwasoutweighedbythe medicalpart,adswithintheindustrynonethelessplayupthissenseofadventure,travel andleisureintheirpromotionofdestinationcountries.Eventhosepatientsrecovering fromelectivesurgeriesrarelydoalotoftravelingbecausetheyareeithertooweak,or toovisiblybruisedandscarredtoseekthesepursuits,butmostmedicaltouristsdobring companionswiththem,whotendtopartakeintouristactivities. Figure3:Medicaltourismadsfeaturingbeachesandothertouristattractions. (Sources,clockwisefromtopleft:ThaiTravelNews2011;EscapefromAmerica2011; MedicalTourismPanama2010;YourMedicalTravel2008;JohnnyForeigner2010; Surgeon&Safari2009) Medicaltourismtodayisanindustrywithanincredibleaggregatepotentialfor growth.Withinanthropology,itisvaluabletoexaminethespecialcasesofmedical travel,butitisequallynecessarytoexaminethemostwidespreadformsofmedical tourism.Thisethnographyaimstostudyupandtostudypower(Nader1974)by criticallyexaminingtheformalmedicaltourismindustry.

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21 ChangingPatternsofMedicalTravel Globalizationisnotnewtohealthcare;peoplehavesoughthealinginforeign landsforthousandsofyears.However,thistravelnowtakesaverydifferentpatternthan inthepastcentury,aspatientsnowtravelfrommoredevelopedcountriestoless developedcountriestotakeadvantageoflowercosts,proceduresthatmaynotbe availableintheirhomecountries,andarelativelyhighqualityofhealthcare.Inthepast century,itwasthemoredevelopednationsoftheworld,suchastheUnitedStatesandthe nationsoftheEuropeanUnion,thatwereconsideredpopulardestinationsformedicaland healthproceduresbecausethesenationshadthephysicians,facilities,andtechnologyto providehighqualitymedicalservicesthatmayhavebeenunavailableinmany developingnations.Today,thistrendhasreversed. Asthedemographicsofthesedevelopednationschangeandproblemswiththeir healthcaresystemsarisesuchaslongwaitinglistsforproceduresinCanadaandthe UnitedKingdom,ortheextremelyhighcostsofhealthcareandhighratesofuninsured citizensintheUnitedStatespatientsfromthesecountriesarenowseekinghighquality, lowcosthealthcareoutsideoftheirnationalborders.Inadditiontothesedemographic andsystemicchanges,easeoftravel,expansionoftheinternetandglobal communication,increasingportabilityofhealthinsurance,andtheretreatofneoliberal statesfromtheprovisionofpublicserviceshaveplayedaroleintheexpansionof medicaltourism(Kangas2010;Whittaker2010b). Innationsthatprovidepublichealthservicestotheircitizens,liketheUnited KingdomorCanada,theprimemotivationforcitizenstoengageinmedicaltourismisto avoidlongwaitlistsforproceduresintheirowncountries.Somemedicaltouristshave alsotraveledtoprotecttheirprivacy,particularlywhenreceivingcosmeticsurgeries,orto

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22 obtainservicesforwhichaccesswasrestrictedorillegalintheirhomecountry(specific examplesoftheseformsofmedicaltourismwillbediscussedinfurtherdetailinthenext section).TheprimaryreasonforAmericanstoseekhealthcareabroad,however,isthe lowercost,whichinsomecasescanbeaslowas10percentofthepriceintheUnited States.Aninefficientmarket-basedhealthcaresystemintheUnitedStateshasledto inflatedcostsofhealthinsurancethatnowleave47millionAmericansuninsured. Americanswhoareuninsured,underinsured,andwholackcoveragefordentalcareor electiveproceduresaretheprimarypopulationsseekingcareoutsideofthebordersofthe UnitedStates.Contrarytothebeliefsofmanymedicaltourismproponents,medical tourismisnotasaviorforpoor,sick,uninsuredAmericans;thepoordonothavethe meanstotraveloutofthecountryforcare,andtheveryillcannottravel.Furthermore,it isnottheelitewhotraveleither,becausetheycanaffordthehighcostofcarewithinthe UnitedStates.Rather,itisthosewhoaresomewhereinbetween:middle-classAmericans whoarenotwillingorabletopaythehighcostofhealthcarewithintheUnitedStates, butdohaveenoughexpendableincometotraveloutsideoftheUnitedStatesforcareand payoutofpocket.However,asinsurancecompaniesbegintoconsidermedicaltourism optionstosavecosts,thisprofileischangingtoincludemoreinsuredAmericans. Medicaltourismfacilitiesindevelopingcountriesareabletoprovideservicesat thesereducedcostspreciselybecauseoftheirinferioreconomicstatus.Lowerfixedcosts, wages,andadministrativeexpenses;cheaperpharmaceuticals;andtheabsenceofthe litigiousmedico-legalclimatethatexistsintheUnitedStatesallcontributetothiscost differential(Unti2009).Asanexample,theprofessionalliabilityinsurancepremiumfor

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23 asurgeoninIndiaisonly4percentofthepremiumforacomparablepracticingsurgeon inNewYork(Lancaster2004). TheProceduresMedicalTouristsTravelFor Althoughmedicaltourismasanindustrybeganwithproceduresoflimited medicalcomplexitylikeelectiveproceduresordentalcare,whicharenotcoveredon mostinsuranceplans,ithasnowexpandedintomorecomplexprocedures.Today, medicaltouriststravelforawidearrayofprocedures,fromheartvalvereplacementsto jointreplacementstobrainandspinalsurgeries.ThepopularpresswithintheUnited Statesmostoftenchoosestofocusonthesemorecriticalproceduresundertakenin foreigncountries,highlightingthereducedcost.Thisnotonlyservesasamarketingtool formedicaltourism,butalsoasareflectiononthehighcostswithintheU.S.health systemascomparedtoothercountries.Thiswasexemplifiedwiththehighlypublicized caseofHowardStaab,whotraveledtoIndiaforaheartvalvereplacementandsparked livelydebateaboutthebenefitsanddangersofmedicaltourismanditspotentialimpacts ontheU.S.healthcaresystem. 6 Patientsmostcommonlytravelforproceduresthatareavailableintheirhome countrybutthattheyhaveprohibitedorlimitedaccessto(e.g.,becauseofcostorwait time),buttherearethosewhotraveltoaccessproceduresthatareunavailableintheir homecountryaswell.Thismightbebecauseoflimitedinfrastructure,technology,or 6 HowardStaab,inmanyways,ispatientzerowithinthemedicaltourismindustry.In2004, Staab,53,uninsuredandself-employed,foundoutthatheneededamitralvalvereplacement, whichcostupwardsof$200,000intheUnitedStates.HetraveledtoIndiaandhadtheprocedure donefor$10,000.Hispartnerandtravelcompanion,MaggiAnnGrace,wroteabookabouthis lifesavingsurgeryinIndiaentitled StateoftheHeart .Thetworeceivedafloodofpress coveragethatspurredsubsequentdiscussionsaboutmedicaltourism.

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Table1 :CostComparisonofCommonMedicalTourismProcedure (MedicalTourismAssociation2010) 2 4 :CostComparisonofCommonMedicalTourismProcedure sbyCountry

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25 expertise,orbecauseaprocedureiscontroversial,experimental,orillegal. 7 Prominent examplesoftheseincludestemcell,organtransplant,reproductive,abortion,orgender reassignmentprocedures. Inthecaseofstemcelltourism,patientstravelabroadforstemcelltreatments thatarenotapprovedwithintheirhomecountries.Thisformofmedicaltourismislikely notasrelatedtocostasotherforms,butratheritrepresentshopeforpatientsseekinga cureforterminalillness(e.g.,Parke,etal.2010;Song2010).Liberationtherapy,also knownasvenoplastyorveinopening,forthetreatmentofmultiplesclerosisisanother exampleofanexperimentalprocedureforwhichpatientstravel.Anotherexample, thoughsignificantlylesscontroversial,ishipresurfacing,whichisnowanaccepted alternativetofullhipreplacement,butwasnotapprovedbytheFoodandDrug Administration(FDA)intheUnitedStatesuntil2006.Indiandoctorshadbeen performinghipresurfacingforoveradecadebythetimeFDAapprovalcamethrough (Neely2009).Becauseethicaldebatesandlegislativeprocessescantakeasignificant periodoftimeandregulatorystructuresaremorestringentindevelopedcountries, medicaltouristsmightchoosetoseektheseprocedureselsewhere. Inadditiontoexperimentalprocedures,therearemedicaltouristswhotravelfor illegalorhighlystigmatizedprocedures,suchasabortion(e.g.,SethnaandDoull2010) orgenderreassignmentsurgeries(e.g.,Aizura2010;Wilson2010).Whilenotalways illegalintheirhomecountry,theseproceduresareoftensostigmatizedthatpatients mightchoosetoleavetheirhomecountrytoensureprivacyoranonymity. 7 SeeKangas2010foranaccountofYemenitravelersseekingtreatmentsnotavailableinYemen forchronicillness,followingamoretraditionalpatternofmedicaltravelfromlessdevelopedto moredevelopedcountries.

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26 Anillegalandhighlycontroversialformofmedicaltourismthathasbeengaining attentionamongresearchersandthepopularpressistransplanttourism.Shortagesof donororgansfortransplantshavecreatedcommercialopportunitiesabroadintheglobal organtrade.Patientsinsearchoforganscannowpurchasethemontheblackmarket(itis illegaltopayfororgansintheUnitedStates).Thisisawayfordesperatepatientsto circumventtheregulatoryframeworkoftheircountries,butitraisesseriousbioethical concerns.Indevelopingcountries,thepoorsometimessellakidneyforaslittleas $1,0003,000;thesameorganisthensoldtoawealthypatientinadevelopedcountryfor upwardsof$40,000.Especiallyamongthepoor,thispracticecanhaveverydetrimental effectsonthehealthoftheorganseller(e.g.,Cohen2003;Cohen2005;Scheper-Hughes 2002).Themedicaltourismindustryhasstruggledwiththisissue,andalthoughmost medicaltourismassociationsnowsaythatpatientsmustbringtheirowndonor,thereis virtuallynoregulationofthispractice. Reproductivetourismisanotherformofmedicaltourismthathasbecome extremelypopularinrecentyears,sometimescalledprocreationvacationsinthepress. Duetothehighcostoffertilitytreatments,limitedinsurancecoverage,andlegaland policyimplicationsinsomecountries,womenandcouplestravelabroadforinvitro fertilization(IVF)treatments(e.g.,BlythandFarrand2005;InhornandPatrizio2009; Speier2011;Whittaker2010a).Whilethispracticeinitselfmightnotbeviewedas ethicallyquestionable,insomecases,thecouplemaychoosethegeneticcharacteristics ofthefertilizedeggthataremostdesirable,orhaveanotherwomanactasasurrogate mother.ThissurrogacypracticeoccursfrequentlyinIndia(e.g.,Kumar2008; Venkatachalan,etal.2010),whereinanIndianwomanisimplantedwithafertilizedegg

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27 andcarriesthepregnancytotermforacouple.Thegeneticparentscanevenshop around,lookingthroughphotosofpotentialsurrogates,evenincaseswherethe surrogatemothersgeneticmaterialisnotusedintheprocess.Potentialsurrogatesmust firstprovetheirfertilitybyhavingonechildoftheirown,andthenmayactasapaid surrogateuptofivetimes.Therateofcesareansectionsamongthesesurrogatesisnearly 100percent.Whilecesareansectionsprotectthehealthofthebaby,theyaremuchmore dangeroustothehealthofthesurrogatemother,especiallywhensomewomenundergo theproceduremultipletimesthroughouttheirproductiveyears(Venkatachalan,etal. 2010). AsMeghani(2010)notes,differentkindsofmedicaltourismprocedures,suchas reproductive,transplantandcosmetic,raisedifferentethicalissues.Theformsof medicaltourismdiscussedaboveraiseseveralsignificantethicalandmoralissues,from eugenicconcernstothepost-colonialvalueofthirdworldbodiesthatarenowbeing usedintheserviceofkeepingfirstworldbodieshealthy.Theseethicalimpactsof medicaltourism,aswellasthesocio-culturalandeconomicimpacts,willbediscussedin moredetailinChapterSix.Whileitisimperativethatthesecontroversialgrayareasof medicaltourismcontinuetobeexposedandcriticallyexamined,itisalsoimportantto keepinmind,again,thatalthoughmedicaltourismcantakeplaceinpursuitofurgent, controversial,orillegalprocedures,initscurrentstate,themajorityofproceduresare electiveornon-urgent.

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28 Table2:Commonsurgicaltreatmentspromotedbymedicaltourismagencies(Unti2009) Specialty Procedure Cardiacandvascularsurgery Aorticaneurysmrepair Atrialsepticdefectrepair Cardiacvalvereplacements:aorticandmitral Carotidendarterectomy Coronaryarterybypassgrafting Femoropoplitealbypasssurgery Varicoseveintreatments Cosmeticandplast icsurgery Abdominoplasty Blepharoplasty Breastaugmentation/reduction Cosmeticskinrefinishingandbodycontouring Faceliftsandimplantsurgery Liposuction Rhinoplasty Dentistryandoralsurgery Bridgesandimplants Endodonticprocedures;rootcanalsurgery Generaldentistryprocedures Orthodonticprocedures Toothveneers Ear,nose,andthroatsurgery Bronchoscopy Cochlearimplants Nasalseptoplastyandreconstruction Sinussurgery Tonsillectomyandadenoidectomy Tympanoplastyandtubeinsertion General,colorectal,andoncologicsurgery Bariatricsurgery;bandingandbypass Bowelsurgery:colectomyandotherprocedures Breastsurgery:biopsy,lumpectomy,mastectomy Cholecystectomy Gastrointestinalendoscopy:upperandlower Hemorrhoidectomy Herniorrhaphy Laparoscopicsurgery Neurosurgery Treatmentofbraintumors Treatmentofspinedisorders Skullbasesurgery Obstetricsandgynecology Gynecologiclaparoscopy Hysterectomy:abdominalandvaginal Invitrofertilizationandintrauterineinsemination Tuballigationandreversal Ophthalmologicsurgery Cataractsurgery Corneaalterationprocedures Glaucomatreatments

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29 Table2(continued) Orthopedicsurgery Anklefusion Arthroscopicandarthroplastyprocedures Carpaltunnelrelease Backprocedures:diskectomy,laminectomy,spinal fusion Hipreplacementandresurfacing Kneereplacement Shouldersurgery Transplantsurgery Organtransplantation:heart,kidney,liver,lung Urologicsurgery Cystoscopy Genitourinaryprostheticimplantsurgery Prostatectomy Testicularcancersurgery MedicalTourismDestinationCountries About20nationsareconsistentlyidentifiedaslegitimatemedicaltourist destinationsbythepopularpressandmedicaltourismcompanies.Someestimatethatas manyas50countriesmaybecurrentlypromotingmedicaltourism. Figure4:Mapofpopularmedicaltourismdestinations. CostaRica Cuba SouthAfrica Israel Jordan Turkey Lithuania Hungary Malaysia Thailand Argentina Brazil China Jamaica Korea Philippines Mexico Singapore India UAE Panama

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30 Fromanindustryperspective,thereisacertainblueprintfordestination countriesthatmustbemetbeforemedicaltourismispromotedthere.Theseincludean existingtourisminfrastructure,highqualitymedicalcareandtechnology,accredited facilities,apoolofskilled,English-speakingworkersandphysicians,andcapacitywithin theprivatesectortopromoteanddevelopthisindustry.Thesecriteriaautomaticallyleave outthepoorestofnations.Mostmedicaltourismdestinationsarelower-middleincome countriesthatalreadyhaveanactivetourismindustry. Additionallywhilequalitymedicalcareisessential,theseplacesmustalsomatch thetouristimaginationforsuchatrip.Theymustbeconsideredbeautiful,exoticand adventurousbutnotsoexoticoradventurousthattheylackmodernamenities.Medical touristsarealsoshieldedfromtheundesirablethirdworldcharacteristicsofthe destination,suchaspoverty,violence,orunsanitaryconditions. Inadditiontohighqualitymedicalservices,medicaltouristsalsoexpectto receiveVIPtreatmentwhentheyobtainhealthcareabroadpersonalmedicalattention, luxuryaccommodations,door-to-doortransportationservices,personalcareduringthe recoveryperiodandhighqualitymeals(Turner2007).Manyfacilitiesprovide internationalpatientswithahospitalsuitecomparabletoafivestarhotel,completewith flat-screenTVs,wirelessinternetaccess,guestsuitesandsidetripstolocaltouristsites. BumrungradInternationalHospitalinBangkok,Thailandisthelargestprivatehospitalin SoutheastAsiaandservesover400,000foreignerseachyear(BumrungradInternational Hospital2012).Itisthefirst,andmostwell-knownmedicaltourismfacility,andisan exampleofafacilitythatofferstheseamenities;italsocontainsaStarbucks,AuBon Pain,andMcDonaldsinitslobby.

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31 Figure5:BumrungradHospitallobbyandapatientroom. (MedicalTravelSite2007;Bloomberg.com2011) Itisnotalwaysthemodernamenitiesandconciergeservicesthatmostappealto medicaltourists.Medicaltouristsoftenimaginethemselvesrefugees,escapingan inequitable,unjust,uncaringhealthcaresystemthatdoesnotcareabouttheirneeds.They aredrawntothenotionthatwarmandcaringnursesandphysiciansindestination countrieswillspendtimewiththemtoassuagetheirfears,andgivethemthepersonalized carethattheydesire.InCostaRica,foreignpatientswhowererecoveringfromplastic surgeryfeltthathealthcarepersonnelhadadifferentmindsetaroundhealthcare provisionandaconcernforthetotalwellbeingofthepatient(Ackerman2010).Thisis ironic,because,atthesametime,medicaltourismiscontingentonintensified commercializationandWesternizationofmedicalservicesinCostaRica,aswellasthe expansionofaneoliberalmodelofhealthcare.AtthesametimethatCostaRicaisseen aspeaceful,green,naturalanddifferentfromtheUnitedStates,itmustbeperceivedas havingadvancedWesternbiomedicaltechnology,physiciansandstandardsofcare. Itisimperative,then,thatdestinationcountrieswalktheselines.Theymustbe exoticenough,butnotsoexoticthatpatientsfeeluncomfortabletravelingthere;they mustbepoorenoughfortheretobeacostdifferentialincare,butnotsopoorthatthey

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32 areunabletoprovidequalityhealthcareandinfrastructure;andtheymustbeseenas fundamentallydifferentfromWesternnotionsofbiomedicine,whileatthesametime offeringWesternbiomedicalcare. TheCurrentStateoftheMedicalTourismIndustry Whereasthepracticeofmedicaltourismbeganatanindividuallevel,apowerful industryhasformedaroundthispracticewithinthepastdecade,andthenumbersof medicaltouristshaveincreaseddramatically.AreportbytheDeloitteCenterforHealth Solutions(2008)estimatedthat750,000Americanstraveledabroadformedicalcarein 2007andprojectedanincreasetomorethan1.6millionby2012,withsustainableannual growthof35percent.Theyfurtherestimatedthattheworldwidemarketformedical travelwasworth$60billion,andexpectedthatitwouldgrowto$100billionby2020. DataChallengesandQuestionablestatistics Thesefiguresarelikelythemostquotedstatisticsonglobalmedicaltourism,but eventhesearequestionable,anditisnotclearhowthesefiguresweredetermined. Inconsistentdefinitionsandmethodsforcollectingandreportingmedicaltourismdata makeitextremelydifficulttoprovideanaccurateestimateofthenumberofmedical touriststravelingforhealthcare.Aresearcherwhopublishesonmedicaltourism criticizedthedatacollectionofmajorresearchfirms,stating,Accuratefigureson medicaltourismarenoteasytocomebybydefinition,almosteveryofficialfigureis flawed.Theyareoftenbadlycollected,imperfectlycollatedandspuntoinfinity (Youngman2009). Oneoftheprimarychallengesofcollectingdataisdetermininghowmedical tourismisdefined.Whilemedicaltourismasaglobalindustryhasbeenwidelydefinedas

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33 patientswhotravelforthespecificpurposeofreceivingmedicaltreatment,thisdefinition doesnotalwaystranslateintoattemptstomeasuretheflowofpatients,whichsometimes includetouristswhohaveanaccidentwhiletraveling,orexpatriateswholiveinthe countryandreceiveregularhealthcarethere,asmedicaltourists.Desiresforprivacyof travelingpatientsalsoresultsinunderreportingofproceduresbypatients.Additionally, medicaltourismstatisticsseemtochangedependingontheparticularagendaofthe reportingagencyorfacility.Forexample,whentryingtopromotethemedicaltourism industrytopatientsorinvestors,numbersofmedicaltouriststendtobegreatly exaggeratedbyreportingagenciestogivetheimpressionthatmedicaltourismismore mainstreamandlessrisky.Somehospitalsalsoinflatetheirfiguresbycountingthe numberofpatientvisitsinsteadofthenumberofvisitingpatients.Youngmansaysthat agencies,experts,politicians,andhospitalsoftenmakeludicrousestimatesofactualor potentialnumbersandgivesanexampleofanAsianministerwhosaidhiscountryhad 100,000medicaltourists,whilethenextweekanotherministerclaimeditwas200,000 (2009).Ontheotherhand,whenreportingpatientnumberstothegovernmentfortax purposes,especiallywithinsmallerclinics,numberstendtobeunder-reported. Aftersortingthroughthedataandpickingoutwhathedeemedthemorereliable sources,Youngmanestimatedthatthenumberofmedicaltourists,excludingemergency cases,expatriates,thosewhotravelforwellnessorspas,andinternaltravel,a conservativeestimatewouldbeintherangeof5millionmedicaltouristsglobally. Despiteascarcityofaccuratedata,thereisnoquestionthatmedicaltourismhas increasedsignificantlyasapractice,andcontinuestodoso.Whatisnoteworthyisits shiftfromaverysmallnichemarkettoaboominaveryshortperiodoftime,asthe

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34 practiceshiftsfromanindividualtoanaggregateform. GlobalActorsintheMedicalTourismIndustry Theremarkablepotentialofmedicaltourismanditsrapidexpansionhasresultedina dramaticincreaseinthenumberofactorswithstakesinthisnewindustry.Inadditiontothe riseinnumberofassociationsorfacilitatorcompaniesthatactasintermediaries,thenumber ofinsurancecompaniesexploringmedicaltourismasanoptionandthenumberofaccredited healthcarefacilitiesthatcatertoforeignershavebeenontherise.Theseactors,whoserveto overseeandregulatetheindustry,promotequalityservicesandprotectthereputationofthe industry,aswellastoprofitfromit,arediscussedinthesectionthatfollows. MedicalTourismFacilitatorCompanies Medicaltourismisoftenpartofapackageinwhichallarrangements,medicaland otherwisefromobtainingapassportorvisa,toflight,groundtransportation,hotelstay, meals,andtourismorvacationplansaretakencareofbyasinglemedicaltourism facilitatorcompany.Facilitators,formerlycalledbrokerages,takethelegworkoutof arrangingcareabroadbyworkingwithreputableprivatehospitals,physicians,travel,and accommodationproviders.Thenumberofmedicaltourismfacilitatorshasexpanded exponentiallyinthepastfiveyears.Currently,therearemorethan100U.S.-based facilitators;fourfacilitatorcompanieshaveopenedinColoradosince2007.These companiesareprivate,for-profit,andtypicallyownedandoperatedbyAmericanCEOs. Theychargefeestotravelingpatients(orcompanieswhosendpatients)forarranging theseservices,aswellasafeetoforeignhospitalsforprovidingthemwithpatients, usuallyapercentageofthetotalcostoftheprocedureperformed.AlthoughtheUnited

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35 Stateshasaveryhighnumberoffacilitatorcompanies,thesecompaniesdoexistin severalothercountries(bothsendingandreceiving)aswell. InternationalAccreditations&Branding Turner(2007)discussesthewaysthatthemedicaltourismindustrysignals quality,meaningthatinordertobesuccessful,theindustrymustpresentitselfassafe, well-regulated,andpossessingthesamestandardsforhealthcareasintheUnitedStates. Oneoftheprimarywaysthatmedicaltourismfacilitatorsandinternationalhospitals signalqualityisthroughinternationalaccreditation.U.S.-basedJointCommission International(JCI)isoneofseveralgeographicallyspecificaccreditingorganizations, andthemostrecognizedaccreditingbodyforU.S.patientstravelingabroadforcare. 8 It wasestablishedin1997andaccrediteditsfirsthospital(inBrazil)in1999.Sincethen, JCIhasaccreditedover300publicandprivatehealthcareorganizationsin39countries (JointCommissionInternational2011).Smallerfacilitiesareaccreditedbyseparate organizations,suchastheAccreditationAssociationforAmbulatoryHealthCare (AAAHC),whichaccreditsclinics. 8 OtheraccreditingagenciesincludetheInternationalSocietyforQualityinHealthCareInc. (ISQua),TrentAccreditationScheme(TAS)outoftheUK,AccreditationCanada,Australian CouncilonHealthCareStandards(ACHSI),andIrishHealthServicesAccreditationBoard, amongothers.

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36 Figure6:AmedicaltourismbloggershowsthatBumrungradHospitalinThailandis U.S.Approved!(Anti-AgingandLongevityProject2009) Anotherwaythatqualityissignaledisthroughco-brandingwithwell-known, medicalfacilitieswithintheUnitedStatesandEurope.Respectedmedicalcentersinthe UnitedStates,suchastheClevelandClinic,HarvardMedicineInternational,Johns HopkinsHospital,DukeMedicine,CornellMedicalSchool,andColumbiaUniversity MedicalCenter,havepartneredwithhospitalsabroadtopromotequalityservicesat lowercosts(e.g.,DeloitteCenterforHealthSolutions2008;MilsteinandSmith2007; Sobo,etal.2011).ItmustbenotedthattheseU.S.hospitalchainsretainaportionofthe profitsmadebytheirinternationalaffiliates. Inadditiontothehighlightingofaccreditationandco-brandingwithWestern affiliates,studiesofhowmedicaltourismassociationsandcompaniesmarkettopotential medicaltouristshaveshownthattheWesterneducationandtrainingofphysiciansin destinationcountriesisplayedupaswell(e.g.,Johnston,etal.2010;Sobo,etal.2011). AdstypicallystatethatmostoftheirphysiciansareeducatedinU.K.orU.S.andare boardcertified(Sobo,etal.2011).Stateoftheartfacilitiesandcuttingedge technologyarealsoadvertisedveryprominentlytosignalquality.

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37 InternationalInsuranceCompanies Althoughinsurancecompanieshavebeenslowtoadoptmedicaltourismoptions, thereareseveralthatarepilotingprogramswithintheirexistinghealthbenefitplans. AnthemBlueCrossandBlueShieldofWisconsin,UnitedGroupProgramofFlorida, BlueShieldandHealthNetofCalifornia,andBlueCrossBlueShieldofSouthCarolina arealltestingthewaterswithpilotmedicaltourismplans,andsomethirdpartygroups, likeUnitedHealthCare,havestartedtoreimbursepatientsforproceduresundertaken outsideoftheUnitedStates(DeloitteCenterforHealthSolutions2009).In2006,the UnitedStatesSenateSpecialCommitteeonAgingheldahearingonmedicaltourism, callingataskforceofexpertstoexploretheimpactandsafetyofthispractice.In addition,statelegislativebillswereintroducedinbothColoradoandWestVirginiain 2007toincentivizestateemployeestocrossbordersforhealthcare(Assembly2007; WestVirginiaGeneralAssembly2007).Althoughneitherbillpassed,andtheSpecial Committeehearingneveramountedtomuch,theseactionswerenotableinthatstateand federallegislatorswerenoticingthepotentialcostsavingsofmedicaltourismatan aggregatelevel. 9 TheguidelinesformedicaltourismreleasedbytheAmericanMedicalAssociation (AMA)(2008)statedthattravellingabroadforcaremustbevoluntaryandthatdomestic alternativesshouldnotbeinappropriatelylimited.Whiletherewerenocasesof companiesrequiringthatpatientstravelabroadforcare,itisclearthat,todate,most insuredpatientschoosenotto.AetnaInc.offeredcoverageabroadfor27,000employees 9 Bothbillswereviewedasaggressiveintheprovisionoffinancialincentives,andthismayhave beenaprimaryreasonwhytheywererejected.

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38 ofHannafordBros.supermarketchaininthenortheast,andtwoyearslater,notone employeehadchosenthisoption(Bajgrowicz2010). MedicalTourismAssociations Medicaltourismassociations,suchasCalifornia-basedHealthCareTourism International(HTI),whichopenedin2006,andtheFlorida-basedMedicalTourism Association(MTA),whichopenedin2007havebeenestablishedtopromotetheindustry andprotectitsreputation.TheMTA,inparticular,hastriedtoestablishitselfasthe leadingtradeassociationformedicaltourisminternationallyandpromotesitselfas objectiveresourcefortransparency,communication,andeducationwithintheindustry. Theassociation,madeupofinternationalhospitals,insurers,agencies,educational institutions,andotheraffiliatedcompanieswhosepurposeistoincreasetheawareness andutilizationofoverseashospitalsformedicalcare,targetsU.S.consumersin particular.Whenlaunched,thestatedgoalsoftheMTAweretopromoteuseoftheir hospitalandclinicaffiliatesbypatientsandinsurers,tocontrolthegrowthandstandards oftheindustry(standardsbasedonU.S.criteria),toprotectthereputationofmedical tourismthroughqualityassurancemeasure,toactastherepresentativefordealingwith thegovernmentsofU.S.anddestinationcountries,andtocreateacomprehensivewebsite forpeopletolearnaboutmedicaltourism(2007). Althoughlegallyanon-profit,theMTA,ownedandrunbyacouple,Jonathan EdelheitandReneMarieStephano(bothattorneys)hasdrawnmuchcriticismforusing theorganizationsnon-profitstatusasashieldtorunprofitableactivities(Ratner2009) andforlegallyandethicallyquestionableactivitieswithinthesector.Stephanosetupa veryprofitableconferenceandeventbusinessthatrunstheannualWorldMedical

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39 TourismandGlobalHealthCongress(WMTGHC)fortheMTA,nowinitsfifthyear, whichlinksmedicaltouristcompanies,large-scaleemployers,insurancecompanies,and internationalhospitalsintobusinessnetworks.Theregistrationfeeforthecongressis $1,200,andpriorityisgiventospeakerswhosponsortheevent(Ratner2009).Congress sponsorspayanywherefrom$500to$100,000,dependingontheirlevelofsponsorship, withhigherlevelsofsponsorshipyieldingmoreadvertisingexposureandotherbenefits. TheMTAalsopublishestwotrademagazinesonmedicalandhealthtourism,whichsell adspacetomembersandfeaturedestinationsthatarepayingmembersoftheassociation. TojointheMTA,feesareanywherefrom$500(foranindividual)upto$5,000(for medicalorpharmaceuticalsuppliers).Hospitalspay$3,000formembership,and governmentspay$2,000.Additionally,theMTAhasastringoftrademarkedcertification programsthatmemberscanpaytogothrough. 10 CriticsoftheMTAhavesuggestedthat thenon-profitMTAismerelyashellcompanyfortheseprofitableactivities. AddingtotheseconcernsovertheactivitiesandtransparencyoftheMTA,in 2009,theMTAsuedanotherassociation,Singapore-basedInternationalMedicalTravel Association(IMTA)overservicemarkinfringementandunfaircompetition,despitethe factthatthetwoassociationshaveverydifferentagendasandgeographicserviceareas. Onecommenterwrote,Itisdeplorablethatthetwolawyerswhoownanassociationthat hasonlybeenintheindustrysinceMayof2007believetheyownthewordsmedical tourismassociation,whichdescribesaconceptusedregularlybythemedia,thepublic, andisnotuniqueinanyway(Ratner2009).Discussionoverwhoownsmedical 10 Theseinclude InternationalPatientServicesCertificationforHospitalsandClinics, InternationalPatientCenterTraining(whichmustbereceivedpriortotheInternationalPatient ServicesCertification,CertifiedInternationalPatientSpecialist,andaMedicalTourism FacilitatorCertification.

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40 tourismheatedupagainin2011whenawriterforInternationalMedicalTravelJournal (IMTJ)foundthatEdelheithadregistered370webdomainnamesofpotentialmedical tourismwebsites,includingdomainnamesthatshouldbelongtocompetitorconferences andcompanies,suchastheannualEuropeanMedicalTravelConference(EMTC)andthe TrentAccreditationScheme(analternateaccreditingbodytotheJointCommission InternationalwhichismorepopularinEurope).Additionally,Edelheitregistereda domainforacommonmisspellingoftheleadinginternationalmedicaltourismhospital BumrungradHospitalinThailand(EdelheitregisteredBrumrungrad.com)sothatany userswhomisspelledthehospitalsnamewouldberedirectedtotheMTAwebsite (Ratner2009). Thoughtheaccusationsdiscussedabovehavenotbeenresolvedyet,thepointmustbe madethatmedicaltourismisnotabenignindustrythatexistsonlytoprovidehealthcareto thoseinneed.Especiallyasmedicaltourismcontinuestoshiftfromanactivityofindividual patientstoanactivitycoveredbyhealthinsuranceplans,theaggregatepotentialofthe industryisdrasticallyincreasing.Ithasbecomeabigbusiness,withmanycompeting interestsandpowerfulactorsinvolved.Thereismuchprofittobemadeinthisindustry.

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41 Figure7:Amodeloftheglobalmedicaltourismindustry(createdbyauthor). TheRoleofGovernmentsinDestinationCountries Thelevelofinvolvementandroleofgovernmentsindestinationcountriesvaries, thoughwithintheindustryblueprint,thereisaplanforhowthisshouldwork.The MTApromoteswhatitcallsahealthcareclusterinmembercountries.Ahealthcare clusterisgenerallyanindependentorganizationofhospitals,clinics,medical professionals,supportingbusinesses(i.e.,accommodations,transportation,aftercare,and tours)andthegovernment,whichallcometogethertosupportthemedicaltourism industry(Cook2008;MedicalTourismAssociation2012).Theclusterisfundedbyall participantsandmaybesupportedbygovernmentfunding.Itismeanttorepresentthe interestsofallofitsmembers,topromotethemembersofthecluster,andtobuildthe reputationofthecountryformedicaltourism.TheMTAsuggeststhatadvertisingand Tertiary RegionalInstitutions WorkforceStructure DevelopmentPolicies NationalInfrastructure PolicyMakers ResearchInstitutions JointCommissionInternational TrentAccreditationScheme InternationalOrg.forStandardization Accreditingbodies Secondary GovernmentAgencies Privateinsurance Public/socialinsurance Privateemployers Insurers& Employers Tourism Industry MedicalSuppliers MinistriesofHealth TourismBureaus ForeignTradeBureaus FDA,orequivalent SocialInsuranceInstitutions Hotels Transportation TourOperators Technologies Pharmaceuticals Core MTAs Facilitators HospitalGroups/ Hospitals

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42 marketinggoalsbeestablishedandthatthesetieinwiththeMinistryofTourismandthe MinistryofHealthforgovernmentalsupport.Theclusteristopromotetheimageof countryaboveallelse,andregulatewhoshouldbeabletopromotemedicaltourism withinthecountry(EdelheitandStephano2008).AccordingtotheMTAmaterialson developingahealthcarecluster, Formingahealthcareclusterisprobablythemostimportantsinglestepin establishingamedicaltourismdestinationandtoenhancethelocations chancesofsuccessasadestinationformedicaltouristsandincreasing patientflow.Allthemedicaltourismstakeholders,suchashospitals, doctors,MinistryofHealth,Tourism,EconomicDevelopment,Tourism Operators,Hotelsandmoremustworktogethertopromotethisimageof highqualityofhealthcaretoestablishabrandnameforthelocation throughouttheworld(MedicalTourismAssociation2012). Itfurtherstatesthatover40governmentsareinvolvedinsupportingmedical tourism,anumberthatisgrowing,andthatgovernmententitiesshouldworktogether withtheprivatesectoronmedicaltourisminitiatives.Whatisnotcleariswhetherthese governmentsreceiveanybenefitsfromtheindustry,orwhatthosebenefitsmightbe. GlobalImpactsofMedicalTourism Thusfar,mostdiscussionoftheimpactsofmedicaltourismhasbeenaroundhow thispracticewillaffecttheU.S.healthcaresystem.ReportswithintheUnitedStates contendthatthisgrowthholdsimportantimplicationsforU.S.healthcareproviders, healthplans,consumers,andthegovernment,(Unti2009)andmayresultina$16 billionlossinrevenueforU.S.healthcareproviders(DeloitteCenterforHealth Solutions2009).ManyhealthcareproviderswithintheUnitedStatesexpressanimosity towardspayersthatsendpatientsawayandpatientswhochoosetogoabroad,therefore eliminatingdomesticrevenues,butexpectphysicianstoprovidefollow-upcarefor patientsreturninghome(whichhaslowercompensation).ACostaRicanphysicianwhom

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43 Ispokewithtoldmethestoryofoneofhispatients,awomanwhocametohimfora facelift,forwhichhecharged$3,000.Sheneededfoursuturesremovedwhenshe returnedhometotheUnitedStates,andherU.S.physician,upsetthatshehadgonetoa foreigncountry,toldherthathewouldchargeher$3,000toremovethesutures.Onthe otherhand,somearguethatmedicaltourismwillactasareliefvalvefortheU.S.health caresystem,reducingsomeoftheburden,andallowingthosewhocannotaffordcareto finditelsewhere.RatherthanasolutiontotheproblemsoftheU.S.healthcaresystem, medicaltourismisasymptomofitsmalaise. AlthoughimpactsontheU.S.healthcaresystemareprominentindiscussionsof medicaltourismsgrowth,veryfewquestionshavebeenaskedaboutwhatthisgrowth couldmeanforthedestinationcountriestowhichpatientsaretraveling.Becausetherise ofmedicaltourismisarelativelyrecentphenomenon,andbecauseaccuratedataishard tocomeby,manyofitspurportedimpactsarespeculative.Untilveryrecently,critiqueof medicaltourismfromthesocialscienceshasbeenalmostnonexistent.Meanwhile, powerfulglobalindustryactorshavebeenferventlypreachingthebenefitsofthe industryathomeandabroadsinceitsinception.Theirconsiderableideologicaland financialinvestmentsinmedicaltourismhavetranslatedintomediainundationwith upbeat,optimisticaccountsofmedicaltourismanditsbenefits,andmutedcriticisms.The followingsectionlaysouttheproposedbenefitsofmedicaltourismondestination countryhealthsystems,aswellasthepotentialnegativeimpactsandconcernsaboutthis expandingindustryatagloballevel.

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44 ThePotentialBenefitsofMedicalTourismforDestinationCountries Theargumentssupportingmedicaltourismareprimarilyeconomic.Medical tourismembodiesthepromisesofaneoliberalhealthcareeconomyandisviewedasa progressiveeconomicstrategybymanyindustryactors,aswellasgovernmentactorsin destinationcountries. 11 Itboostsrevenuewithinthetourismsector,anddoessoatarate estimatedtobeatleastfourtimeshigherthanconventionaltourism(Taborda2011).Itis reportedthattheserevenuesdonotjuststaywithinthehealthsector,butimpactauxiliary industriesaswell,stimulatingrippleeffectsatrecoveryretreats,hotels,touroperators, transportationservicesandatthegovernmentlevel(Cook2008).Medicaltourismis alsoanimportantareaofgrowthforforeigninvestmentindestinationcountries. Theunderlyingassumptionisthatincreasednationalrevenuetranslatesinto improvedhealthcareforthecitizensofdestinationcountries.Advocatesofmedical tourismclaimthatrevenueearnedthroughperformingmedicalproceduresforforeigners willsupportthepublicsectorandcomplementpublichealthefforts,withtheseeffects tricklingdowntothepoor.Itisalsoassertedthatmedicaltourismwillcreatejobsfor locals(bothwithinandoutsideofthemedicalfield),promisingtohaveimportant knock-oneffectsthatmaybenefit eventhepoor (Economist2008,emphasismine). Proponentsalsoarguethatmedicaltourismwillreversebraindrainbykeeping professionalspracticingintheirhomenationsratherthanemigratingtopracticeinforeign countrieswherepayishigher.TheheadofWockhardthospitals,alargemedicaltourist hospitalgroupinIndia,reportedthattwodozenIndiandoctorsreturnedfromtheUnited StatesandtheUnitedKingdomtoworkinhisfacilities(Madden2008). 11 NeoliberaldiscourseanditsroleintheexpansionofmedicaltourismgloballyandwithinCosta RicawillbediscussedindetailinChapterFour.

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45 Manywithintheindustryclaimthatmedicaltourismactuallyincreasesqualityof carewithinboththepublicandprivatesectorsindestinationcountriesbyimproving standardsofcare,infrastructure,technologyandtraining.Stephano,oftheMTA,states thatitraiseshealthcarestandardsandincreasescompetition,whichraisesthebarevenin thepublicsector(Murray2009).Othersclaimthatmedicaltourismisgooduseofthe excesscapacityofprivatehospitals,andincreasestheavailabilityofdiversespecialists forthewholepopulation(BookmanandBookman2007). Medicaltourismcanalsoserveassourceofnationalpride.Song(2010)discusses theinversionofcoreandperipherywithinbiomedicalresearchthatmedicaltourism represents,highlightingthestoryofaChinesephysicianwhoprovidesstemcell treatmentstoparalyzedpatientswhotravelfromcountriesconventionallythoughttobe technologicallysuperiortoChinatoreceivethiscare.Thephysicianjustifieshisdecision totreatforeignersoverChinesepatientsasawaytoassertChinasnewdominanceand superiorityinthefieldofregenerativemedicine(Song2010).Theintersectionofmedical tourismwithnationalrhetoricinCostaRicawillbediscussedingreaterdetailin subsequentchapters. ThePotentialHarmsofMedicalTourismforDestinationCountries Areweinthewealthyworldreallysoblindandselfishthatitdoesnot evenoccurtoustoasktowhatextentmedicaltourism,intheend,boils downtopoorcountriessubsidizingthecostofhealthcareforrich countries?(ReadercommentinMilstein2009) Critiquesofmedicaltourism,likethisone,increasinglysuggestthateconomic andotherconjecturedbenefitsdisproportionatelyfavorthesendingnationsand negativelyimpactlocalaccesstohealthcareindestinationcountriesinanumberof

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46 ways.Inshort,thecostsofmedicaltourismtopublichealthprovisionmayoutweighthe benefits. First,aspreviouslymentioned,inorderformedicaltourismtopresentacost differentialattractiveenoughforforeignerstotravel,inequitiesbetweenthesendingand receivingnationsmustremainrelativelystable.Thismeansthatifdestinationscountries receivesignificantboostsintourismrevenuethattranslateintoincreasedwagesfor medicaltouristphysicians,orhigherfixedcostsoradministrativeexpensesthatpushthe priceofmedicaltourismup,thedemandformedicaltourismwilldecline,andthe industrywilllikelyshiftitsfocustoothercountriesthatcanmaintainabetterprice differential.Medicaltourismmayalsocontributetohighercostsofhealthcarewithinthe privatesectortocreatelocalfreezones(BlythandFarrand2005)intheprivatesector, aspricesincreasetolevelsthatareinaccessibletolocals. Similarly,theprofitsfrommedicaltourismthataresupposedlygoingtowards improvementsinpublichealthseemtoremainalmostexclusivelywithintheprivate sector.Medicaltourismcontributestothedevelopmentofatwo-tieredhealthsystem whereelite,technologicallysophisticatedhospitalscatertowealthyforeigners,whilethe impoverishedmajoritymustusepoorlyresourcedpublichospitals.Althoughmedical tourismdidnotcreatetheseproblems,itrepresentsthemanifestationofinequitableand inefficienthealthcaresystems,andhasthepotentialtoworsenexistingconditionsin developingcountries.Thereiscurrentlynomechanisminplacetoensurethatmedical tourismsupportspublichealthcaresystemsindestinationcountriesinawaythathelpsto alleviatetheseinequities.

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47 Muchoftheprofitgeneratedbymedicaltourismremainswithforeignersrather thanwithdestinationcountries.Medicaltourismassociations,facilitatorcompanies, accreditationschemes,recoveryhomes,aswellasprivatehospitalsandhospitalgroupsin destinationcountriesareoftenforeign-owned.Inaddition,manyofthephysiciansthat workwithinmedicaltourismreceiveatleastsomeoftheirmedicaltrainingintheUnited StatesandEuropeandholdmembershipsinmedicalorganizationthere.Muchofthe state-of-the-arttechnologythatisusedwithinthemedicaltourismindustryisalso importedfrommoredevelopedcountries,furtherdivertingrevenues.Theprivilegingof Westernbiomedicineandtechnologywithintheindustrymeansmoreprofitsstaywithin theWesternworld. Beyondeconomicramifications,medicaltourismalsohasimplicationsforthe qualityofhealthcarewithindestinationcountries,ashumanresourcesmaybesiphoned fromthepublictotheprivatesector.Externalbraindrainwhereinhealthcarepersonnel leavedevelopingcountriestopracticeinmoredevelopedcountrieswheretheyearna highersalaryinthepresenceofmedicaltourismisbeingreplacedbyinternalbrain drain,ashealthcarepersonnelleavethepublichealthcaresectortoworkinprivate hospitalsthattreatwealthymedicaltourists. MedicaltourismwasrecentlycitedinThailandsphysicianshortage,as physiciansopttopracticeathospitalslikeBumrungrad,whereremunerationishigher (NaRanongandNaRanong2011).Manyofthesedestinationcountriesarealready plaguedwithhumanresourceshortages.Between1990and2004,Indiahadonly60 physiciansper100,000people,whiletheUnitedStateshad256physiciansper100,000of itspopulation,andyetThailandandIndiaaretheleadingdestinationsformedicaltourism

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48 (Meghani2010).Physiciansoftenchoose,aswell,tospecializeinproceduresthatcaterto foreigndemand,ratherthanpreventiveorprimaryhealthcare. Overarchingthesemoretangibleeffectsofmedicaltourismoneconomicand humanresourcesareimpactsatanideologicallevel.Medicaltourismoperatesfromthe fundamentalassumptionsthathealthisacommoditysubjecttotheforcesofthemarket, andthataneoliberalhealthcaremodelisthemosteffectivewaytoprovidehealthcare. Thereisironyinthefactthatmedicaltourismsubsistsonthefailingsofthismodelof healthcareindevelopednations.Therapidlyexpandingtradeinhealthcarehas implicationsforthehealthsystemsofbothsendingandreceivingcountries,butmore fundamentallyontheviewofhealthasacommodityratherthanarightandglobalpublic good. TheResearchProject Therearesignificantgapsinourunderstandingsofthisnewconfigurationof healthcaremobilityanditsimplications.Thisresearchcriticallyinvestigatesthese potentialandactualimpactsofmedicaltourismonthehealthsystemsofdestination countries.Medicaltourism,asaglobalindustry,representsanewformofhealthcarein anincreasinglyinterconnectedworld.Itraisesmanyquestionsabouttheshiftingroleof thestateinhealthcareprovision,globalgovernanceforthisemergingindustry,andthe effectsthatneoliberalmodelsofhealthcarehaveondestinationcountrieswithvery disparatehealthcaresystems.Amongdestinationcountries,CostaRicastandsout becauseofitssuccessfulsocializedhealthcaresystemandtheprinciplesonwhichitwas founded.Itprovidesauniquecasestudytoexaminetheeffectsofthisemerginghealth careeconomyanditsideologicalcontradictions.Inthechaptersthatfollow,bothglobal

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49 andlocalaspectsofthemedicaltourismindustry,aswellasitsimplications,are examinedwithinthespecificCostaRicancontext.

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50 CHAPTER3:HEALTHWITHOUTWEALTHTHECOSTARICAN CONTEXT Tounderstandlocalimpactsonhealthsystems,itisimportanttofirstsituatethe researchwithintheLatinAmericanandCostaRicancontexts.Althoughglobalmedical tourismisbecomingmorestandardizedonthesideoftheindustrywiththeemergenceof internationalactorsandstandards,itcannotbeassumedtohaveahomogenouseffect acrossdestinationcountriesthatareverydifferentpolitically,culturally,socially, historically,andeconomically. ThischapterbrieflydiscusseshealthsystemsinLatinAmerica,beforeshiftingto anin-depthdiscussionoftheCostaRicancontext.Itincludesanoverviewofnationaland healthsystemhistoryanddevelopment,thecomplementaryroleofmedicaleducation, andlocalopinionsofthehealthsystem.IargueinthischapterthatCostaRicaverymuch fitstheblueprintcriteriaoftheglobalmedicaltourismindustry,butthatitsnational healthachievementsarebasedonverydifferentideologiesthanthemedicaltourism industry.Ononehand,CostaRicassuccesseshavebeentheresultofastrongwelfare stateandprogressivesocialpoliciesthatviewhealthcareasarighttowhichallare entitled,whileontheotherhand,medicaltourismisbasedonneoliberalprinciplesthat viewhealthasacommodity,tobepurchasedbythosewhohavetheabilitytopay.This chapterwillserveasanintroductiontoseveralofthethemesthatwillbeexpandedupon inlaterchapters. SocialMedicineinLatinAmerica WhilenationsintheLatinAmericanregiondevelopedalongdifferenttrajectories, generalsimilaritiesamongtheirhealthsystemsdoexist,primarilyanorientationtowards

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51 socialmedicine.Thoughdefiningsocialmedicinecanbecomplicatedandpolitically loadedsocialmedicinemostgenerallyreferstoastate-supportedsystemofhealthcare delivery.Thismeansthatthegovernment could fullycontrolthedeliveryandfinancingof healthcare,thoughinpractice,socializedmedicinerepresentsarangeofstrategies,from completegovernmentownershipoffacilitiesandemploymentofhealthcareproviders,to publicfinancingofprivateinsuranceandproviders.InLatinAmerica,theprinciples underlyingsocialmedicinebeliefsthatsocialandeconomicconditionsimpacthealth, thatthehealthofthepopulationshouldbeamatterofsocialconcern,andthatsociety shouldpromotehealthandprovidehealthcareserviceshaveplayedprominentlyin healthsystemdevelopment(Waitzkin,etal.2001).Becauseofthis,LatinAmerican countrieshistoricallyhaveplacedhighpriorityonsocialwelfareprograms,particularly educationandhealth,andtheseprogramshaveoftenfocusedonthepoor.Thesenations haveseenremarkableimprovementsinhealthindicatorsovertime,withtheaveragelife expectancyforLatinAmericaandtheCaribbeanincreasingfrom57yearsin1960to70 yearsintheyear2000.Nonetheless,thereremainsignificantintraregionaldifferencesin healthindicatorsandachievements.Forexample,intheyear2000,CostaRicaandCuba hadthehighestlifeexpectanciesintheregion,at78and77years,respectively,while BoliviaandGuyanahadthelowestat63yearsastriking15-yeargap(Soares2009). DespiteverydifferentstateorientationsinCubaandCostaRica,bothhavebeen laudedasexampleswithinLatinAmericaofthepowerofpoliticalwill,overeconomic wealth,andamessagetotheworldthatpositivehealthindicatorsanddeveloping countriesarenotmutuallyexclusive(Morgan1989).InCostaRica,theshapingofhealth careprioritieswastiedstronglytopoliticalrhetoricarounditslongstandingdemocratic

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52 values,whereasinCuba,itwastiedtorhetoricaroundCommunistvalues.Thekey componentsofpoliticalwill,describedbyRosenfield(InMorgan1989),areahistorical commitmenttohealthasasocialgoal,asocialwelfareorientationtodevelopment, widespreadparticipationinthepoliticalprocess,equity,andinter-sectorallinkagesfor health,which,combined,canovercomepolitical,economic,ortechnicalobstacles. DiscussionofpoliticalwillwasspurredbytheAlmaAtaDeclarationof1978, 12 which promotedpoliticalwillasanessentialelementofprimaryhealthprogramsthat governmentsoflessdevelopedcountrieshadaresponsibilitytoprovidefortheir underservedpopulations. AlthoughacommitmenttosocialmedicineworkedbetterinCostaRicaandCuba thaninsomeothercountriesinLatinAmerica,Morgan(1989)critiquestheideaof politicalwillasdivertingattentionfromglobalpowerrelationships.Attributinghealth caresuccessestopoliticalwillputsattentiononthenationsthemselves,insteadofoutside globalforcesandinternationalagenciesthatoftenshapehealthcarepolicies.This,then, shiftstheblameforinequitablehealthcaresystemstoalackofnationalwill,insteadofon inequitableglobalconditionsablamethevictimmentality.Indeed,themessageof stateresponsibilityforhealthcareputforthbyAlmaAtabecameconvoluted,withthe spreadofneoliberalhealthreformsinthe1980sbyinternationalagencies(particularlythe InternationalMonetaryFundandtheWorldBank).Theimpactsofthesereformsin shapinghealthcarepoliciesinCostaRicawillbediscussedinChapterFour. 12 TheAlmaAtaDeclarationadoptedthe1948WorldHealthOrganizationdefinitionofhealthas astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdisease orinfirmity,recognizedthegrossinequityinhealthstatusbetweenthedevelopedand developingworld,andsetthegoalofHealthforAllbytheyear2000,whichwouldbereached throughthedevelopmentofparticipatoryprimarycareinitiativesbygovernments.

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53 Inanyevent,historically,thenationsofLatinAmericaalladoptedsocialmedicine tovaryingdegrees,andthoughtheyhaddifferentvisionsfor how healthcarewouldbe provided,theysharedanunderlyingphilosophythathealthcare would beprovidedtoall citizens,asahumanrightandasocialgoodtowhichallcitizensmusthaveaccess. CostaRicaasaCaseStudy CostaRica'ssuccessfulsocializedhealthcaresystemmakesitaninterestingcase studyforexaminingtheinteractionbetweenmedicaltourism,aglobalprivateindustry, andlocalhealthcaredelivery,whichisalmostexclusivelystate-sponsored.Borderedby thePacificOceantothewestandCaribbeanSeatotheeast,CostaRicaisabout19,700 squaremilesinsize(itcouldfitinsideofWestVirginia)withapopulationofjustover 4.5millionpeople.ItisastandoutinCentralAmerica,withveryhigheducationand healthindicators,andnostandingmilitary.Itisoneoftheworldslongeststanding democraciesandhasoneofthemostsuccessfuluniversalhealthcaresystemsinthe world,coveringover90percentofitscitizens.Tourismisthenumberoneindustryin CostaRica,anditisparticularlyknownforecotourismbecauseofitsprogressivenational environmentalpoliciesandbiodiversity.Inrecentyears,CostaRicahasbecomea popularmedicaltouristdestinationaswell,attractingmanyAmericansinsearchofhigh quality,lowcosthealthcare. ColonialHistory AlthoughCostaRicacertainlysharesculturalandhistoricalsimilaritieswithits neighbors,itisalsouniquewithinCentralAmerica.CostaRicanstracetheirdemocratic rootstocolonialism(Biesanz,etal.1998).ThoughCostaRica,liketherestofCentral America,wascolonizedbySpain,Spanishcolonizersfoundaverydifferentsituation

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54 whentheyarrivedin1502.WhereasotherCentralAmericannationshadlargeindigenous populationsandagreatdealofgoldorsilvertobeexploited,CostaRicadidnot.Thusit becamealowerprioritycolonytotheSpanish,andwaslargelyignoredbycolonizers. Thislackofattentionandinterestseemstohavehadaprofoundeffectonitscourseof development. Withouthumanlaborormineralwealthtobeexploited,veryfewSpanishsettled inCostaRica.Thosewhodid,havingnoindigenouslabortosetupfeudalcolonies, becamesubsistencefarmers.Becausetherewasnoexploitationoflocalpeoples,relations betweentheSpanishfarmersandtheverysmallindigenouspopulationwererelatively peaceful;therewerenoclassdivisions.Thisruralclasslessdemocracyisthe foundationofthecountry.Fromthesesmallsubsistencefarmersrosethecoffeeelite, whowouldformthefirstgovernmentagovernmentthatwasegalitarianand accommodatingtowardstheindigenouspopulation(Biesanz,etal.1998). This,anyway,isthehighlyromanticized,andoftentold,mythofCostaRican development.Thisidyllicpictureofthecolonialencounterhasbeenallbutdebunked thoughitistruethattheviolencebetweensettlersandtheindigenousinCostaRica occurredtoamuchlesserdegreethaninotherCentralAmericannationswithhigh indigenouspopulations.Inneighboringnations,ethnicandclassconflictplayedan enormousroleinnationaldevelopment,whichwasmarredbyextensiveperiodsof violence.InCostaRica,thedemocraticoriginofthenationwasinterruptedonlyabrief periodofviolencethe44-daycivilwarof1948,whichendedinthe1949abolitionof themilitary.Duringthewar,theUnitedStatessupportedthesocialdemocratic Partido LiberacinNacional (PLN,orNationalLiberationParty),openingthedoortoU.S.

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55 interventioninCostaRica.WhiletheU.S.hasalonghistoryofinterventioninCosta Rica,itpalesincomparisontotherestofCentralAmerica,whichexperiencedfarmore invasiveU.S.actionthroughthe1980s.Mostnotably,theUnitedStatesledpoliticaland militarycounter-insurgenciesinElSalvador,Guatemala,Nicaragua,Panamaand Honduras,whichlefthundredsofthousandsdead(e.g.,Manz2004;Robinson2003). Americanimperialinterventionintheregionbeganinthe19 th century,andcontinued throughthe1980s,withmanydetrimentalconsequences.Inmanyways,thisimperialism definedthedevelopmentoftheregion.Thecontemporaryexpansionofindustryintothe CentralAmericanregionis,inmanyways,amanifestationofthislegacy. ThecolonialhistoryofCostaRicahasimpactedthewaythatCostaRicans imaginethemselves.ThecomparativelackofethnicconflictinCostaRicaallowedthe nationtodevelopinwhattheyconsideraveryEuropeanway.Today,lessthanone percentoftheCostaRicanpopulationisindigenous,comparedto30percentinMexico and40percentinGuatemala.CostaRicansthinkofthemselvesasbothwhiterand smarterthanotherCentralAmericansbecauseoftheir(supposedly)pureEuropean ancestryandadoptionofEuropeaneducationsystems.Biesanzetal.(1998)callsthisthe CostaRican leyendablanca (whitelegend). Theegalitarianmythofnationaldevelopmentalsoremainsprominentinthe nationalidentityofCostaRica,anditisconsideredtohavebeentheimpetusforthe naturalemergenceofdemocracyandpeaceinCostaRica.CostaRicaisoftenreferred toastheSwitzerlandofCentralAmerica,becauseofitsglobalneutralityandlackof military.Theseunifyingmyths,aswellasitsstandoutaccomplishmentsascomparedto therestofLatinAmerica,contributetothenotionofCostaRicanexceptionalismthat

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56 CostaRicansarewhiter,smarter,morepeaceful,democratic,andegalitarianthantheir neighbors(Robinson2003).Theseidyllicimageshavebeenappropriatedglobally, contributingtoCostaRicasdevelopmentasatourismdestinationgenerally,and,more specifically,apopularecotourismandmedicaltourismdestination. HealthSystemSuccesses ThislegacycontributedtothesuccessfuldevelopmentoftheCostaRicanwelfare state,andparticularlyitsuniversalpublichealthsystem.Althoughitsnationalgross domesticproduct(GDP)isfareclipsedbytheindustrializednationsoftheworld,Costa Rica'shealthindicesarethebestinLatinAmerica,withtheexceptionofCuba,andrival thoseinmanyoftheworld'smostdevelopednations.Theseoutcomesaretheresultofa well-developed,publiclyfunded,comprehensivehealthcaresystembuiltonprinciplesof solidarity,universality,andequity.ThisCentralAmericansuccessstoryhasoftenbeen laudedasapotentialrolemodelforotherdevelopingnationsseekingtoachievehealth withoutwealth(Morgan1987;Morgan1989). ThecountryspercapitaincomeisonefourththatoftheUnitedStates,and approximatelythesameasthatofMexico;however,CostaRica'shealthandequity indicatorsaremorecomparabletotheUnitedStates'andwellaboveMexico's(Unger,et al.2007).In2009,CostaRicaspent10.5percentofitsGDPonhealthcareandwas ranked36 th intheWorldHealthOrganizationsrankingsofhealthsystems,whilethe UnitedStatesspent16.2percentandwasranked37 th (WorldHealthOrganization2000). CostaRicansaredeservedlyproudoftheirhealthcaresystem,anditisaprominentpartof nationalidentity.ThosewhoIspokewithdidnothesitatetotellmethatthehealth indicatorsinCostaRicaarebetterthanthoseintheUnitedStates.Onephysicianbeamed,

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57 DidyouknowthatwearerankedbetterthantheUnitedStatesforour nationalhealthsystem?Yes,wearenumber36intheworld,andthe UnitedStatesisnumber37.Andwearethesizeofstateno,maybe one county intheStates.CostaRicaisCostaRicathankstoitsnational healthsystem....Withoutanydoubtitisthebestthingthatwehavein CostaRica.Wehavesomeproblems,likeanycountryhasdeveloped ordevelopingwhenyoutalkaboutpublichealthbutgenerally speaking,wearereallyluckytobeinthiscountry.(16) 13 ThereisparticularprideinbeingconsideredmoresuccessfulthantheU.S.health system,whichisviewedasunfairandinequitablebecauseofitsorientationto approachinghealthcareasabusinessratherthanasocialresponsibility.Ispokewitha retiredphysicianfromthepublichealthsystemwhotoldme, ThepublicsysteminCostaRicawhatitdoesisitprotectsthe population.Andifthereisprofitinpublicprograms,theyare reinvestedformorepublicbenefit.Howeverintheprivatesector,the benefitgoestoshareholderstodistributingdividends.Thereisnot muchreinvestment,andanyreinvestmentthatthereisgoesto increasingprofits,sothegainisnotforthemajority,butforthe ownersoftheprivateservice.IntheUnitedStates,thisisveryclear.In theUnitedStates,25%ofthepopulationdoesnothavemedical coverageofanykindbecausetheydonothavehealthinsurance. [Shakeshishead,pausesforamomentthensmiles]Thereisthis programonthetelevisioncalledEmergencyRoomorsomething likethat.Thatprogramissuchafraud!Becausetheretheyare[U.S. doctors]runningaroundwiththepatient,shoutingthattheyaregoing todoascan,givehimatransfusion,andwhateverelse.Noneofthatis goingtohappenifthecompanion[whocameinwiththepatient]cant demonstratethathehashealthinsurance.Ifhedoesnothave insurance,theytakehimoutthroughthebackdoorwithoutdoing anythingatalltohim!(8) TheU.S.healthcaresystemwasoftencriticizedbyparticipantsashavingagreat dealmoremoneythantheCostaRicansystemandyetstillfailingtoprovidecaretoits citizens.Thisfailureis,afterall,thereasonwhymedicaltouristscometoCostaRicain 13 Participantsinthestudyareanonymous,butIassignedparticipantnumbersforreference. Throughoutthedissertation,whenIdirectlyquoteaparticipant,Ireferencetheirparticipant numberinparenthesisafterthequote.Alistofgeneralindividualcharacteristicscanbefoundin AppendixC.

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58 thefirstplace.TheblamefortheshortcomingsoftheU.S.systemwasplacedmostoften onitsneoliberalprinciplesthatviewedhealthasacommodityratherthanaright.InCosta Rica,itisimpliedthattheyhavetherightideaabouthealthcare,sincetheyhavebeen abletoachievesuchsuccessesspendingroughlyone-fourthlesspercapitathaninthe UnitedStates.Ironically,inMarchof2010,evenconservativetalkshowhostRush LimbaughfamouslysaidthathewouldgotoCostaRicaforhishealthcareiftheproposed reformstotheU.S.healthcaresystempassedanoddchoiceforsomeonesofervently againstuniversalhealthcare(Long2010b).InCostaRica,everyoneevenresident foreignersisrequiredtopayintothegovernment-runhealthsystem,whethertheyuseit ornot. Table3:HealthandEquityIndicatorsforCostaRica,theUnitedStates,andMexico. (Unger,etal.2007) CostaRicaUnitedStatesMexico GDPpercapita (a) $9,46034,3208,430 Healthexpenditure percapita,$5624,887544 Infantmortality (b) 9724 Lifeexpectancyatbirth (c) 78.077.073.3 Giniindex (d) 46.540.854.6 Note .GDP=grossdomesticproduct. Alldataarefor2001withtheexceptionoftheGiniindex,whichreflects2000figures. DatawerederivedfromtheUnitedNationsDevelopmentProgramme. (a) Purchasingpowerparity. (b) Probabilityofdyingbetweenbirthandexactly1yearofage,expressedper1000livebirths. (c) Numberofyearsanewborninfantwouldliveifprevailingpatternsofage-specificmortalityat thetimeoftheinfantsbirthweretostaythesamethroughouthisorherlife. (d) Measurementofinequalityinthedistributionofincomeorconsumptionwithinacountryona scaleof1100. 14 14 Thesefiguresarefrom2000,butImentioninalaterchapterthatCostaRicasGiniindexhas risento50.31.

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59 HistoryandDevelopmentoftheHealthSystem CostaRicadevelopeditspublichealthsystemgradually.Before1941,theCosta Ricansystemwasdisjointed,madeupofprivateorcharitablemedicalcarewithoutcentral organization.In1941,PresidentRafaelAngelCaldernGuardiacreatedCostaRicas SocialSecurityAdministration( CajaCostarricensedeSeguroSocial ,ortheCCSS), popularlyreferredtoas LaCaja. 15 TheCajabeganasasystemforwageearnersthat graduallyexpandedtocovertotherestofthepopulationoverthenext50years.Atthe time,therewasextraordinarilystrongoppositiontotheformationofasocialinsurance system.Themajorityofthenationsphysicians,aswellasthe UninMdicaNacional (NationalMedicalUnion)thefirstunionofitskindwithinLatinAmericaadamantly opposedasocialsecuritysystembecauseoftheimpactthatitwouldhaveonprivate medicalpractice.Infact,unionstatutesstatedthatitsprimaryfunctionwouldbetooppose thedevelopmentofasocialinsurancesystem. However,CaldernGuardiaandhisfollowersenjoyedagreatdealofpolitical poweratthetime,andwhenthesocialsecuritysystemgainedsupportfromboththe CatholicChurchandtheCommunistParty,iteventuallywonout.Theleaderofthe CatholicChurchinCostaRicaatthistimewasMonsignorSanabria,whoseeducationin EuropehadconvincedhimthattheChurchhadasocialfunctioninworkeremployer relations.TheCommunistParty,establishedinCostaRicain1934,heldasoneoftheir maintenetsthatsocialinsurancestoprotecthealthmustexist.AlthoughtheCatholic ChurchandCommunistpartywerenotalignedideologically,theybothbelievedstrongly 15 ThroughoutthedissertationIrefertotheCCSSbyitspopularname,the Caja ,whichliterally translatestothebox.CostaRicansandthepopularpressrefertotheCCSSastheCajaandall ofmyparticipantsreferredtoitinthisway.

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60 inthelabormovement,andwerewillingtobrieflyjoinforcestoensurethatitsucceeded (Cruz1992). Itisimportanttonotethatthedevelopmentofthepublicsocialsecuritysystem wastightlylinkedtoincreasingworkproductivityandeconomicdevelopment,asit originallycoveredtheproductiveworkforceonly.Infact,theprivatehealthcaresystem thatprecededtheCajaisoftensaidtohavebeeninfluencedbytheUnitedFruit Companys(UFC)presenceinCentralAmericaandtheirdesiretobothcivilizetheir nativeemployeesandkeepthemhealthytoprotectthecompanysproductivity(Aliano 2007). 16 TheUFC,aU.S.-basedcompanythatestablishedbananarepublicsinCentral AmericatosellfruittotheUnitedStatesandEurope,isoftencalledthearchetypalmultinationalcorporation.Itwasknownthroughouttheregionforitsimperialpractices,worker exploitation,andpoorworkingconditions.ThelegacyoftheUFCspresencecanstillbe seentodayinCostaRicastwomajorexportswhilecoffeeisviewedasthedarlingof thenationandpartoftheegalitarianandorganicrootsofthenation,bananasareoften vilifiedasrepresentativeofimperialismandoutsideinfluence. In1949,afterthebriefcivilwar,CostaRicaratifiedaconstitutionthatabolished thenationalarmy,enablingfundingtoflowtowardsocialprogramssuchaseducationand health.Withthesenewsocialinvestments,steadyhealthsectorimprovementcontinued, andin1973,theGeneralHealthLawplacedallhealthtreatmentservices,including primarycarefacilitiesandhospitals,underthecontroloftheCaja.Thislegislationalsoset 16 TheUnitedFruitCompany(UFC)wasalsocomplicitintheGuatemalancivilwarwhenheads oftheUFC,whohadunderreportedtheirland-holdingstotheGuatemalangovernment,feared thatthenewlyelectedGuatemalanpresident,JacoboArbenz,wasgoingtoredistributetheirland tothepoor.UFCaccusedArbenzofbeingacommunistand,inresponse,theCIAengineereda coupoftheArbenzgovernment.A36-yearcivilwarresulted,whichleft200,000dead,mostly indigenouspeople.ItwasdeclaredagenocidebytheU.N.(Manz2004,Robinson2003).

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61 provisionsforthecontinuedexpansionoftheCajauntiliteventuallybecameauniversal healthinsurancesystem.InCostaRica,therighttohealthiswrittenintotheconstitution, andthecountryhasauthoritiesbothinsideandoutsidethehealthsectortooverseeand safeguardthisright:the SalaConstitucionaldelaCorteSupremadeJusticia (ConstitutionalChamberoftheSupremeCourt,popularlyreferredtoasthe SalaIV ),an ombudsmensofficecalled DefensoradelosHabitantes (thePeoplesDefender)which exercisesoversightonthetimelinessandqualityofhealthcare,andthe Ministeriode Salud (MinistryofHealth)whichoverseestherightsanddutiesofhealthsystemusers, bothpublicandprivate. WithinCostaRica,andglobally,thiserafromthe1930stothe1970sisseenasa goldenageofsocialprogramsandwelfarestates,inwhichstabledevelopmentand economicgrowthallowedfortheexpansionofsocialpoliciesandagreaterroleofthe stateinpromotingthesesocialrights(Waitzkin,etal.2001).Itwasduringthistimethat theinstitutionalizationofmedicalpracticeinCostaRicabegan,whenthecountrysfirst medicalschoolbecamelinkedtotheCaja,andnewly-graduatedphysiciansbeganentering thehealthsystemthroughthesocialsecuritysystem.Thisjoiningofeducationandhealth carefurtherentrenchedthenationwithinaframeworkofsocialmedicine. InCostaRica,thesocialsecuritysystemwaswidelyembracedasaprojectof nation-building,modernizationandsocialequalization(Ackerman2009)andthe productionofphysicians,patients,andhealthycitizensallbecamethebusinessofthe state.Thenationembracedthepathtomodernizationthroughbiomedicine,andthehealth ofcitizensmediatedthroughaccesstobiomedicalservicesbecamelinkedtothesocial, politicalandeconomicwell-beingofthenation.Individualhealthbecamesymbolictothe

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62 healthofthenation,ortothebodypolitic(Scheper-HughesandLock1987).Underthis system,physiciansbecamethemostimportantcivilservantsinthenation,andhelda prominentsymbolicroleinnationalidentity(Palmer2003).Thedevelopmentofthesocial securitysysteminCostaRicanotonlycametodefinewhatitmeanttobeCostaRican, butalsoinstitutionalizedthestatesroleintheeverydaylivesofitscitizens. MedicalEducationandtheInstitutionalizationofMedicalPractice AsmentionedinChapterOne,amajorconcernabouttheeffectsofmedical tourismindestinationcountrieshastodowiththemanagementofhumanresources,and thepotentialbraindrainofhealthcarepersonnelfrompublictoprivatecarewithin thesecountries.InCostaRicathisisofparticularconcern,ashealthcareisnotonly providedalmostexclusivelythroughthepublicsector,butmedicaleducationandtraining ofphysiciansaresubsidizedthroughthepublicsectoraswell.Publicuniversities, particularlytheUniversityofCostaRica(UCR),areinextricablylinkedtotheCaja.The institutionalizationofmedicalpracticewithinthepublicsectormakesthefollowing discussionofmedicaltourismmorecomplicated,asitisnearlyimpossibletothinkofthe nationsphysicians,includingthosewhotreatmedicaltourists,asseparate fromthepublic systemthatformedthem. AccordingtotheCostaRicanconstitution,primaryeducationiscompulsory.By law,publicexpenditureoneducation,includinghighereducation,mustbeatorabove16 percentoftheannualgrossdomesticproduct.Althoughnotthecaseforprimaryand secondaryschools,publicuniversitiesinCostaRicaareconsideredofmuchhigherquality thanprivateuniversities,andprivateuniversitiesinCostaRicaareoftendismissedas secondrate.ArecentstudybyCONARE(aconsortiumofthecountryspublic

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63 universities)showedthat85percentoffinalyearhighschoolstudentswanttopursuea degreeatapublicuniversity(Long2010a).CostaRicacurrentlyhasfivepublic universitiestheoldest,largestandmostprestigiousbeingtheUCR.Approximately 39,000studentsattendtheUCR,whichislocatedinSanPedro,justoutsideofSanJoss citycenter.Admissionisveryselective;applicantsmusttakeatestforentryandhave goodhighschoolgrades.In2009,ofthe31,042studentsthatcompletedtheadmission test,only16,593scoredhighlyenoughtobeadmittedtotheuniversity.Eventhen,this doesnotensurethattheywillbeadmittedtotheirchosendepartmentormajor.In2007, 60percentofadmittedstudentswereacceptedintotheirdesiredmajor(Universityof CostaRica2012).OncestudentsareacceptedintotheUCR,theireducationishighly subsidized,andeventhosestudentswhodopaytuition(manydonot)paynegligible tuitionfeesofroughly$80$250persemester.Incontrast,privateuniversitieshaveno suchadmissionrequirementsandessentiallyacceptanystudentwhocanpaythetuition, whichmightcostupanywherefrom$500to$4,000persemester,dependingonthe degreeprogramandtheuniversity(Long2010a). AMinistryofHealthOfficialwhomIspokewith,said,TheUCRhasprestige equaltothatoftheCaja;nobodycantakeitawayfromCostaRica(12).TheUCRis internationallyrecognizedforitshighqualityofeducationandisconsideredthemost importantresearchuniversityinCentralAmerica.Manyofthenationspastandcurrent leadersattendedtheUCR.Itdefinesitselfasahighlydemocratic,humanisticinstitutionin contrasttotechnocraticgovernmentthatignorescitizens.Communityparticipationis expectedofstudents,andformsofsocialcommentaryincludingprotestsandsocial movementsareaccepted,andevenencouraged,bytheuniversityanditsfaculty.

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64 InAprilof2010,Ico-presentedapaperattheUCRwithKarina.Theconference wascalled NuevasVocesenCienciasSocialies (NewVoicesintheSocialSciences)andit tookplaceinthe InstitutodeInvestigacionesSociales (InstituteforSocialResearch),an instituteformedtovoicecriticalperspectiveswithinthefieldsofthesocialsciences.The conferencewasentirelystudent-organizedandlastedtwodays.Iwasfeelingparticularly frustratedwiththewaythatthefieldworkhadbeengoingatthistime;justtheweekbefore IhadbeentoldthatmyworkwastoopoliticalandstartednegotiationswiththeCajato endorsemyproject,and,moregenerally,Iwasbecomingdiscouragedwithmyinterviews intheprivatesector,whereIwashearingthespielalittletoofrequently.Inmyfield notesthatweek,Iwrote: Theconferencetookplaceinasmall,verybasicclassroominthe Instituto Itisstarkwhite,outfittedonlywithorderlyrowsofwoodentablesand somechairs.Thereareoutdatedpostersonthewall,tearingatthecorners. About30orsopeoplearepresentfortheopeningoftheconference,even thoughitisonly8am.Thoughitisearly,itisalreadyhotandhumid.The windowsareopen,andthewakingsoundsofuniversitylifecanbeheard. Asthedaygoeson,yellsfromanearbysoccergamefloatinthroughthe openwindowsandsnippetsofpasserbyconversationsareheard. Occasionally,itrains,hard.Themicrophonesgoinandoutduringthe presentationsbutnooneseemstomind.Theyarefullyengaged,andthe atmospherefeelsinformal,butimportant. Itisareliefformetobehere.Afterspendingsomuchtimeamong thosewithhighstakesinthemedicaltourismindustry,whotoutitspraises withoutforethoughtorwithoutconcern,Ifeelathomeinthisuniversity environment.Peopleareinterestedinwhatwehavetosay,andhave thoughtfulcomments.Inourdiscussionafterthepresentation,wefindthat manyarecriticalofmedicaltourism,andafewareevenenragedatthe practice.Theyareconcerned,asIam,abouttheconsequencesofmedical tourismforCostaRica.Thereisasenseofsolidarityhereinthisroom, aboutwhatitmeanstobeCostaRican. ExcerptfromFieldNotesApril27,2010 ThereisastrongspiritofsocialactivismattheUCR;Iwitnessedmanyinstances ofthis,includingpublicmarchesfororagainstpresidentialcandidatesduringtheFebruary

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65 2010election,performancesanddocumentariesproducedbystudentsandfaculty,and protestsoversocialandpoliticalissues.Iarrivedatthecampusonedaytoconductan interviewonlytofindthattheuniversityhadbeenshutdownwithoutnotice,sothat studentsanduniversityemployeescouldhavetheopportunitytoprotestthegovernments proposedfinancialcommitmenttotheSpecialFundforHigherEducation(FEES),which wastobecut,anddemandanincreaseineducationfunding. MedicalSchools Thenumberofmedicalschoolshasgrownsignificantlyinrecentyears;thereare noweightinthecountry.Likeuniversitiesingeneral,therearebothpublicandprivate medicalschoolsinCostaRica,butthepubliconesareknownasbeingmuchbetterin everyfield.TheUCRhasthemostrespectedmedicalschoolinthenation,andlikelyin CentralAmerica. TheUCRwascreatedin1940,alongsidetheCaja,duringthereformist administrationofPresidentRafaelngelCaldernGuardiaanditgrewintandemwiththe Caja.LiketheCaja,itisconsideredafoundationalinstitutionandplaysaprominentrole inCostaRicannationalidentity.Aretiredphysicianandprofessorwhowasinstrumental inthedevelopmentofboththeCajaandtheUCRhadthistosayabouttheintertwined historyoftheseinstitutions: Itwasaparalleldevelopment.Weorganizedandopenedthe medicalschoolbecausetherewasnomedicalschoolinthecountry anditwasabsurdtothinkthatwecouldhaveanationalhealth systemifwedidnothaveafactorytocreatetheworkersforthe systemthedoctors.So,paralleltothepoliticalproject,I developedtheacademicprojectorganizingthecommissionto openthemedicalschool,developingthefirstcoursesandIwasone ofthefirstuniversityprofessorsthatthemedicalschoolhadinthe country.(8)

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66 ThespecialrelationshipthattheUCRshareswiththeCajaisoftencriticizedby otheruniversities,particularlyprivateones,whofeelthatthepreferentialtreatmentgiven toUCRstudentsputstheirownstudentsatadisadvantageinreceivingmedicaltraining, andinfindingworkpost-graduation.Despitethiscriticism,however,receivinga residencypositionhasbecomemorepoliticalovertheyears,andprivateuniversity studentsarenowabletogetpositionsbasedonmoneyorpersonalconnectionsmoreoften thaninthepast.UCRmedicalstudentsandresidentswhomIinterviewedfeltthatthiswas unfair,andthattheyweremuchbetterpreparedtobecomeaphysicianthantheirpeers fromprivateuniversitieswhomtheysometimeshadresidenciesalongside.Thetension betweenpublicandprivateinstitutionshasbeenincreasingastheprivatesectorbeginsto takeamoreprominentpositioninCostaRicansociety,atopicthatwillbeexplored furtherinthenextchapter. MedicalResidencies Byvirtueofgraduatingwithamedicaldegreefromanundergraduateuniversity, whichtypicallytakesfourtofiveyears,graduatesbecomegeneralphysicians.Onlythose whocontinueontobecomespecialistsreceiveresidencytraininginCostaRica,andonly theCajaprovidesthistraining.Thetimeofresidencyvariesdependingonthespecialty;a residencyinpediatricsisfouryears,whilearesidencyinneurologytakesten.Duringthe residencyperiod,residentsworkasageneraldoctorandarepaidasone(about2-3million colones,or$4,000$6,000peryear),butcompleteshiftswithintheirspecialty,which supplementsthisbaseincomesubstantially.Uponcompletionoftheresidency,specialists receiveplacementswithinCajafacilities,theirsalaryincreases,andtheyareexpectedto workfewershifts.

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67 BecausetherearealimitednumberofresidencyslotsopenintheCaja,gettinga residencyisnotonlysomewhatpolitical,butitisverycompetitiveaswell.About450 medicalstudentseachyeargraduatefromall8medicalschoolsinthecountry,withabout 80ofthosecomingfromtheUCR.Of1,300graduateswhowouldliketopursue specialties,about250passthefirsttesttobecomeaspecialist.Thosewhopassthenhave totakeasecondtestfortheparticularspecialtytheywishtoapplyfor.Mostphysicians whomIspokewithhadtakenthespecialisttestmorethanonce.Intheneurosurgery specialty,whichisconsideredoneofthemostdifficult,therewerefouropeningsin2009. Onlythreephysicianstookthetest,andnonepassed.Inthiscase,thefourpositionswere notfilledandremainedopenforthenextyear.Furthermore,eveniftheapplicantsdopass theextremelydifficultexaminations,theyarenotguaranteedaresidency.Thenumberof spotsavailabledependsthenumberofresidentsneededwithinthatparticularspecialty,a figurethatiscalculatedbyCENDEISSS( CentrodeDesarrolloEstratgicoeInformacin enSaludySeguridadSocial ,ortheCenterforStrategicDevelopmentandInformationin HealthandSocialSecurity).So,theremightbetenspotsopeninaparticularspecialtyand twentyapplicantswhohavepassedthetwotests,inwhichcaseonlythetoptenwillgeta residencyposition.Withingeneralsurgery,100150peoplesometimescompetefor46 spots.Itisnotunheardofforsomephysicianstoapplyupto20timeswithoutgettinga residency. Thosewhocannotgetaresidencypositionmustchoosetoeitherkeepapplying (possiblyinadifferentspecialty),workasageneralphysician,orchangecareers altogether.Somewhocannotobtainaresidencymovetotheprivatesectorandopen medicalofficesthere.Theproblemwiththisisthat,upuntilrecentyears,patientvolume

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68 intheprivatesectorhasbeensolowthatitisdifficultforanunspecializedphysicianto makealivingsolelywithaprivatepractice.However,politicalchangesandthepromotion ofmedicaltourismhaveopenedmoreopportunitiesforphysiciansintheprivatesector. Someoftheseunspecializedphysiciansadvertisethemselvestomedicaltouristsasbeing abletoperformproceduresatalowercost,eventhoughtheymightnotbelicensedinthe areaofspecialty.Specialistswhoworkinmorelegitimatemedicaltourismfacilities cautionagainstusingthesephysicians,whocantarnishthereputationoftheindustry,and areadangertopatientstheyare peligrosobruto (adangerousbrute),accordingtoone participant(28). Insum,themedicalresidencywithintheCajaisextremelyimportantbecauseitis theonlyplacewherethenationsspecialistsaretrained.Thespecialrelationshipbetween theUCRandtheCajacontinuesduringtheresidencyperiod,asalmostallmedical residentsareconcurrentlyUCRstudentsandCajaemployees,wheretheynotonlyearna salary,butalsobegintoaccrueseniority,andreceiveallthebonuses,incentives,and benefitsofotherCajaemployees.OnceemployedbytheCaja,healthcarepersonnel moveuptheranksbasedontheiryearsofexperienceworkinginthepublicsystem.They areabletoaccruehighersalariesandmoreemploymentbenefitsastenurecontinues.A careerwithintheCajaisconsideredtobeverystable;itisnearlyimpossibletogetfired. Somecriticizethistenuresystem,however,asbeingpoorincentivetoincreasework performance(atopicthatcomesupagaininlaterdiscussionofneoliberalactors). QualityofCareintheCaja TheCajasubsidizesmedicaleducationandtrainsthenationsphysicianswiththe expectationthattheywillremaininthepublicsectorservingCostaRicans.After

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69 residencytrainingiscomplete,physicianstypicallydoremainintheCajabecauseitis wheretheygainexperience.Thesheernumberofpatientsandpathologieswithinthe publicsectorallowsphysicianstogainskillsveryquickly.Themedicaldirectorofa privatehospital,whohadworkedintheCajaearlierinhiscareer,said: IfyoudidnotworkintheCajayoudonothaveexperience.Becausethe patientvolumethatyouseeintheprivatesectorisverylittlecomparedto thevolumewhichyouseeinthepublicsector,andthemajorityofrare diseasesorcomplicateddiseasesyoudonotseeithere[intheprivate sector.]Theprivatehospitalsarelighthospitals,aswewouldsay.They arehospitalsthatdoliposuction,removeavein,operateonakneebut whenapieceofthecolonhastoberemoved,averybigtumor,etc., everythinglikethatisintheCaja.SoifyouhavenotworkedintheCaja, whatexperienceareyougoingtohave?(12) TheCajaprovidesexcellenttrainingforphysicians,andalmostallofthenations physicianswork,orhaveworked,inthepublicsector.Despitemysamplingmethodof locatingCajaphysicianswithintheirprivatepractices,discussedintheIntroduction,only onephysicianthatIinterviewedhadneverpracticedintheCajaatall(inthisparticular case,hedecidedtogobacktomedicalschoollaterinhislifeandwashappywithasmall practiceasageneralphysicianintheprivatesector.) Partlyduetotherigoroustrainingandvastexperiencethatphysiciansgaininthe publicsystem,bothpatientsandhealthcarepersonnelconsidertheCajatoprovide extremelyhighqualityhealthcare.TheCajaiswherepatientsgoforcomplex,chronic,or emergencymedicalservices,notonlybecausetheydonothavetopay(beyondtheir wagecontributions),butbecausethepublicsystemisconsideredthebestequippedto handletheseproblems.TheonephysicianIinterviewedwhohad not workedintheCaja atallsaid, IntheCaja,thosearepeoplewhohavebeentrainedinthepublicsystem andthesystemhaspaidforthemtobetrained.Thesepeoplearethebest

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70 ofthebestthatwehaveinthecountry.Theyhavegainedtheirexperience inthepublicsector.Itsnotthesamethingifyoudoanopen-heartsurgery intheprivatesector,whereyoudooneayear.Youdoone aday inthe Caja.Soyoubecomereally,reallygood.(34) ThegreatmajorityofCostaRicanphysiciansandpatientsworkin,andusethe Caja,butithasbeenfacedanumberofchallengesinrecentyears,whichwillbethetopic ofthenextchapter.Thesearenotarounditstechnicalcapabilities,butratherits administration,waittimes,andhighvolumesofpatients,whichleavelittletimefor physicianstospendwitheachpatient.Theseconstraintshaveledagrowingnumberof physiciansandpatientstomigratetotheprivatesector.Althoughitisrareforaphysician toforegotrainingintheCajaaltogether,itbecomingmoreandmorecommonasacareer trajectoryforaphysiciantoworkforanumberofyearsintheCaja,gainingexperience andexpertise,andthenmovetoaprivatesectorpracticeaftertheyhavegainedenough experienceandestablishedaclientbase. SolidarityasIdeology:PrinciplesoftheCaja Despiteitsrestrictions,CostaRicanslovetheCaja,considerittobeofhigh quality,andaredeservedlyproudofitsachievements.Participantsacrossthisresearch uniformlypraisedtheCajasfoundingsocialprinciplesandtheunderlyingbeliefofthe healthsystemthathealthisarightisnotquestioned.Whenaskedwhatthebestthings abouttheCostaRicanhealthcaresystemare,almostallparticipantsreferenceditssocial principles: AttheCaja,itdoesntmatterifyouarethePresident,ifyouarea homelessperson.Iftheyneedtodoasurgery,theylluseeverything. Theywontsay,ohno,hedoesnthavemoneyno,no.Welldothe surgery.PeopledonotdieintheCajabecausetheydonthave insurance.ThatsthethingIlove.(38) Inadditiontobeliefinhealthcareasaright,notonepersonIspokewith

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71 complainedaboutthefactthatwealthierCostaRicanssubsidizehealthcareforthepoor. Themottoofthe HospitalSanJuandeDios, oneofthemostbelovedCajainstitutionsin thecountryis elbienquelehacisalospobreslohacisavosotrosmismos (thegood thatyoudoforthepoorisgoodthatyoudoforyourself).Someproudlyreferredtothe CajaasaRobinHoodsystem,saying: Thefocusofhealthshouldalwaysbedirectedtoequity,solidarity, universality,andthefocusshouldbeonattendingtothepersonwho needsitthemostandwhohasfewerresources.Becausewehaveseen thateconomicissuesarerelatedtohealth--thelessIhave,themore probabilityIhaveofgettingsick.Sotherewillbemanymoreproblems inthelargerpopulationwhenwedonttakecareofthepoor.Thehealth systemcantfavor,orleantowards,theelitepopulation.Itshouldwork infavorofthesimplerpopulationthatisinneedofservices.Thosefor mearetheprinciplesthatshouldalwaysgovernus.(22) TheCajaishailedasthegreatsuccessofCostaRica.Ihearditcalledthepillarof thenation,andthemotherofCostaRica,andcreditedwithkeepingthesocialpeace, and,preventingwar.ACajaadministratorsaidabouttheCaja, Thisinstitutionmakesthedifferencebetweenusandothercountriesin LatinAmerica.Itgivespeacetothecountry.Thewarsinother countriesguerillawarsarebecauseoftheirsocialcircumstances theyfightbecausetheydonthavehealth,becausetheydonthave education.SomeonetoldmethatGuatemalaspends30percentoftheir PIB[GDP]30percentoftheincomeofthecountryforthearmy.Why doyoudothat?InCostaRicawespendthe7percentonhealth.Togive healthtothepeople;andwedonthavewar.(45) Althoughmanyhadcomplaintsaboutthedeteriorationofthesocialsystem, citizensstillhavegreatconfidenceintheCaja.A2004pollconductedbytheUCRasked CostaRicansabouttheirprideandconfidenceinstateinstitutionsandnationalvalues. ThosepolledsaidtheyhadmoreconfidenceintheCajathaninthejusticesystem,the police,thenationalgovernment,ortheCatholicchurch(Ackerman2009).The achievementsofthesocialsecuritysystemplayaprominentroleinthestoryofCosta

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72 Ricanexceptionalism.ItisanenormouspartofCostaRicannationalidentityandwhatit meanstobeCostaRican. Today,theCajacontinuestodominatehealthinsurance,employment,andhealth careprovision,operating29hospitals(comparedto6hospitalsintheprivatesector)and 940primaryhealthcareteamscalledEBAIS( EquiposBsicosdeAtencinIntegralde Salud )anextensivenetworkofclinicslocatedthroughoutthecountry.Ithasmorethan 48,000employees,includingthelargemajorityofthenationsphysicians(CCSS2010). Fundingforthesystemcomesfrommandatorytaxationonwagesfromemployers (9.25%),employees(5.5%)andthestate(0.25%),andtheCajacurrentlycoversabout90 percentofthepopulation(Muiser,etal.2008). TheCostaRicanImageandtheMedicalTourismBlueprint Oureducationsystem,ourhealthcaresystemtheygiveacertain conditiontothecountry.Sure,youcangosomewhereelse,toa neighboringcountryandyoucanfindsomegoodsurgeons,buttheyare notsurroundedbythecorrectsystem.Soifyouhaveunplanned complications,heartproblems,orsomethingelse,youbenefitfromthe [public]well-developedsystemofmedicinearoundyou.SoIthinkour systemiswhatmakesitasafeplaceformedicaltourism.Itsnotjust aboutthenicebuildingswithalotofluxury,andtransportationand hotelsthehealthsystemiswhatmakesthedifference.(15) Theabovequoteoutlineswhataplasticsurgeonwhofrequentlyworkswith medicaltouristsexplainedtome.Itisthesuccessesofthehealthsystemthathaveopened thedoorforthedevelopmentofmedicaltourisminCostaRica.CostaRicafitsthe blueprintofthemedicaltourismindustryquitewell.Ithashighqualityhealthcare,a skilledworkforce,andalargeEnglish-speakingpopulation.Sincethe1970s,ithasgrown intoaverypopulartouristdestination,largelyduetoitsimageaspeaceful,healthy,and natural.Itishometooneoffivebluezonesintheworld,whereinpeoplelive

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measurablylongerlives,andwasnamed Times opedpiecein2010 CostaRicaisparticularlywellknownasanecotour progressiveenvironmentalpoliciesand theworldsbiodiversity(five CostaRica).Thenationalsloganforthe CostaRicanTourismBoard)is amorerecentsloganfocusesonmedicaltourism, TheseidyllicimagesofCostaRicaign an dunsanitaryconditionsthatexist touristdestination. Figure8 :SloganoftheCostaRicanTourismBoard:Aquse all).( InstitutoCostariccensedeTurismo2011 measurablylongerlives,andwasnamed thehappiestplaceonearth edpiecein2010 (Kristof). CostaRicaisparticularlywellknownasanecotour ismdestination progressiveenvironmentalpoliciesand itsownershipof adisproportionatepercentag theworldsbiodiversity(five percentoftheworldsanimalandplantspecies CostaRica).Thenationalsloganforthe Instituto CostariccensedeTurismo CostaRicanTourismBoard)is Siningredientesartificiales (Noartificialingredients)and amorerecentsloganfocusesonmedicaltourism, Aqusecuratodo TheseidyllicimagesofCostaRicaign oremuchofthepoverty,increasingviolentcrimes, dunsanitaryconditionsthatexist ,butfitperfectlywiththeidealarchetypeofamedical :SloganoftheCostaRicanTourismBoard:Aquse curatodo(Herewecure InstitutoCostariccensedeTurismo2011 ) 73 thehappiestplaceonearth ina NewYork ismdestination dueto adisproportionatepercentag eof percentoftheworldsanimalandplantspecies arefoundin CostariccensedeTurismo ,(ICT,orthe (Noartificialingredients)and Aqusecuratodo (Herewecureall). oremuchofthepoverty,increasingviolentcrimes, ,butfitperfectlywiththeidealarchetypeofamedical curatodo(Herewecure

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74 Figure9:IdyllicimagesofCostaRica:waterfalls,volcanoesandbeaches (Photosbyauthor). ItisironicthattheCostaRicansystemthatinvitedmedicaltourismclashesso dramaticallywiththeneoliberalprinciplesofmedicaltourism.Aprivatehospital administratorthoughtthattheCajahelpstobrandthecountry,makingananalogyto groceryshopping: Youarenotgoingtogotoasupermarkettobuymeatifyouknow beforehandthatthemeatthattheysellinthat Automercado [anational supermarketchain]isaproductofcattlethatsuffersfrommadcow disease.Butwhenyouhaveacountrythatshowsgoodhealthindicators,a well-maintainedpublichospitalnetwork,presentsawell-definedface,or brand,whenitcomestohealthtreatmentthenthepublicsector complementstheprivatesectorinthesaleofhealthservices.Itisnotthat thepublicsectorgoesouttosellservicesandprovidesservicestohealth touriststhemselves,butitisaboutthefacethattheCostaRicanstate presentsanditisafacethatcomplementsthe[medicaltourism]activity thatisbeingdeveloped.(18) ThefacethatCostaRicapresentstotheworld,anditsexceptionalismwithinthe region,hashelpedittobecomeaverypopularmedicaltouristdestination,particularlyfor Americans.However,thehealthsystemdevelopmentsthathaveallowedCostaRicatofit themedicaltourismblueprint,andemergeasadestination,havebeenachievedinavery differentwaythantheneoliberalmodelonwhichthemedicaltourismindustryis founded.ThesocializedhealthcaresysteminCostaRicansystemmakesitastandout

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75 comparedtoothermedicaltourismdestinations,whichmightalreadybemoreorientedto privatehealthcareprovision,orthatalreadyhaveinequitablehealthcaresystems.

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76 CHAPTER4:PRIVATIZATIONOFTHEHEALTHCARESYSTEM JustastheCajahascontributedtotheriseinmedicaltourism,theshiftinnational prioritiestowardsprivatizationandglobaleconomicdevelopmenthasmeanta contractionofthepublicsystemthat,inmanyways,isaccountableforthisglobal recognitioninthefirstplace.Inrecentyears,therehavebeensignificantinternaland externalchallengestothehegemonyofthepublicsystem,andprivatehealthcareison therise. Demographicchanges,misuseandcorruptionwithinthepublicsystem, challengesinmanaginghumanresources,andfinancialburdensoftenintensifiedbythe privatehealthcaresectorhaveallcontributedtointernalstrainonthehealthcare systemandhaveaffectedtheabilityoftheCajatotakecareofitscitizens.These pressures,alongwithenhancedopportunitiesintheprivatesectorspurredby privatizationandmedicaltourismhaveledphysiciansandotherhealthcarepersonnel toseekemploymentoutsideoftheCaja,exacerbatingthedifficultiesofhealthcare provisionthroughthepublicsector. TheRelationshipbetweenthePublicandPrivateHealthCareSectors Multipletimesduringthecourseofmyresearch,IwasaskedwhyIshouldbeso concernedwiththepublichealthcaresystemwhenIwasstudyingmedicaltourism,which iswhollyintheprivatesector.Iwastoldthatthereisnorelationshipbetweenoneandthe other;thepublicandprivatehealthcaresectorsfunctiontotallyseparately.WhenIaskeda medicalstudentaboutwhethermedicaltourismhasanynegativeimpactsfortheCaja,he respondedsharply:

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77 Privateisprivate.Ifatouristcomestohavesurgeryhere,itdoesnthavetoaffect aCostaRicancitizen.Heisinaprivatehospital,heispayingforhissurgery,itis incomeforthedoctors,itcreatesmorejobsandthathelpsthegrowthofthe country.Besides,mostofthesurgeriesareaesthetic,thatswhatIunderstand;so publichospitalswontgetinvolvedinthatanyway.Itisjustprivate.(37) Thoughtherelationshipbetweenthepublicandprivatehealthcaresectorsisnota simpleone,andmaynotbereadilyapparent,Iargueinthischapterthatthisrelationship notonlyexists,butthatthetwosectorsareintricatelyconnected.Thephysiciansand personnelwhopracticeinthepublicandprivatesectorsarethesame;thepatientswho seekcareinthepublicandprivatesectorsarethesame;sometimeseventheequipment andfacilitiesusedineachsectorarethesame.SincetheinceptionoftheCaja,theprivate sectorssurvivalhascometodependonitsrelationshiptothepublicsectorinvarying capacitiesovertime.Theirrelationshipis,atbest,symbiotic,and,atworst,parasitic withtheprivatesectorbenefittingfromitspositionastheCajashoulderstheburdenof providinghealthcaretoanincreasingCostaRicanpopulationwithdecreasingfundstodo so.PrivatizationinCostaRicahasbeenmorepassivethaninotherLatinAmerican countries(Clark2010),butithasbeenoccurringnonetheless. TheRoleofthePrivateSectorinHealthCareProvision Contrarytotheprominentplacethatstate-sponsoredmedicineholdsinCosta Ricannationalidentity,theroleoftheprivatesectorinthenationalhealthcaresystemhas beenmorelimited,homegrown,andpragmatic(HomedesandUgalde2002).Thisis nottosaythattheprivatesectorhasnothadanotableroleinthehealthsystem historically.Therehavebeenseveralattemptstopromotemixed-medicinemodels,which havebeenentangledwiththeCajasdevelopment.Theovertjustificationforthesemixedmedicineprogramsistorelievestrainonthepublicsystemandreducewaitlisttimesfor

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78 patients,thoughthisrationalehasbeenquestionedbycriticsofprivatization,suggesting thatthetrueintentismorepoliticallyandeconomicallydriven(Salas2009).Inparticular, pressuresbyinternationalagenciessuchasIMFandWorldBank,andtheinclinationof OscarAriasgovernment 17 towardsprivatization,arecitedassomeoftheactualreasons behindincreasedprivatizationwithinthehealthcarearena. Thefirstofthesemixedmedicinemodelsoccurredinthe1970swhentheCaja piloteda medicinadeempresa program(companydoctorprogram),underwhich companiesagreedtopaythesalaryofaCajaphysicianandprovideofficespace,whilethe Cajaprovidedallnecessarytestingandmedications.Thoughstillusedonasmallscale today,theprogramsimpacthasbeenlimited.Then,inthelate1970s,theCajapiloted anothermixedmedicinemodelwhereinpatientsinsuredbytheCajapaidoutofpocketto goseeaprivatesectorphysician,withtheCajaprovidinganynecessarytestsor medications.Thisprogramisalsostillusedtoalimiteddegreetoday,butitneverreally tookholdbecauseitbothoffendsastronganti-privatizationcurrentwithintheCajaand, becauseitisbasedonfee-for-servicepayments,istooexpensivetoexpand(Clark2010). Amoresuccessfulventureoccurredin1988,whentheexecutivepresidentofthe Caja,Dr.GuidoMiranda,underpressurebyPresidentArias,pilotedacooperativemodel ofhealthcare.ItwasimperativetoDr.MirandathattheCajanotbeprivatizedandthatit maintaincontroloverthecooperative.Hesuccessfullysetupthefirsthealthcare cooperativeintheSanJossuburbofPavas,called Coopesalud, whichwaspublicly 17 OscarAriaswasthepresidentofCostaRicafrom19861990,and,afteraCostaRicanlaw changedconcerningre-election,againfrom20062010.HewontheNobelPeacePrizein1987 forpromotingpeacewithinCentralAmerica,whichwassteepedinwarfareatthetime.Hecalled formoreintegrationintheregionandproposedaCentralAmericanParliamentduringhisfirst administration.Duringhissecond,however,hedeclaredthatCostaRicawouldnotjointhis Parliament.Heisregardedasaneoliberal,thoughhebelongstothesocialdemocraticparty, PLN.

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79 fundedandprivatelymanaged.Thismodelwasdeemedasuccess,andtheCajacontinued expandingituntiltheexistingsixcooperativeswereoperatinginCostaRica.Fouraretrue cooperatives,oneisoperatedbytheUCRMedicalSchool,andoneisrunbyafor-profit doctorsgroupcalled AsociacindeServiciosMdicosCostariccenses (ASEMECO, AssociationforCostaRicanMedicalServices),whichownsoneofthebigthreeprivate hospitals, ClnicaBblica ThecooperativesarealllocatedinpopuloussuburbsofSanJosandserve upwardsofhalfamillionusers(Daz2009).ThoughobligatedbytheCajatoprovidea packageofessentialservicestothepopulation,theyareotherwisefreefrompubliclaws regardinghealthcarepurchasingandmanagement.Thereisdebateaboutwhetherornot thecooperativesaremoreefficientthanCajafacilities,andmanyhaveclaimedthatthey actuallyaremoreexpensivetooperatethanotherpublicfacilities.Whenthisissuecame tolightafewyearsago,cooperativesbecameobligatedtoundergoapublicbidding processinordertogaintheCajasbusiness.Reportssuggestnotonlythatthecooperative modelislessefficientthantheCaja,butthattheyreferpatientstoCajafacilitiesmore thanisnecessary,creatinganunduestrainonpublicfacilities(HomedesandUgalde 2005). Intheearly1990s,anothermixedmedicinemodel,thefreechoicemedical program,wasestablishedallowinguserstoseekcarefromaprivatephysicianoftheir choosing(withintheCaja,patientscannotchoosetheirphysicians)witheconomic assistancefromtheCaja.Thepublicsectoralsobegancontractingoutcomplexdiagnostic testingto ClnicaBblica, withtheofficialreasonofavoidingtechnologicalrisk.This contracthasbeencritiquedasaresultofpoliticalpressuretocreateaspaceforprivate

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80 medicinewithinthecountryandforpersonalfinancialgain(Salas2009).Thecontract became,inamatterofyears,apurchaseofmillionsofdollarsonmedicalequipmentthat benefittedtheprivatesector.The ClnicaBblica directortoldmeinaninterviewthatover 20percentofhishospitalssalesarecurrentlytotheCaja(8). Therearemanysuspicionsaboutthenatureofthesepublicprivaterelationships, andthewaythatprivatesectorentitieslikeASEMECO,and ClnicaBblica winthese bids.ThisbecamenationalnewswhenRafaelngelCaldernFournier,ex-Presidentand, ironically,sonoftheCajasfounder,wasconvictedin2004forhisinvolvementinthe largestcorruptionscandalintheCajashistory.Heawardedamulti-milliondollarCaja contracttoaprivatepharmacychain,theFischelCorporation,thendispersednearly$8 millioninpayoffstohighlyrankedCajaofficials(Arbol2009).ThisnotoriousCaja scandalisfreshinthenationalmemory,andithascausedotherdoubtsaroundwhowins privatesectorbidsforCajacontracts. Itisapparentthat,inspiteofthenationalorientationtopublichealthcareinCosta Rica,theprivatesectorhasalwaysintervenedtosomedegreeinthemanagementand provisionofhealthcare,andseveralpolicydecisionshaveallowedforgreaterprivate participationovertime.Inreality,theprivatesectorissustainedbytheCajaandpublic sectorcontractstoprovideservicestoCajausers.Thisisanimportantpointtokeepin mindaswefurtherdiscussCostaRicasshifttowardpassiveprivatization,theburdenthat privatemedicinecreatesforthesocialsecuritysystem,andhowmedicaltourismimpacts thepublicsector.ThepublicprivaterelationshipinCostaRicaiscomplex,butthetwo sectorsareundeniablyconnected.

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81 ThePrivateSectorToday Ascomparedtothe29CajahospitalsinCostaRica,thereareonly6private hospitals,thenewestofwhich, HospitalMetropolitano ,openedinlate2011.Thebig threehospitalswhereIconductedfieldwork HospitalClnicaBblica CIMA ,and HospitalHotel LaCatlica ,arepopularamongAmericanexpatriatesandmedicaltourists, andallthreehavegainedJCIaccreditationsince2006. CIMA (highlightedinthefieldnote excerptthatbeganthisdissertation)openedin2000andadvertisesitselfasultramodern anddesignedandorganizedforAmericans,withforeignerscomprisingover25percent ofitspatients(CIMAHospital2012). Twomoreprivatehospitalsareslatedtoopenby2013intheSanJos metropolitanarea(Arce2011a),aswellastwosatellitehospitalsof ClnicaBblica and CIMA intheGuanacastearea,themostpopulartouristareainthecountry.Ifthese openingsgoasplanned,thenumberofprivatehospitalsinthecountrywillhavedoubled since2011,ashockinglyfastgrowthforsuchasmallcountry.Thisdoesnotinclude smallerclinics,whichhavebeenontheriseaswell. Despitethisunprecedentedprivatesectorgrowth,theCajacoversover90percent ofCostaRicans,andthosewhoarenotcovered(mostlythosewhoworkintheinformal economy,theself-employed,orundocumentedimmigrants)arestilleligibletouseits serviceseventhoughtheydonotpayintothesystem. Mostlocalswhoaccessprivatefacilitiesdosoasalimitedhealthcarestrategy. Thelownumberofprivatesectorusersisprimarilycost-related,buttheCajaisalso widelyacknowledgedasprovidingthebestcareavailableforillnessesandinjuries becauseitwillperformeverytestrequiredandtakeallnecessarymedicalmeasuresto treatpatients,regardlessofthecost.ForthemajorityofCostaRicans,thecostofprivate

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82 careistoohighandtheprivatesectorremainsoutofreach.However,longwaittimesin thepublicsectorhaveledpatientswithfinancialmeanstoseekcareintheprivatesector, andstudieshaveshownthatupto30percentofthepopulationnowusesprivatehealth careinsomecapacity(e.g.,Connolly2002;Herrero2001;UniversityofCostaRica2006). OnlyupperclassCostaRicansandforeignerscanaffordtoregularlyreceivetheir healthcarewithintheprivatehealthcaresystem,butmiddleclasspatientsusetheprivate sectorinalimitedcapacityforexample,theymightgetdiagnosedwithintheprivate sectortoavoidalongwaittimeinapublicfacility,butupondiagnosis,returntotheCaja fortreatmentandmedicines,especiallyforcomplicatedorexpensivecare.Thisresultsnot onlyindoubleexpendituresforCostaRicanfamilies(whopayfortheCajafromtheir wages,andoutofpocketforcareintheprivatesector),butalsoinastrainonthepublic healthcaresector,whichperformsthemostcostlyprocedures. InternalPressuresontheCostaRicanHealthCareSystem DemographicChangesinCostaRica TherearedemographicchangesoccurringinCostaRicathatcontributetoastrain ontheCajaaswell.Thepopulationhasbeengrowingatasteadyrate,while,atthesame time,peoplearelivinglonger.Lifeexpectancytodayisnearly20yearslongerthanitwas in1960(IndexMundi2009).Thisdemographicshifttowardsanagedpopulation (commontodevelopinganddevelopednationsalike)meansanincreaseddemandfor healthservicesrelatedtotreatingchronicconditions,whichareoftenthemostexpensive. AgrowingimmigrantpopulationinCostaRica,mostlyNicaraguans,hasalso increasedthecostsofhealthcare.Accordingtothe2000census,therewere226,374 NicaraguansresidingpermanentlyinCostaRica,nearlysixpercentofthetotal

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83 population(Muiser,etal.2008). Thisfiguredoesnotincludeshort-termmigrantworkers fromNicaragua,orthosenotcapturedbythecensusforlackofafixedaddress. NicaraguanimmigrantsareperceivedasathreatbecausetheyusetheCajawithout payingintoit.Ithasbeenfound,despitetheseanti-immigrantsentiments,thatimmigrants oftendopayintothesystemmorethanpopularopinionsuggests(Tllez2011),andthatit isoftentheiremployerswhofailtopayintothesystem(Salas2009).Immigrantstendto workthelowestpayingjobswithinCostaRica,ascoffeepickers,bananaplantation workers,maids,orguards,andoftentheretakeplaceintheinformaleconomy,orbosses flatlyrefusetopaytheobligatory9.25percentcontributionfortheirworkers. IntensifyingviolenceandpovertywithinCostaRica,aswellaspatternsofglobal neoliberalconsumption(suchasanaffinityforfastfood)havealsoledtoincreasingly expensivetreatmentswithintheCaja,asobesity,cardiovasculardisease,cancers,and otherdiseasesofaffluencehavemadetheirwaytoCostaRica(Tllez2011).Though thisconsumptiontakesplaceintheprivatesector,theassociatedmedicalcostsare absorbedbythepublicsector.Inlieuofpreventivecare,theseproblemshavetranslated toanincreasedemphasisonhigh-techandintensivemedicalinterventions,whichare veryexpensivefortheCaja. ThreatstotheCajasFinancialStability TheCajaisfacingseriousproblemsoffinancialsustainability.Allresidentsof CostaRica,regardlessoftheirenrollmentinthepublicsystemorimmigrationstatus,are entitledtouseCajaservices,andanyonewhoentersapublicfacilityforemergency serviceswillnotbeturnedaway,eveniftheylacktherequiredinsurance.TheCajaalso offersseveraloptionsformedicalcoverage.Whilesalariedworkersandtheiremployers

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84 payaportionoftheirmonthlywagesintotheCaja,ifahouseholdincomedependson thatsingleworker,thentheentirefamilyreceivesinsurancefromthesecontributedfees. ContractworkersarefreetoenrollintheCaja,payingamonthlyflatfeethatvaries accordingtotheworkersincome.Thegovernmentpaysforstudentsandthoselivingin extremepoverty. Theseenrollmentoptionscomplywithuniversalhealthcoverageunderthe constitution,butmakethesystemdifficulttoregulate,anditisquiteeasytogetaround payingtheenrollmentfees.TheCajahashaddifficultycollectingmandatedfees, particularlyfromtheself-employedorthosenotemployedinthelegitimateeconomy, andauditsoftheCajacollectionsystemshowedsignificantproblemsofcontribution evasionanddelinquentpayments.In1998,itwasestimatedthatabout30percentofthe Cajasannualincomewaslostduetoevasion,whichdoesnottakeintoaccountthe growingproblemoflatepayments(Muiser,etal.2008).Amedicalstudenttoldme, They[theCaja]shouldmakeeverybodypay,buttheycannot.Before, everybodypaidintotheCaja,sothatmadehealthcareavailableforthose whocouldntpayforit.Butnow,alotofpeopledodgethesystemand dontpaytheCaja.Sothepoorpeoplewhousethemostresourcescant pay,andthewealthypeoplearentpayingintothesystemeither,andwe endupwithasystemthathasnomoneyandstillhastocoverabigpartof thepopulation.(43) Inadditiontomanycitizensnotpayingintothesystematall,itisnotuncommon tofindinstanceswhereinsomeonewillwaituntiltheyarediagnosedwithaseriousor chronicillnessandthenenrollintheCajatoreceiveexpensivetreatments.Thesystemis structuredinsuchawaythatifacitizenbeginspayingforCajainsurancetoday,heorshe canbeginreceivingservicestomorrow,regardlessofhealthstatusorcostoftheservices.

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85 Patientsandphysiciansalikeoccasionallyfindwaystomanipulatethelong waitlistsforproceduresthatimpactthesystem.Patientsmightputthemselvesonmore thanonewaitlistforthesameprocedurewhichispossiblebecausethereisno centralizedtrackingsystemtomonitortheliststhusdecreasingtheefficiencyofthe system. Physicians,especiallyspecialists,whomanagetheirownpatientswaitlists, sometimesabusethesystemtoo.Forexample,theymighttakepatientsoutofturn becauseofpersonalrelationships,oracceptbribes,knownas biombos (thisliterally translatesintoafoldingscreen) inexchangeformovingapatienttothetopofthelist. Biombosoccuracrosspublicandprivatesectorsduetothefactthatmanyphysicians workinbothsectors.Forinstance,aphysicianintheprivatespheremightaccepta biombofromaprivatepatienttopushthemtothetopofthewaitlistinaCajafacility.In thesecases,thepatientbenefitsbynothavingtopayforexpensiveprivateservicesand avoidsthelongwaittimesfortreatmentintheCaja,whilethephysicianmakesextra moneyoffthebooks.Occasionally,areversestrategymightbeused,wherein physiciansharvestthepatientsfromthepublicsector,andbringthemintotheirprivate officewheretheycanchargethem(34).Thesetacticsworkbecause,asoneeconomistI interviewedpointedout,itisnotonlythedoctorswhomovebetweensectors,butthe patientstoo: Asaphysician,youarehiredbytheCaja,butat3:00whenyoufinish yourday[inthepublicsector],yougoacrossthestreettoyourprivate office.Andyourpatientsinonespherecouldbethesamepatientsasinthe other.Andthenwellonlyangelswillkeepgoodaccountingofthe situation.(14)

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86 Cajaphysicianshaveoccasionallybeenknowntouseanotherstrategytoincrease theirpublicsalarieswhereintheyperformfewersurgeriesduringtheirscheduled7amto 3pmworkdayandthenscheduleproceduresafterhours,duringwhichtimetheyreceive overtimepay. UnnecessaryPatientReferralstotheCaja WithintheCaja,accesstothehealthcaresystemshouldtheoreticallybethrough theprimarylevelofcare;however,usersofCajaservicesmay,andoftendo,opttogo straighttoaCajahospitalratherthanuseaprimarycarefacilityfirst.Inaddition,the EBAISprimarycareclinicsandthepublicprivatecooperativestendtoreferpatientsto Cajahospitalsmorethanisnecessary(i.e.,whentheycouldinsteadbetreatedonan outpatientbasisorwithintheclinic).Thiscontributestoextremelyhighpatientvolumes intheCajahospitals.Aprivatesectorphysiciansaid, Here,everybodytriestogettothehospitals.TherearethreeClassA hospitals,andinthesehospitals,everybodycomesinwithjustacold thestructurethesystemofEBAISthatwehavenowthatdoesntwork. Allthedoctorsendupsendingthepatientstothehospitals.Imeanthey donthaveresourcestoworkwithattheEBAIS.Theresourcesshouldbe withtheEBAIS,intheprimarycareclinics.Sotheyhaveeverythingthey needtosolveproblems.Andthebighospitalsshoulddedicatetomore seriousillnesses.Butthatsnotthewayitworkshere.Here,ifyouarein theemergencyroomatahospital,youllseediarrhea,toothaches,colds, everything.Sotheemergencyroomsgetsaturatedandthenthehospital collapsesbecauseitdoesnthavethecapacity.(33) Often,themunicipalitypaysfortheprovisionofprimaryhealthcarewhilethe stategovernmentpaysforhospitalcare.Thereisatendencyamongfirstlevelphysicians tounnecessarilyreferpatientstothesecondlevelofcaretodiminishtheirownworkload andreducetheexpendituresofthemunicipalunit.Morethan43percentoftheservices

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87 providedinthepublichealthsectorarehospitalservices,comparedwith11.1percentin theprivatesector(Herrero2001). Evaluationsofthepublicprivatecooperativeshavesuggestedthatthismodelis actuallylessefficientthantheCaja,andmorecostlywithoutevidenceofimproved quality(HomedesandUgalde2005).Thecooperativesreceiveacapitationpaymentfrom theCajafortheirservices,buttheCajaprovidesallnecessarytests,specialtycare, hospitalizationandmedicines.Residentsintheselectedgeographicalareasjointhe cooperativesatnocost,butcontinuetousetheCajaforallnon-primaryhealthservices andemergencies.Theevaluationsalsoindicatethattherearemorereferralstopublic hospitals,notbecauseofmedicalneed,butasawaytoreducethecooperatives expendituresandphysicianworkloads(HomedesandUgalde2005).Thisincreasescosts andworkloadsoftheCaja,andreducestheoverallefficiencyoftheCostaRicanhealth system.Surplusprofitsofthesenon-profitcooperativesaredistributedmostlyamong physiciansandotherstaffmembers(HomedesandUgalde2005),ratherthansupporting theCaja. Privatehospitals,too,oftenreferpatientstotheCajaforthemostcomplicatedor criticalsurgeries.Privateproviderstypicallymakethesereferralsbecauseapatientcan't affordtopayforthetreatment,theprocedureisnotconsideredprofitable,orbecausethey wanttoavoidhighdeathorcomplicationratesthatmightputofftherichpatientsand foreignerstheyaretargetingforbusiness. Beyondthesereferrals,patients(eventhewealthy)alsojustprefertousetheCaja forchronicillnessandforcomplicatedprocedures.AprofessoratUCRsaid, Exceptforthewaitinglists,publichealthcareisgood.Itiseven sometimesbetterthanprivatecare.Itsrecognizedacrossthecontinent,

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88 andthespecializedcareisfantastic.Eventherichpeoplewillstaywiththe Cajabecauseofthat.Youknow,theymightgototheprivateambulatory servicesforadelivery[birth]oracesareansection,orsomethingcheap, likeasmalloperationakneethingorsomethingthatisnotahuge thingtheywilldoitintheprivatesectorbutiftheyreallyhavecancer orsomethingserioustheygotothepublicsector,totheCaja.(22) Thismeansthatthehighestnumberofpatientsandthemostexpensiveprocedures andtreatmentsallremainwithinpublichospitals,placingaheavyburdenonthesystem. Asaresultofallofthesefactors,revenuesenteringtheCajatendtobelessthanthe benefitspaidout.Thisisaproblemthathasbecomemoresevereoverthepastdecade.As ofFebruary2010,theCaja,hadaccruedan$82milliondeficit(theannualbudgettotals $1.8billion)andowed$46millioninoverduepaymentstoserviceprovidersandmedical equipmentsuppliers(Tllez2011).Ironically,thecentralgovernmentitselfis consistentlyinarrearsonthequotasthatitowestotheCaja(0.25percentofsalaryper workerplus9.25percentforitsownemployees)and,in2011,itowedtheCaja$220 million(Tllez2011). NationalManagementofHumanResources ThemanagementofhumanresourceshasalsobeenachallengefortheCajain recentyears.In2004,toaddressthemismatchbetweenthehighnumbersofgraduating physiciansandthelownumberofresidencyspots,thegovernmentsignedanagreement tograduallydoublethenumberofresidencyspots,increasingavailablepositionsby50 peryearfrom350in2004to700in2007(Clark2010),whichremainsthecurrent number.ThisoccurredundertheAriasadministration,which,likethecurrent administration,isknownforaninclinationtowardsprivatizationandpromotingglobal industry.ThisagreementwasintendednotonlytobetterfilltheneedsoftheCaja,but alsotoproducephysiciansfortheprivatesectortobolsteritscapacity.Despitethis

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89 relativelysharpincreaseinpositions,medicalstudentsandresidentswithwhomIspoke stillcriticizedtheCajaslong-termmanagementofresidencies,sayingthatitoftengoes toextremes,withCajaopeningseveralpositionsatoncewhentheyseeaneedina particularspecialty,andthennotopeninganyatallthenextyear(43). Thedifficultyingettingaresidencyanddearthofavailablepositionsis paradoxicalbecausewithinparticularspecialtyareasthereareextremeshortageswithin theCaja.Oneexplanationforthiscouldfoundintheexamplementionedintheprevious chapter,whereinfourneurosurgerypositionswerenotfilledbecausenoonepassedboth teststobecomeaneurosurgeryresident.Butanotherreasonfortheseshortagesisbecause theplanningareaofCENDEISS,whichcalculatestheannualneedsofthedifferent specialtyareasfortheCaja,makestheassumptionthatuponcompletingtheirresidency, thespecialiststrainedintheCajawillstaytheretopracticemedicine.Whilethiswasthe caseformanyyears,andisstillthecaseformanyspecialties,thenumberofphysicians whomigratetotheprivatesectorshortlyaftertheirresidencyhasincreasedsharplyover thepastdecadeorso.Themostnotableexampleofthiswasanesthesiologists,wholeft indrovesfortheprivatesector(23).In2009,theextremeshortageofanesthesiologists stoppedoperationswithintheCaja.Thoughthisisthemostwidelyusedexampleofa specialtyshortageduetoflighttotheprivatesector,therearemorespecialtiesthatare beginningtoshowsignsofasimilarpattern,especiallyplasticandaestheticsurgery (thoughthesearestillprivate-sector-dominatedspecialties).SarahAckerman(2009),in herstudyofplasticsurgerytourismwithinCostaRica,notedthatmostof CIMA smidcareerplasticsurgeonsresignedfromstateemploymentshortlyaftercompletingtheir traininginreconstructivesurgery,tothedisappointmentoftheirmentors.Privatesector

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90 migrationisbecomingmorecommoninemergingtouristspecialtiesaswellincluding orthopedics,radiology,urologyandpathology.ManyphysiciansIinterviewedwere concernedthat,withmorepatientvolumeintheprivatesector,thesetypesofspecialist shortageswithintheCajawouldbecomeverysevere. TheContratodeAprendizaje In2004,tobetterfulfilltheneedsoftheCaja,andtocombatoutflowtothe privatesectoratthesametimethattheadditionalresidencypositionsbegantobe openedtheCajainstituteda contratodeaprendizaje, oratraineeshipcontract,with medicalresidents.InexchangeforsubsidizededucationandtrainingofferedbytheCaja duringtheirresidencyperiod,residentswererequiredtosignacontractstatingthatthey wouldservethreeyearsintheCajaforeachoneyearofresidencytrainingthattheyhad received.Theseyearsofservicecouldbecarriedoutinanypublicfacility,anywherein thecountrywheretheCajaneededthem.Thisessentiallymeantthatnewspecialists wouldserveaminimumofnineyearswherevertheyweresent.Iftheyfailedtofulfill theseterms,theywouldberequiredtopayafineof32millioncolones(approximately $64,000)tobereleasedofthiscommitment(CCSS2004). Thecontractdidnotapplytothosewhowerealreadyenrolledinaresidency,so thefirstcohortofphysicianstowhomthetermsappliedgraduatedin2010.Most residentsfeltthatitwasfairtogivetheseyearsofservicetotheCajaupongraduating, andthatitwastheirsocialresponsibilitytodoso.However,whenthefirstcohortof specialistsgraduated,thingsbegantogobadly.Theyweresenttoassignedposts throughoutthecountry,includingveryremoteandrurallocations.Whilethiswas stipulatedinthecontract,thedecisionsaboutwhereeachphysicianwouldbesentwere

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91 supposedtobemadethroughaseriesoftransparentcriteria,butinpracticeseemedtobe morepoliticalinnatureandlackedclearjustificationforwhyresidentswerebeingsentto theselocations.Insomecases,theclinicswhereresidentsweresentlackedresources (eithertechnologicalorhumanresources)topracticetheirspecialty.Onesurgeontoldme thathewassenttoaremotecommunityclinicwheretherewasnoanesthesiologist,and sohewasunabletoperformanysurgeriesthathehadbeentrainedtodo(37).Thisisalso animportanttimeinthelifeofgraduatingphysicians,whentheyarestartingtomarryand havefamilies.Theplacementssometimessplitupfamilymembersorcouples,moved physicianstoplacesthatwereconsidereddangerous,orthatlackedsufficienteducation andhealthservicesthatareconducivetoraisingafamily. Ingeneral,theproblemswiththe contratodeaprendizaje arepoliticalor administrative,andnotbecausedoctorseitherwanttopracticeinprivatesectorordonot wanttopracticeinthepublicsector.Youngphysiciansoverwhelminglyrecognizethat theyneedtoworkintheCajainordertocontinuelearningandinordertohaveenough patientvolumetoimprovewithintheirspecialty.Thatsaid,therearesomewhochooseto leavefortheprivatesectorandviewthiscontractasanalienationoftheirrighttodoso. KarinaandIheardaccountsofphysicianswho,toavoidanundesirableplacementbythe Caja,finishedtheirspecialtytraining,tookoutloanstopaythecontractssanction,and thenlefttheCajatopracticeintheprivatesectorwheretheycouldrecoupthecostsofthe finemorequickly.Thisisarareresponse,however.Mostnewlyformedphysicians comingfrompublicuniversitywheretheireducationwassubsidized,andfreshoutof theirresidencyinCaja,wheretheydidnotearnmuchmoneyarenotusedtosaving muchmoney,andtheprospectofpayingthe32millioncolonesanctionisdownright

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92 impossible. The2010ResidentsStrike OnJune14,2010,900medicalresidentswentonstrikewiththesupportofthe UninMdicaNacional (NationalMedicalUnion)andthe SindicatoNacionalde MdicosEspecialistas (NationalUnionofMedicalSpecialistsor SINAME ).Theonly demandoftheresidentswasthattheCajaabandonthetraineeshipcontract,claimingthat therearenootherjobswhereonemusttakeonadebttowork(Long2010b).After severaldays,thetwounionscalledforitsmemberstojointhestrikeaswell,addingan additionallistofdemandsforimprovedequipmentandworkingconditions. Thestrikelasted13daysbeforeacompromisewasreached.TheCajaloweredthe contratodeaprendizaje requirementforgraduatedspecialiststoworkanywhereinthe country,fromthreeyearstooneyearforeachyearofresidency.Thenewagreementalso replacedthe32-millioncolonesanctionwithaneightpercentcontributionfromthe residentsbasesalary,whichremainsuntouchedforthedurationoftheirresidencywith theCaja.Iftheresidentcompletestheirtermintheassignedposition,theyreceiveallof themoneyback.Iftheyoptoutoftheagreement,thefundremainswiththeCaja. Althoughacompromisewasreached,thissolutionsignificantlyimpactstheabilityofthe Cajatofillruralpositions,particularlyinundesirableareas,whichoftenhavethemost need.ItalsoisdemonstrativeofgeneraldissatisfactionwithCaja,aswellasemerging ideasofindividualchoicethatarecontrarytotheimageofphysiciansaspublicservants tothepeople.Furthermore,ithighlightsanerosionofhealthcareachievementsin particularareasofthecountry,andanincreaseinviolence,drugs,andpovertythatmakes theselocationsundesirabletolive.

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93 DeterioratingConditionsintheCaja Thesepressuresonthepublicsystemhaveledtoadeteriorationofconditions withintheCaja,forbothpatientswhousethesystem,andhealthcarepersonnelwho workthere.Patientsmostoftencomplainedaboutthelongwaittimesforappointments withintheCaja(whichcanbelongerthanayear),andtheimpersonalwaythattheywere treated(patientsaretypicallyallowedtospendonly15minuteswithphysicians). Physiciansthoughtthattheseconditionswereextremelyfrustratingaswell.An administratorof HospitalSanJuandeDios ,alandmarkwithinCostaRica,andonce calledthecrownjeweloftheCaja,toldme, Hereiswhatishappeningatthismomentinourhospitals.InJanuaryof thisyear[2010],Ihadawaitinglistof8,600patients.Totalinall specialties.Somethingthatwedidinthepastthatmotivatedour employees,economically,wasthattheywouldstayafter4pmanddonight shifts,andtheymademoremoney.And,forme,itresolvedabout250 patientsamonthfromthewaitinglist,so3,000peryear.Sothisyear,I havetriedtohavethem[Cajaadministration]togivemethenighthours again,andthereisnomoney,nobudgetforthat.SoIstartedwith8,600 patientsonthewaitlistinJanuary.InAugust,Ihad10,800.Andin DecemberIwillhave12,000. SotheadministrationthendemandsthatIopenmoreconsultationsto takecareofthewaitlist.SoIopenmoreconsultations,andtheydemand morefromthepeoplewhoworkhere,sotheygivemore,butwiththe sameresources.Doyouknowwhattheydo?Theyleave!The anesthesiologists,thenurses,thedoctors,theyallprefertogotoaclinic wheretheycanbecalmandcanworkinpeace.Thatisnothere[inthe Caja].Theyjustleaveandwhoevercanleavewithoutfulfillingthe contract[contratodeaprendizaje]becausehedoesnthaveaneedforthis, goestotheprivatesector.TheydontwanttobehereImean,howcan weretainthem?(42) Manyexpressedadesiretoeventuallyacquireenoughclientstobeabletoleave thepublicsectoraltogetherandmoveintotheprivatesector,wheretheycouldearna significantlyhighersalaryandhavemorecontrolovertheirtime.Aphysicianworking fortheCajamightmakesomewherebetween$1,500and$3,000permonth,whichthey

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94 cansupplementbybeingoncallorworkingadditionalshifts.Aplasticsurgeonor orthopedistworkingintheprivatesectormightmakeupto$10,000foronesurgery.A coupleofprivatesectorsurgeonswhomIspokewithtoldmethatwithjustoneinsurgery theirprivatepractice,theyareabletoearntheequivalentofanentiremonthssalaryfrom theCaja.Whilethisisnotthecaseforallspecialties,specialiststoldmethattheycould makeatleastfourtimesmoreintheprivatesector,iftheyareabletokeepenoughclients. WithintheCaja,physiciansarepaidthesamebasesalaryregardlessofthe numberofsurgeriestheycomplete,whileprivatesectorphysiciansarepaidpersurgery. BecauseofthetenuresystemintheCaja,itispossibletomakeaveryhighsalary,but typicallynotuntillaterinthephysicianscareer.Notallspecialtiesaresolucrativeinthe privatesector,andseveralphysiciansenjoythestabilityandbenefitsthatcomewiththeir Cajapositions,aswellasthelackofpersonalresponsibility.Forexample,oneprivate sectororthopedisttoldme, Weearnmoremoneyoutsidethesocialsecuritysystem.Alotmore money.Butwehavemoreresponsibilitywithourpatients.Andthe doctorsthatdontwanttoworkprivatelyitsprobablybecauseofthat.If youdoasurgery8aminanyCajahospitalandthatpatientstartstobleed at10pm,thereisanotherdoctorthatisgoingtoseehim.Intheprivate sector,no,youhavetowakeupandgoseethepatient.(9) ThecurrentconditionoftheCaja,aswellasglobalpressuresonthesystemto change(whichwillbediscussedinChapterFour)haveledtodisenchantmentamong citizenswiththeCaja.Thesocialethiconwhichthesystemwasfoundediseroding,and middleclassCostaRicansandphysiciansalikenolongerhavethebuy-inthattheyonce hadinthecollectivesystem.PhysiciansintheCajaarethoughttoworkforintrinsic motivation,whileintheprivatesectortheyworkformoney(22).Manyfeelthatthe Cajaisbeingtakenoverbythepoor,andbyforeignerswhodonotpayintothe

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95 system 18 .TherearestillphysicianswhoremainintheCajabecausetheyfeelthatitis theirsocialresponsibilitytodoso.AnadministratoratHospitalSanJuandeDiossaid that, WorkingintheCajaisdifficult.ButIliketoworkforthesocialsecurity.I feelgood,andproductivewhenIgivetopeoplewhodonthavemoney, andgivethemanopportunitytohavehealthcare.EvenifIcouldmake moremoneyelsewhere,Iwouldstay.IknowifIwenttoprivatepractice,I probablywouldhavealotofmoney.Idontknow,Ithinkthemoneyis notimportant.Butsomepeoplesay,youhavetoworktoliveandnotlive towork.(45) ThebenefitsofremainingintheCajaarebecomingfewer,whileemployeesare askedtodomorewithdiminishingresources.IheardseveraltimesthattheCajais broken,orthatitneedstochange.Butthroughouttheresearch,noonetoldmethat theywantedtheCajatodisappearaltogether,andtherewasagreatdealofconcernover thefutureofthepublicsystem.Anolder amadecasa ( housewife)surveyedat Coopesalud saidthatsheusedtheCajanearly15timesforhermedicines,surgeries,and treatmentsfortheH1N1fluthatshehadlastyear.Shetriestoneverusetheprivate sectorbecausetherearetoomanymoneyneedsatthehouseandwroteinanopen commentsection,IdontknowwhatwewoulddowithouttheCaja.Disenchanted patientsandemployeesalikeknowthatCostaRicaneedstheCaja.Itkeepsthesocial peace,givesaccesstothosewhowouldnotbeabletopurchasecareintheprivatesector, andrepresentsthesolidarityofwhatitmeanstobeCostaRican. 18 Inthiscase,thepatientswerereferringtoimmigrantsfromNicaraguaandotherpartsofCentral AmericaandtheCaribbean.Thosesurveyedandinterviewedmadeaninterestingdistinction betweenmedicaltouristsasforeignersusingthesystem,andimmigrantsasforeignersusingthe system,whichwillbeexaminedfurtherintheChapterSix.

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96 Figure10:Atleft:theformercrownjeweloftheCaja,HospitalSanJuandeDios, withpatientswaitingoutside.Atright:anEBAISprimarycareclinic.(Photosbyauthor). WorkinginBothSectors Atthetimeofdevelopmentofthesocialsecuritysystem,itwasagreedthat physicianswhoworkfortheCajawouldalsobeabletopracticeintheprivatesectora concessiontotheprivatephysicianswhoweresoadamantlyagainstthedevelopmentof thesocialsecuritysystem.Fromtheoutset,physicianshaveprotectedtheirrightto practiceintheprivatesector,andatthetimethattheCajawasestablishedin1941,thekey componentsoftheircontractwiththestateincludedclinicalautonomy,unfettered opportunityforprivatesectorpractice,guaranteeddecentwages,andwell-stocked hospitals(Clark2005). Thisfurthermuddiesthepublicprivaterelationshipinthatmanyphysicianswho practicefulltimeintheCajaalsoworkintheprivatesectoraftertheirworkdayinthe publicsectoriscomplete.Therearenolawsorrestrictionsagainstdoingso,andthisis popularlyviewedasakindofcompromisewhereinphysiciansareabletosupplement theirsalaryandtheCajaisabletoretaintheirphysicianswhilepayingthemless.Itisa waytoliveinthebestoftwoworlds,asoneparticipantputit(14).Theybeginby openingaprivateofficewheretheycanworkacoupleeveningsperweekaftertheirwork day(7am3pm)iscomplete,andthengraduallyexpandtheirhoursintheprivatepractice

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97 untiltheycanmaintainenoughclientsintheprivatesectortomakethemovepermanently, andleavetheCaja.Inthepast,mostphysiciansandnursesdidnothavethisoption becausetherewasnotahighenoughpatientvolumeintheprivatesector,butwith increasingprivatizationandtheestablishmentofmedicaltourism,thisischanging.A physicianwhohadchosenthiscareerpathandmovedfulltimeintotheprivatesectorafter yearsofworkingintheCajatoldme, Whenyouarebeginningandyouneedtolearn,tohavemoretraining,you canonlydothatinthesocialsecuritysystem,becausetheyareteaching hospitals.Thatsthereason.Andlater,whenyouhavetheexperience wellthenweusethatexperienceinprivatepractice.(29) Intheearly1990s,approximatelytenpercentofhealthprofessionalsworkedinthe privatesector;bythelate1990s,thisproportionhadrisento24percent(Connolly2002); today,ithasbeenestimatedthatatleastathirdofthenationsphysicianshaveaprivate practice(Ackerman2009).Themedicaldirectorof HospitalHotel LaCatlica toldme thatof105doctorsat LaCatlica ,only38ofthemdonotalsoworkintheCaja,andof those38,mostareretiredfromtheCaja,orvoluntarilylefttodedicateexclusivelyto privatepractice.Themajorityofthosewhovoluntarilyleftwereorthopedistsbecause thereareenoughclientsforthemat LaCatlica .Hecontinuedbysayingthatthatfor otherspecialties,likeneurosurgery,cardiovascularsurgery,orpulmonology,itwouldnot beprofitableenoughforthephysiciantoliveonlyoffofonlytheirprivateconsultations (becausepatientsusetheCajaforthoseprocedures),andsothesespecialiststendtosplit theirtimebetweentheCajaand LaCatlica .Theflowofphysiciansisalmostalways

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98 fromtheCajatotheprivatesector,andnottheotherwayaround. 19 Asonenurseputit, thelinkbetweenthepublicandprivatesectorsisalwaysthedoctors(41).The physicianswhoworkinbothsectorstendtobethebestphysiciansinthecountrywithin theirspecialty.Iftheywerenot,theywouldnotbeabletoattractenoughpatientstomake alivingintheprivatesector. PassivePrivatization WhiletheconnectionsbetweenthepublicandprivatehealthcaresectorsinCosta Ricamaynotbestraightforward,thetwosectorshaveacomplexandconvoluted relationshipthat,attimes,hasstemmedfromoverthistorical,politicalandeconomic decisions,and,atothertimes,hasoccurredwithoutpurposiveintent.Asprivatefacilities andhospitalgroups,foreigninvestmentinhealthcare,andthenumberofmiddle-class CostaRicansusingtheprivatesectorrapidlygrowwithinCostaRica,state-sponsored healthcareisslowlycontracting.Aphysicianwhowasinstrumentalintheresidentstrike saidtome, ThereisatrendoccurringherethatCajahaslesseverytime.Before,ina Cajahospital,thecleaningstaff,maintenancestaff,thedoctors,nurses, laundrypeopletheywereallemployeesofCaja.Now,thelaundry serviceisnotfromCaja,itisprivatelymanaged.Cleaningservicesarenot fromCaja,therearesub-contractedfromaprivatecompany.Thepeople thatmakerepairsarenotfromCajaanymore.Andsomewanttotakeit evenfurther,andmaybeCajawonthavedoctorsornursesoranything, onlyinfrastructuresotheycouldhirepeopletogoandoperatethere.This doesntmakemuchsensetome,butitwouldnotbesoharmfulifwehad faiththateverythingwasbeingdoneinatransparentway,butwhenyou seehowbidsaremade[forpubliccontracts],theyarenotdoneinafair way.Itistheir[administrators]friendswhoarebenefittingandthisall meanshigherexpensesforsocialsecuritythanhavingemployeesdirectly hired.Ithinkthisisrelatedwithneoliberalism,withthisnewideology. 19 Interestingly,thisisnotthecasefornurses,whodonotearnasignificantlyhighersalaryinthe privatesector,andtendtopreferthestabilityofpublicsectoremployment.Jobsaremuchless stablefornursesworkingintheprivatesector.

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99 (46) Ingeneral,despitethefactthatmostCostaRicansareupsetaboutthe deteriorationoftheCaja,theydonotconnectthedeteriorationoftheCajato privatization.ManyCostaRicansdonotfullyunderstandwhatprivatizationis.A medicalresidentsaid,Wedontknowwhatprivatemedicineis.MakingaTico understanditisverycomplicated...wedontknowwhatitmeanstopayfor health(36).SimilartostudiesofhealthcitizenshipthathavetakenplaceinCuba, itseemsthatanewkindofcontradictoryCostaRicanisformingraised socialist,wantstobecapitalist,butdoesntknowwhatcapitalistis(Brotherton 2003). ThetendencyofCostaRicanstoviewthepublicandprivatespheresseparately,as wasdiscussedintheopeningofthischapter,aidsinthepassiveprivatization(Clark 2010)thathasbeenoccurring.Theseparationofthetwospheresisentrenchedin neoliberaldiscourse,whichrejectspublicsectorinterventionintheprivatesector,and considersthemarkettofunctionentirelyonitsown,unencumberedbystateintervention. ManywhomIspokewithadamantlymaintainedthisbeliefthattheprivatesectorlives onitsown(4).Perpetuatingthediscoursethatthepublicandprivatespheresare completelyseparatehasallowedtheprivatesectortotakefromthepublicsectorwithout givingtoit.Denyingaconnectionbetweenthetwosectorshasalsomeantlessguiltonthe partofhealthcarepersonnelandpatients,whobelievethattheirdecisionstopracticein theprivatesector,tousetheprivatesectorforhealthservices,ortoevadepayingintothe Cajaaremattersofindividualchoicethatdonotimpactthehealthcaresystem. Thedenialofapublicprivateconnectionalsomeansthattheproblemswiththe

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100 systemaresituatedfirmlywithintheCaja,ratherthanonoutsideforcesthatimpactthe system,orontheparasiticrelationshipthattheprivatesectoroftenhaswiththeCaja.This framingdisconnectsprivateexpansionfromthecontractionofstateservices,allowing privatizationtocreepintothepublicdomainratherunceremoniously.Atthesametime, theprivatesectorwhileevadesanyresponsibilityfordeclininghealthconditionsand increasinginequitiesthatareoccurringinCostaRica.Themaintenanceofthisdivide, whilenotintentional,supportsneoliberalforcesthatarepushingdownontheuniversal healthcaresystemandcontributestothevulnerabilityofthepublicsectortoprivatization.

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101 CHAPTER5:NEOLIBERALPRESSURESONTHEHEALTHCARESYSTEM Althoughtheblameforthecurrentshortcomingsofthehealthcaresystemisoften placedontheCajaitself,therapidprivatizationthatisoccurringinCostaRicaisnot exclusivelyduetostrainsonthesystemfromwithinCostaRicasborders.Infact,many oftheburdensontheCajadiscussedinthepreviouschapteroriginateoutsideofthe country.Externalpressuresonthesystem,particularlyglobalneoliberalinfluencesthat havebeenprominentforcesofglobalizationoverthepastdecades,havegravelyaffected theabilityoftheCostaRicanstatetodeliverhealthcaretoitscitizens.Inthischapter,I examinetheexternalneoliberalpressuresonCostaRicashealthcaresystemthathave leftthepublicsectorvulnerableinparticular,StructuralAdjustmentPrograms,Free TradeAgreements,andthespreadofneoliberalexpectationswithinhealthcare.These globalimpositionshaveleftthecontemporaryCostaRicanstateatacrossroadsonone handclingingtothesocialprinciplesuponwhichthenationwasfoundedand,onthe other,strugglingtofindaplaceintheglobaleconomy. ThePrinciplesofNeoliberalism Themedicaltourismindustryisdeeplyentrenchedinneoliberalideology. Neoliberalismisatheoryofpoliticaleconomicpracticesthatproposesthathumanwellbeingcanbestbeadvancedbyliberatingindividualentrepreneurialfreedomsandskills withinaninstitutionalframeworkcharacterizedbystrongprivatepropertyrights,free marketsandfreetrade(Harvey2005).Privatization,deregulation,andcommodification arekeyprinciplesoftheneoliberalagenda,withtheendgoalbeingeconomic development.Underneoliberalism,theroleofthestateismerelytosupportprivate enterprise,ratherthantoregulateorprotectitscitizens.Usingthismodel,allsectorsof

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102 theeconomyaretobeoperatedforeconomicprofit,includingthosethataretiedtosocial welfare,likehealthcareprovision.Thisisduetotheassumptionthatmarketsareselfregulatingandcreateresponsibleandrationalindividualswhoareself-governingbecause theyhaveinternalizedthehegemonicmarketlogic(Foucault1991). 20 Neoliberalism governsthroughfreedomandpersonalresponsibility(Rose1999).Underneoliberal governmentality,thestateretreatsfromdirectprotectionofitscitizensandinstead attemptstoformthemintorationalconsumersthroughthelogicofthemarket. Inneoliberaldiscourse,GDPgrowthisseenastheprimaryvitalsignofahealthy economyandthebestproofthatsocietyisdeveloping.Thisassumptionthateconomic growthbringsprosperityandbetterlifeforusalliswidespread,andhasremainedlargely unquestionedandunquestionable(Kim,etal.2000).Thisistheargumentmostoften citedbyproponentsofmedicaltourismthattheindustrywillbringeconomicprosperity throughboostingthetouristsectoranditscontributiontotheGDP,andthatprosperity willthentrickledownfromthetop,eventuallyreachingthepoor.Thispervasiveview assumesthatmedicaltourismbringseconomicgrowth,thatanyeconomicgrowthisgood growth,andthatthisprosperitywillpositivelyaffectallsegmentsofthepopulation.The sloganformedicaltourism:FirstWorldtreatmentatThirdWorldprices 21 (Gupta2004) exemplifiesrelianceonaneoliberalmodelthatiscenteredonprofitmotive. 20 IamusingGramscisconceptofhegemony(Gramsci1971)here,inwhichrulingclassinterests becomeacceptedascommonsensebythesubordinatedclasses,andthevaluesofthoseinpower becomeinternalizedasnormal.Itisanunconscious,deeplypenetratingforcethatisabsorbed uncriticallyandleadstomoralandpoliticalpassivityandthemaintenanceofthestatusquo. 21 Thiswasoneofthefirstslogansformedicaltourism,buttheindustryhasceasedusingitto avoidgivingtheimpressionthatthereisanythingthirdworldaboutthemedicaltourism experience(Turner2007).

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103 Inaneraofglobalization,whereinindividuallives,atalocallevel,become affectedbyeconomic,politicalandculturalforcesatagloballevel,localconcerns becomedeeplyintertwinedwithnationalandglobaldiscourses(Appadurai1991).The spreadofneoliberalismgloballyistightlylinkedtotheStructuralAdjustmentPrograms (SAPs)ofthe1980sand90s,whichwereshapedbythedominantindustrializednations oftheworld.Theseloanprogramsmadeneoliberalreformsaconditionfordeveloping nationstoreceivemoneytorebuildtheireconomies,whichhadcrashedduringtheglobal economiccrisisofthe1980s.Itsspreadisalsotiedtotheinstitutingofglobalfreetrade agreementsthatallowedtradegoodstoflowfreelyacrossinternationalbordersandgave precedencetotheglobalmarketplaceoverdomesticmarkets.Theseneoliberalreforms wereintendedtoimprovehealthcaresystemsofdebtornations,butinfactcausedthem muchharm(e.g.,CastroandSinger2004;Farmer1999;JanesandChuluundorj2004; Kim,etal.2000;Labonte2004;Navarro2007).Neoliberalismhastendedtobenefitthe dominantglobalpowersandtheircorporateinterestsattheexpenseofdebtornations, especiallyimpactingthepoorofthesenations. ImpactsofStructuralAdjustmentProgramsonPublicHealth SAPsinLatinAmerica Theeconomiccrisisofthe1980shittheLatinAmericanregionhard,resultingin significantinterventionbytheWorldBankandInternationalMonetaryFund(IMF).It wasatthistimethattheWorldBankbegantoplayaprominentroleininternational healthpolicy,especiallyindevelopingcountries.Bytheendofthe1980s,theWorld Bankhadbecomethelargestinternationalhealthlender,settingthecourseforhealth

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104 systemreforminLatinAmericaandaroundoftheworld;thesereformswouldhave lastingconsequences(HomedesandUgalde2005). SAPs,basedontheneoliberaleconomicprinciplesdescribedintheprevious section,wereimplementedthroughoutLatinAmericatocorrectwhatwasseenasthe failureofsocialwelfarestates.Theloantermslaidoutmeasurestobetakentotransform welfarestatesintomorestreamlinedandefficiententitiesinorderreducethelargepublic debtsthatgovernmentshadaccrued.Whetherornotstates should betransformedwas neverquestioned.Thekeyelementsofthesepoliciesweredecentralizationand privatization,whichwereviewedastheonlymeanstoincreasedproductivityand efficiencyofthestate.Thistranslatedintoadrasticreductioninpublicsectorspending andcutstothesocialwelfareprogramsthatconstitutedalargepartofpublicexpenditures inLatinAmerica. Althoughthedecentralizationcomponentoftheloanswassomewhatmore successfulintheregion,onlyafewcountriesinLatinAmericaevenpartiallyprivatized themanagementordeliveryoftheirpubliclyfinancedhealthservices.Tosomeextent duetohistoricalorientationtowardsocialmedicine,themajoritymadelessradical reformsbyincreasingprivatesectorinvolvementinhealthcarethroughcontractswiththe publicsector(likeCostaRicasmixed-medicinemodels),orinotherways,ratherthan completelyprivatizingtheseservices. Thelevelofadoptionofneoliberalreformsinthehealthcaresectorhasnotbeen uniformthroughoutLatinAmerica.ChileandColombia,forexample,followedthe neoliberalreformsmostclosely,dismantlingexistingsocialsecurityprogramsand privatizinghealthservicesduringtheSAPreformperiod.Chile,inparticular,hada

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105 healthsystemthatwasconsideredoneofthebestorganizedandmostcomprehensivein theregion(priortoa1973coup)andinfact,theCostaRicansocialsecuritysystemis basedontheChileanmodel.ChilewasthefirstcountryinLatinAmericatoimplement neoliberaleconomicreforms,duetostrongconnectionswiththeUniversityofChicago,a strongholdofneoliberalthoughtatthetime(Harvey2005).Chilesetupasystemof privatehealthinsuranceproviderscalled InstitucionesdeSaludPrevisional (ISAPREs ). Today,ChileisoneofthewealthiestLatinAmericannations,butonly22percentofthe populationisenrolledinISAPREsandthosewhoareenrolledpayout43percentofthe countryshealthexpenditures(HomedesandUgalde2005).Inotherwords,therearehigh healthcarecosts,highincomeinequality,andlowaccesstohealthcare. ColombiafollowedtheSAPblueprintverycloselyaswell;ithasbeencalleda livinglaboratorytotestneoliberalreforms(Abada-Barrero2012).DuringtheSAP period,Colombiauniversalizedapackageofmandatoryhealthservices,whichwere administeredanddeliveredbytheprivatesector.Aftersomeinitialsuccesswiththis, therewereadramaticincreasesinhealthexpenditures,whichrose178percentbetween 1984and1997duetobureaucraticallycomplexpaymentandcoveragesystems,andyetit stillfailedtocoveralargepercentageofthepopulation(HomedesandUgalde2005). Studiesshowthatthereformshavedriventhecountryintoamajorpublichealthcrisis (Abada-Barrero2012). SAPsinCostaRica ThestridesthathadbeenmadewiththeCajaandastrongsocialwelfarestatein CostaRicawereputtothetestduringthelostdecadeofthe1980s(Edelman1999).

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106 CostaRicainitiallyresistedthetermsofSAPs, 22 butthegovernmenteventuallyhadlittle choicebuttoconformtotheloanconditionsinordertoreceivefinancialreliefforits ailingeconomy.TheproposedreformprogramforCostaRicafocusedon decentralizationandthetransferofservicesfromthepublictotheprivatesector.Because publicandprivatesectorhealthcareprovidersarethesameinCostaRica,thistransfer wouldmeannotonlyamoveofservicesfromonesidetotheotherside,butamoveof theworkerswhoprovidetheservicesaswell.Thereformprogramalsofocusedon expandingprimarycareandseparatingthepurchaserandprovidersofhealthservices, whichwereboththeCaja.Anewsystemwasproposed,inwhichthehospitals,rather thantheCaja,wouldberesponsibleforhiringandfiringtheirownpersonnel,andwould handlethepurchaseofservicesandtechnology.TheCajawouldthenevaluate performanceofthehospitalsandrewardorpenalizethemaccordingly.Hospital authorities,laborunionsandtheCajaadministrationflatlyrejectedthisproposition. Instead,Cajaadministratorstookadvantageofthenon-specificSAPguidelineson how thesetransformationsweretotakeplace,andoptedtofocusalmostexclusivelyon theelementofexpandingprimarycare.Theprimaryhealthcaresystemwasoverhauled andreorganized,andprimaryhealthteams(EBAIS)wereplacedthroughoutthecountry sothatservicesweredistributedmoreequitably.Thiswasthemajoraccomplishmentof thereformperiodinCostaRica. Beyondthisrestructuring,therewasagenerallackofinterestinreorganizingand decentralizinghealthsystemmanagement,andCostaRicanauthoritiesweighedheavily onthesideofequityoverefficiencyintheircompliancewiththestructuraladjustment 22 ThefirsttwoIMFloanagreements,in1980and1981,werecancelledduetogovernment noncompliancewithausteritymeasures(Taft-Morales1991).

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107 loans.TheWorldBankadmitsthatdecentralizationoftheCajadidnotsucceedinCosta Ricaandreportedthatitseffortshadbeenunderminedbyinternalopposition(World Bank2003).ComparedtoothercountriesintheLatinAmericanregion,CostaRican reformsshowedrelativelyweakcommitmenttotheneoliberal-inspiredSAPs. Essentially,CostaRicatookwhattheywantedfromthereformandlefttherest.AsClark statedthelong-termdominanceofCostaRicascentralizedstatehealthcaresystem, rejectionofradicalorneoliberalreform,anddependablefocusonequitygoalsmakesit anoutliercomparedtootherLatinAmericanmodelsexceptforCuba(2010).Caja authoritiestooktheopportunitytoimprovesomeaspectsofpublichealthcaredelivery duringthistime,butthepopularandpoliticalsupportfortheCajaneverwavered,andits principleswereneverquestioned,despiteoutsidepressuretoprivatize. InCostaRica,attemptstoprivatizetheCajaandotherstateentitieshave consistentlymetwithstrongpopularresistanceandcollectiveaction(Edelman1999; Palmer2003).InEdelmans(1999)accountofa1988peasantuprisinginCostaRica,he documentsacampesinomovementinwhichsmall-scalefarmerswentonstrikeover IMF,WorldBank,andUSAIDagreementsthatharmedlocalagriculturalistsbydumping alargeamountofinexpensivestaplefoodsintotheCostaRicaneconomyduringthe SandinistaRebellioninNicaragua.AleaderoftheUniversityofCostaRicatoldme, IfeelthatCostaRicareallyisprivilegedinthesensethatwehavent succeededinbeing"armtwisted"asthey[internationalaidorganizations] twistedarmsinColombiaorChileorNicaraguaorElSalvadoror GuatemalawiththeWorldBanktryingtosellusimportedmodelsfrom outsiders,sayingthesemodelsarebetterthanournationalmodel.Wehave builtourownmodelofhealthserviceandhavebeenexpandingthe coverageoftheserviceandthroughasingleinstitution.Weareoneofthe onlycountriesinLatinAmerica,perhapsintheworld,thathasasingle publicproviderofhealthservices,trulypublic.(7)

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108 Becausethestatehascontributedsoenormouslytoeconomicandsocialprogress, theconsequencesofneoliberalreforms,whichrepresentedtheundoingofthestate,anda shiftfromastatisttoamarketeconomy,wereespeciallydangerousinCostaRica.A founderoftheCajasaidaboutSAPs,rathersarcastically,Curiously,wehadalready universalizedourhealthcarewithout240millioninloans.Hecontinued,andwhenyou gotherouteoflessstateandmoremarketthismeanscommercializinghealthand losingallthatwehavesucceeded(8).Thispopularresistancetooutsidepressuresand forcesofneoliberalglobalizationmakesCostaRicaaninterestingplacetoexaminethe effectsofanindustrylikemedicaltourism,firmlyentrenchedinneoliberalprinciples. ImpactsofTradeAgreementsonPublicHealth FromthesamerootsastheWorldBankandtheIMF,thecurrentstructureof internationaltradeagreementsandtheWorldTradeOrganization(WTO)evolved. 23 The WTO,aswellasglobalandregionaltradeagreements,suchastheGeneralAgreementon TradeinServices(GATS),theNorthAmericanFreeTradeAgreement(NAFTA),andthe CentralAmericanFreeTradeAgreement(CAFTA)servetheexpresspurposeof removingrestrictionsoncross-bordertrade.Theseagreementsencourageprivate investmentandderegulationforawidespectrumofservicesandoftensupersedenational lawsandregulations,includingthosethatgovernpublichealth. GATS,a1995WTOtradeagreement,liberalizedtradeinservices.Ithasabuiltincomponentofprogressiveliberalization,meaningthatcountriesundertheagreement 23 TheestablishmentoftheGeneralAgreementonTariffsandTrade(GATT)resultedfromthe BrettonWoodsAccordsafterWorldWarII,fromwhichboththeWorldBankandIMFwere established.ThegoalofGATTwastostimulateeconomicdevelopmentafterthewar.Theloose setofagreementsunderGATTwouldlaterbereplacedbytheWorldTradeOrganization(WTO) in1994.

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109 canonlyliberalizemoreservices,butnotless.Essentially,onceaservicehasbeen liberalized,thereisnowaytoreverseitwithoutpayingasanction.Thesesanctionsarea setamount,ratherthanapercentageorslidingfeescale,whichmeansthatpoorer countriesarepenalizedmorethanrichones(Labonte2004).Theprimaryconcernabout GATSisthatitwillleadtoincreasedprivatizationofessentialpublicserviceslikehealth care.Globally,about30percentofalleconomicactivitiesaregovernment-provided publicservices,mostofwhichareconsideredessentialservices,meaningthatthereis alwaysamarketforthem.Thismakesthemattractivetoprivateinvestorsbecause essentialservicesaresafeinvestments;in2004,servicesaccountedfor60percentofall foreigndirectinvestment(Labonte2004).Medicaltourismisconsideredtradeinhealth servicesunderGATS,withinthesecondoffourservicemodesconsumptionabroad whereinindividualsutilizeaserviceinanothercountry. TheNorthAmericanFreeTradeAgreement(NAFTA),andtheCentralAmerican FreeTradeAgreement(CAFTA)alsoservethepurposeofliberalizingcross-bordertrade. Underthesetradeagreements,therehavebeenseveraldocumentedlegalcasesinwhich therightsofamulti-nationalcorporationhaveprevailedovertherightsofanational government,evenwhendomestichealthwasendangered. 24 TheAgreementonTrade-RelatedIntellectualPropertyRights(TRIPS),whilenot afreetradeagreement,protectsintellectualpropertyrights,almostallofwhichareheld bycompaniesindevelopednations.ItrequiresWTOnationstoprotectpatentrightsfor 24 Foranaccountoftheimpactsofvariousfreetradeagreementsonpublichealthcareprovision, seeShafferetal.2005.Thisarticlealsocontainsexamplesoflegalactionsunderinternational tradeagreements,whereincorporationshavesuccessfullysuednationalgovernmentsfordamages duetoimpedingfreetrade,evenincaseswherethetradegoodinquestionclearlythreatenedthe receivingnationspopulationhealth(forexampletoxicwaste,hormonetreatedmeatproducts,or theuseofgenericmedicines).

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110 20years(althoughdevelopingnationshaveanexceptionuntil2016).Themostfervent debateaboutTRIPSwithinthepublichealtharenahasbeenoveraccesstomedicines. Theagreementhascauseddrugcoststoincreasedramatically,decreasingaccessfor poorernations;inparticular,accesstoanti-retroviraltherapies(ARTs)hasbeenatopicof muchdebateindiscussionsoverTRIPSimpacts.TRIPSreducesaccesstogeneric medicationsindevelopingcountries,atopicthatwillbediscussedwithinCostaRicain thenextsection. Undertheseagreements,governmentsfacealossofsovereigntyinpolicy-making decisionspertinenttohumanservices(i.e.,healthcare,waterandsanitation,energy, education),whicharetreatedascommoditieslikeanyotherssubjecttotraderules.Such agreementshavecausedthestate,socentraltohealthcarewithinLatinAmerica,tobe displacedandhavetransformedthecapacityofgovernmentstomonitorandtoprotect publichealth(Shaffer,etal.2005).Thisdisparityindomesticandinternationalhealth agendashasthepotentialtoexposevulnerablepopulationstoforcesoftheinternational politicaleconomybyremovingthestateasabufferbetweencitizensandglobalforces. Yet,becausethesenewlawsandregulationstakeplaceoutsideofnationalbordersand supercedenationalregulations,thereisnoclearformofgovernancetoregulatethese internationalinteractions.Scholarshavecalledthisaneweraofpublicpolicythatcalls fornovelformsofglobalhealthgovernance,accountabilityandresponsibility (KickbuschandBuse2000).Thisglobalizationrepresentsaperiodofsignificantchange forpublichealth,andraisesquestionsaboutnationalandinternationalresponsibility.

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111 TheCentralAmericanFreeTradeAgreement OnOctober7,2007nowamemorabledateforCostaRicansCostaRicavery narrowlybackedthe TratadodeLibreComercio (TLC),knownhereintheUnitedStates astheCentralAmericanFreeTradeAgreement(CAFTA)byavoteof51.6percent.The popularreferendumthattookplacewashighlycontroversial.CostaRicawasthelastof theparticipatingnationstoratifyandtheonlynationtodecidevianationalvote. CAFTAisatradeagreementbetweentheUnitedStatesononesideand Guatemala,Nicaragua,Honduras,ElSalvador,CostaRica,andtheDominicanRepublic ontheother.Itsaim(muchlikeNAFTAbetweentheUnitedStates,CanadaandMexico) istoliberalizeCentralAmericanmarkets,creatingafreetradezone.Pursuanttothe termsofCAFTA,80percentoftariffsonU.S.exportswereeliminatedimmediately,with remainingtariffstobephasedoutoverthefollowingdecade.Itdoesnotsubstantially reduceU.S.importduties;however,asthemajorityofgoodsproducedinparticipating countriesalreadyentertheUnitedStatesduty-freethroughtheCaribbeanBasinInitiative (CBI). TheroadtotheratificationofCAFTAwasnotasmoothone;fromthestart, CAFTAwasanextremelycontentiousissueforCostaRicans.In2003,theCostaRican governmentwalkedoutoffinaldiscussionsbecause,amongotherreasons,itcouldnot accepttheU.S.conditionsregardinginsurancecompanies.UntilratificationofCAFTA, theinsuranceindustry,alongwithotherindustriesinCostaRica,werestatemonopolies, andthegovernmentwasrightfullyfearfulofpowerfulU.S.companiesenteringthis market,asthefinancialresourcesofmanyofthesecompaniesarelargerthanthoseofthe entireCostaRicangovernment(HomedesandUgalde2005).

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112 ThesigningofCAFTAwastheprimaryissueofthe2006presidentialelection withOscarAriasof PartidoLiberacinNacional (PLN,ortheNationalLiberation Party),whowouldwintheelection,supportingtheagreement,andOttnSolsofthe PartidoAccinCiudadana (PAC,ortheCitizensActionParty)firmlyagainstit.Sols warnedthatCAFTAwouldcauseafloodofcheapU.S.goodsintothemarket,forcing Figure11:ElectionDay,February2010.CostaRicansoutsupportingtheircandidates. YellowandredflagsareforPAC(Sols);greenandwhiteisforPLN(Chinchilla). (Photosbyauthor). small-scalefarmersandsmallbusinessesoutofthemarket,andwouldraisethecostof healthcarethroughintellectualpropertylawsthatpatentdrugs,andwouldbreakup nationalmonopoliestothedetrimentofCostaRicans.In2005,hemadeanotable

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113 statement,publishedinthe NewYorkTimes inanarticleentitledU.S.TradePact DividestheCentralAmericans,saying,thelawofthejunglebenefitsthebigbeast.We areaverysmallbeast(McKinley2005).In2006,SolslostnarrowlytoArias,andin 2010,heranagainandlosttoAriasPLNsuccessor,LauraChinchilla,popularlyreferred toaslamarionneta(themarionette,orpuppet),becauseofheraffinityforcarrying outAriasagenda. Therewasagroundswellofpopularresistanceandprotestsagainstthesigningof CAFTA,andeventhreeyearsafterthereferendum,whileIwasinCostaRica,strong criticalreactiontoitsimplementationremained,withprevalentaccusationsthatthe referendumwascorrupt(CouncilonHemisphericAffairs2007).Pollsleadinguptothe referendumshowedthataslittleasthreedaysbeforehand,amajorityofthepopulation wasplanningtoopposeCAFTA(Lydersen2007). OnarainyFridaynightinJanuaryof2010,Iviewedadocumentarycalled Santo Fraude (HolyFraud)inanauditoriumabsolutelyoverflowingwithenragedviewers. Thefilm,producedbytwoUCRprofessors,detailedthecoercion,liesandcorruptionthat hadtakenplaceonthepartofAriasgovernmenttoensurethatthe SialTLC (Yesto CAFTA)campsucceededduringthereferendum.Amongthechargesagainstthe administrationwerethatitboughtvotesfromthepoorforroughlyfortydollars,paidfor transportationtoandfromthepollsforthosewhowouldvoteyes,threatenedthejobs oflocalleadersiftheydidnotsupportthetreaty,violatedthethree-dayperiodofsilence beforethereferendum,andusedbribesandthreatstoensureyesvotes.Besidesthese legallyquestionabletactics,theyescampwasalsoaccusedofplayingdirtyinother waysbyattemptingtodemonizetheiroppositionthroughlinkingCAFTAopponentsto

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114 HugoChavezandFidelCastro,andspendingupwardsof$500millioninadvertising (comparedto$30millionbyCAFTAsopponents). TheUnitedStatesalsointervenedunlawfullyinthevotewiththreatsthatifCosta RicadidnotratifyCAFTAtherewouldbecommercialrepercussionsspecificallythat CaribbeanBasinInitiativetradepreferencestowardsCostaRica(whereintheU.S. governmentunilaterallylowersitstariffsonCostaRicanproducts)wouldnotberenewed (Lydersen2007;ThirdWorldNetwork2007).Intheend,despitephenomenalpopular resistancewithinCostaRica,itwasaGoliathwithalotof dinero beatingaDavid (ThirdWorldNetwork2007). TheagreementtookeffectinJanuaryof2009,afterseveralattemptsbyCAFTA oppositiontostalltheprocessbychallengingnotonlytheoutcomeofthereferendum,but alsotheconstitutionalityofitsprovisions.TheeffectsofCAFTAweremassive.Fourteen nationallawsneededtochangeinordertoaccommodateitsterms,including,most notably,alawthatopenedpreviouslypublicindustriestoprivatizationandinternational competition.CostaRica'sinsurance,telecommunications,electricitydistribution, petroleumdistribution,potablewater,sewage,andrailroadtransportationindustriesall ofwhichwerestatemonopoliesopenedtomarketcompetition.Inthehealthcarearena, thismeanttheopeningofthenationalhealthinsurancescheme( InstitutoNacionalde Seguros ,orINS)tocompetitionfrominternationalprivateinsurancecompanies.Costa Ricaisunaccustomedtoprivateinsuranceschemes,andnationalcompanieswilllikely haveahardtimecompetingwithinternationalinsurers.Thetermsalsomeanadheringto intellectualpropertyrightsprovisionsunderTRIPS,whichinterfereswiththeabilityof CentralAmericandrugindustriestoproduceandsellaffordablegenericdrugs.Though

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115 theimplementationofCAFTAtermshasbeenaslowprocessinCostaRica(andCosta RicafallsundertheTRIPSexceptionuntil2016)thismayimpacttheabilityoftheCaja tousegenericmedicinesinthefuture. FollowingontheheelsofCAFTA,inApril2010,CostaRicasignedfreetrade agreementswithChinaandSingapore,and,inJanuary2011,aregionalCentral AmericanEuropeanUnion(EU)tradeagreementcameintoeffect.Additionally,Costa RicaisindiscussionstojointheAsiaPacificEconomicCooperation(APEC)forumand theOrganizationofthePetroleumExportingCountries(OPEC)(BureauofWestern HempisphereAffairs2011).

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Figure12 :ResistancetoCAFTA/TLC.Clockwisefromtopleft:1)Marchagainst CAFTA,October23,2006;2)OscarArias:FromNobelPrizetodictatorof democracy;3)Newspaperarticle:CAFTAto toCAFTA;5)Graffiti:Godisneoliberal;6)Protestsign:theprincipleofsolidarity ofthestateinstitutionsthatservethepeople(majority)isingreatdangerofdisappearing ifCAFTAisapproved.Source (Arsonheart2006). :ResistancetoCAFTA/TLC.Clockwisefromtopleft:1)Marchagainst CAFTA,October23,2006;2)OscarArias:FromNobelPrizetodictatorof democracy;3)Newspaperarticle:CAFTAto favortheUnitedStates;4)Graffiti:No toCAFTA;5)Graffiti:Godisneoliberal;6)Protestsign:theprincipleofsolidarity ofthestateinstitutionsthatservethepeople(majority)isingreatdangerofdisappearing ifCAFTAisapproved.Source s:Authorphotos; CostaRicadice:NOalTLC 116 :ResistancetoCAFTA/TLC.Clockwisefromtopleft:1)Marchagainst CAFTA,October23,2006;2)OscarArias:FromNobelPrizetodictatorof favortheUnitedStates;4)Graffiti:No toCAFTA;5)Graffiti:Godisneoliberal;6)Protestsign:theprincipleofsolidarity ofthestateinstitutionsthatservethepeople(majority)isingreatdangerofdisappearing CostaRicadice:NOalTLC

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117 GlobalImpactsofNeoliberalism Proponentsoffreetradeagreementsarguethattheywillproducejobsand stimulatetheeconomythroughnewmodesofinternationalexchangeofgoodsand services.Opponentscontendthatitisnotfurthereconomicgrowththatisneeded,but rathermoreequaldistributionofwealth,andthatfreetradeagreementsonlycontribute furthertothesedisparities.Criticalliteratureontheimpactsoffreetradeandglobaltrade agreementshaveshowncompellingevidenceofthedetrimentaleffectsoftrade liberalizationandprivatizationofpublicservices,findingthatinequalitymeasures worsened,andfiveyearsaftertheimplementationofSAPsthesemeasureshadnot yetrecoveredtopre-SAPrates(Labonte2004).Furthermore,thenationsthatwereheld upasexamplesofthepositiveeffectsofliberalizationonpovertyreduction,suchas India,ChinaandVietnam,haveseensharpincreasesinincomeinequalitiesalongwith theirgrowingGDPs(Labonte2004). LatinAmericaremainsthemostunequalregionintheworld(Morley2001) overthepasttwodecades,povertylevelshaverisen,andanestimated130millionLatin Americans(ofatotalregionalpopulationof450million)havelittle,ifany,accessto formalhealthcareservices(Muntaner,etal.2006).SimilartoLatinAmericanpostreformpatterns,theconcentrationofwealthinCostaRicahasshiftedtowardtheupper class(Morley2001).Between1988and2005,theincomeofthepoorest20percentofthe populationfell13.9percent,andthatofthetop20percentincreased67.9percent (NotiCen2007),whiletheGiniIndexrosefrom34.48in1986to50.31in2010(World Bank2012). Theseaccountsofstructuraladjustmentandglobalfreetradeimpactscallinto questiontheconventionalwisdomofneoliberalismthatpostulatesanumberof

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118 assumptionsabouteconomicgrowthanditstranslationintoqualityoflife(Scott1998). Theliteratureonneoliberalreformsandliberalizationoftradetendstoreflectjustthe oppositethatthesereformshavemeantthatasmallproportionofthewealthyare gettingwealthierandalargepercentageofpooraregettingpoorer.Thishasbeenthecase inCostaRica,andtheproblem,asmanyinseeit,isnotthatthecountryispoor,butthat accumulatingwealthisnotreachingthepoor. Neoliberalreformsaimedatderegulation,privatizationandwithdrawalofthestate, havebeenalmostuniversalsincethe1970s,evenamongwelfarestates,thoughsome reformshavebeenmorecoercivethanbychoice(Harvey2005). Thepastdecadeshave witnessedagrowingrolebytheprivatesectorinthepaymentanddeliveryofhealthcare, asmanystateshaveprivatized,orpartiallyprivatizedtheirsocialsecuritysystemsinan efforttoreducepublicsectorspending.Yettodate,theevidenceontheefficacyof privatizationinimprovinghealthoutcomeswhilereducingcostsremainsunconvincing. Withinthesocialsciences,alargebodyofcriticalliteraturehaspointedtothe negativeimpactsofneoliberalhealthpolicyreformsaimedatdismantlingwelfarestates inLatinAmerica.Theseneoliberalpolicieshavebeenshowntoexacerbateexisting socialandeconomicinequalities,increasepoverty,andencourageatransferofresources fromthemajoritytowealthynationalandinternationalownersofcapital,(e.g.,Armada andMuntaneer2004;FarmerandCastro2004;HomedesandUgalde2005;Horton,etal. 2012;Navarro1998;Turshen1999). Thisliteraturedocumentsnotonlytheimpactsof privatizationandtheneoliberalrestructuringofthestate,butalsotheunintended consequencesonsafetynetinstitutionsandonvulnerablepopulations. ParticularlyinLatinAmerica,wheresocialwelfarestatesweresostrong,neoliberal

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119 policiesraisequestionsaboutstatesovereigntyandtheappropriateroleofthestatein healthcareprovision.Whereastheroleandresponsibilityofthestateundersocial medicineistoprotectandpromotesocialandeconomicwell-beingofthepopulation,the roleofthestateunderneoliberalismistocreatemarketswheretherearenone,preserve aninstitutionalframeworkappropriatetomarketpractices,andtoguaranteetheproper functioningofmarkets.Beyondthat,stateinterventionisminimal(Harvey2005). Thoughwearenowawarewhattheeconomicconsequenceshavebeenof neoliberalreformsontheground,whatremainslesscleararetheimpactsatan ideologicallevel.Morethanjustaquestionableeconomicdecision,thesigningof CAFTAwasanideologicalblowforCostaRicanswhoweresoproudoftheirsocial developmentsandthefactthattheyhadachievedthemintheirownway.AsLaura Carlsen,thedirectoroftheAmericasPolicyProgramsaidafterthereferendum, Itwasn'tjustavoteonCAFTA,butaclashbetweentwodifferentmodels ofdevelopmentthiswillcomeupnotonlyinimplementinglegislation butinelectionsandalltypesofsituationswhereyoufindachoiceor potentialchoicebetweenthosetwomodelsofmorestateinvolvementand distributionofwealth,versusleavingthingstotheinternationalmarket(In Lydersen2007). UnlikeSAPs,whereintheCostaRicangovernmenthadlittlechoicein implementingneoliberalreforms(andeventhen,resistedimplementation),withCAFTA, therewasachoice,andthegovernmentintentionallychoseapathtowardsglobalization. IntheeyesofthepublicandCAFTAcritics,thischoicemeantarenunciationofthe nationalproject(VargasSols2004). IndividualImpactsofNeoliberalism Neoliberalismrepresentsamoreubiquitousglobalshiftthatisoccurringasithas transformedfromanoveleconomicconfigurationtoadominanthegemonicdiscourse

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120 andethicinitself,capableofguidinghumanaction(Harvey2005).Theunderlying assumption,thatmaximizingthereachofthemarketmaximizessocialgood,hasbecome pervasive.Evenasdeliveringhealthcarethroughfor-profithealthinsurancecompanies hassoclearlyfailedtoimprovehealthoutcomesorreducecosts,thereisstillincredible ideologicalinvestmentinneoliberalism(Horton,etal.2012),whichhasspilledoverinto personalvalues.Neoliberalvaluesoffreedom,individualchoice,competitionand individualresponsibility(Harvey2005)havebecometiedtowhatitmeanstobea responsiblecitizen,andthisrhetorichasbecomecommonplaceindiscussionsofhealth careprovisionandreform. Neoliberalismhas,inshort,becomehegemonicasamodeofdiscourse.It haspervasiveeffectsonwaysofthoughttothepointwhereithasbecome incorporatedintothecommon-sensewaymanyofusinterpret,livein,and understandtheworld(Harvey2005). FromtheclashofideologiesthatistakingplaceinCostaRicathesocialvision ofhealthasarightandtheneoliberalvisionofhealthasacommodityhasemergeda newclassofneoliberalactorswhoareabletonavigatebothworlds.Thosewhowork withinmedicaltourismhavebecomesavvyentrepreneurs,attractingmedicaltouristswith theirglobalmedicalexpertiseandcosmopolitanism,aswellastheCostaRicancaregivingvalues,warmthandhospitalitythatmedicaltouristsdesire. CostaRicanphysicians,previouslyconsideredservantsofthestate,nowexercise anddefendtheirfreedomofchoicetoworkintheprivatesectorwheretheycanearna highersalaryandenjoyacalmerworkenvironment.Medicalresidents,trainedbythe publicsystem,exercisethesamechoicetoleavetheCaja,ortopracticemedicineina locationoftheirchoosing.Theseindividualfreedomsareovertakingthesenseofsocial responsibilitythatonceguidedthecareerofthephysician.Theirjustificationsfitwithina

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121 neoliberalframeworkthatemphasizesindividualfreedoms,anduncriticallyseversthem fromtheirconsequences.Iaskedonephysicianaboutthegrowingnumberofmedical residentswhofinishtheirtrainingintheCajaandthenleavefortheprivatesector,and sherespondedquickly,Yes,ofcoursetheydo.Itistheirchoice.Whyshouldntthey? (23).Theseparationofpublicandprivatespheres,asmentionedinChapterThree,is internalizedbyphysicians,allowingthemtodisconnecttheirtreatmentofmedical touristsfromitseffectsonthepublicsystem.Whentheydoacknowledgetheintersecting natureofthespheres,itisnottheirownpersonalactionsthatweretoblame,butrather theactionsofothers.AplasticsurgeonwholefttheCajafortheprivatesector,wherehe worksalmostexclusivelywithmedicaltourists,toldme: Theanesthesiologists,mostofthem,theylefttheCaja.Thatwasamess. AsIamtellingyou,IdontfeelguiltybecauseIperformcosmetic surgery,thatswhyIdontfeelguiltyatall.Butinotherareas,itcanbe verymessy.Medicaltourismcanbegoodandbad.Itwillhappenwith otherspecialtiestoo.Ithasnthappenedyetbecausetherearenotenough patientsfromoutside,butifthisisgoingtobeamajorthing,itisgoingto beamess.ItisgoingtohaveahugeimpactontheCaja.Huge.(21) Thisattitudeofmoralandpoliticalpassivity(Gramsci1971)thatgoesalongwith unconsciousadherencetoneoliberalism,servestoperpetuateitsexpansionbyreducing thesedecisionstomattersofindividualchoiceandignoringtheconnectiontothebroader forcesthatshapethesechoices. Asidefromneoliberalphysicianswhoexercisetheirchoice,therearealso neoliberalpatientsdevelopinginCostaRica,whohavenewexpectationsofspeed, qualityandchoicewithinhealthcare,andnewlyengrainednotionsofpersonal responsibilitytotakecontrolovertheirownhealth.Inthefaceofchangingglobal demographicconditionsnamelyanagingpopulationwithmorechronicdisease

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122 neoliberalreformshaveemphasizedthisindividualresponsibilityaspartofwhatitmeans tobearesponsiblecitizen(Horton,etal.2012).InadiscussionofFoucaultslectureon governmentalityandneoliberalism,Lemkesays, Thestrategyofrenderingindividualsubjectsresponsible(andalso collectives,suchasfamilies,associations,etc.)entailsshiftingthe responsibilityforsocialriskssuchasillness,unemployment,poverty,etc., andforlifeinsocietyintothedomainforwhichtheindividualis responsibleandtransformingitintoaproblemofself-care.Thekey featureoftheneoliberalrationalityisthecongruenceitendeavorsto achievebetweenaresponsibleandmoralindividualandaneconomic rationalactor.(2001) Thisispartofwhathasbeencalledthegreatriskshift,(Hacker2006)wherein individualcitizensandfamiliesbegintoshouldertheeconomicburdenoftheirown healthcare,ratherthanlargerstructureslikeinsurancecompanies,employers,the corporatesector,orthestate.InCostaRica,citizenswhowerepreviouslyunderthecare ofthestatemustnowtakeituponthemselvestoprovidecarefortheirfamilieswhenthe Cajacannotmeettheirexpectationsoftimelinessorquality.Arisingnumberofpatients nowseekcareintheprivatesectorasapragmaticstrategyforsavvypatientswhocan successfullyweavebetweenthepublicandprivatespherestomeettheirneeds.Under neoliberalism,whiletheresponsibilityforhealthcarefallsawayfromcorporateand privateentities,familiesareoftenlefttobeartheburdenofadditionalcosts.CostaRican familiesincreasinglyincurhighercostsforcarewhentheyusetheprivatesectorasa healthcarestrategy,becausetheyarealreadypayingfortheircarewithintheCaja. Neoliberalismencouragesindividualstogivetheirlivesanentrepreneurialform (Harvey2005).Thenewneoliberalpatientisarmedwithinformation,demandingchoice, andencouragingcompetitionbetweenprovidersfortheirbusiness.Aprivatephysician saidthatmedicaltourismisamatterofglobalization.Peopleshoparoundnowforthings

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123 likethis.Theyareinformedandtheywillgowherevertheyneedto,togetdonewhat theywantdone(25).Anothersaiditisjustdoctorshopping.Thepatientgoesshopping. Doctorshoppingfromshoptoshopwhoischeaper?Whichonedoyoulikebest?(30). ThisissueofchoiceisacontroversialoneinCostaRica,because,whilechoiceis acentraltenetofneoliberalism(thereforemedicaltourismandprivatemedicine),patients withinthepublicsectoraretypicallynotabletochoosetheirphysicianortheir medicines.Butexposuretoprivatemedicinehascreatednewexpectationsofindividual choice,andthisisbecomingamorecontentiousissue,andmanybelievethatCaja patientsshouldbeabletochooseboth.Becauseofincreasingadvertisingby pharmaceuticalcompaniesandhigherprivatesectorusage,patientsarenowbecoming awarethattherearemedicationsintheprivatesectorthattheycannotgetwithintheCaja. Apublicsectorofficialexplained, Somephysiciansareusingprivatemedicationsontheirpatients.And thosepatientsreceiveinformationfromotherpatientsandtheinternet,so whentheycomebackheretotheCaja,wearefacingabigissuebecause wearetalkingaboutbudgetsthatCajajustdoesnthave[forthose medicines]Hereinthewaitingroom,whentheyareadmitted,theyshare informationwiththepatientsandtheirfamilies,andsomeCostaRican patientsarebecomingmoredemanding.(20) AninfectiousdiseasespecialisttoldmethatwhenheseespatientsattheCajaandwants togivethepatientmedicinesthatarenotavailablewithintheCaja,heobtainsthe medicinesfromhisprivatepracticeandleavessamplesforthepatienttopickup. TherearecurrentcasesintheCostaRicanConstitutionalCourt, SalaIV, wherein patientsaredemandingaccesstoexpensivedrugswithintheCaja.Thecourtiscurrently consideringwhetherornottodeclarethedenialofnamebranddrugsbytheCaja

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124 unconstitutional,asagainsttherighttolife.Ifthisoccurs,itwillhaveadramaticimpact ontheCajaandtheirabilitytoprovidemedicineswithintheiralreadystrainedbudget. Otherauthors(e.g.,Biehl2006;Biehl2007;Goldstein2007;Petryna2009; Petryna2011)havedocumentedthatthepharmaceuticalindustryitselfisoftenbehindthe movementtosuethestateforaccesstonamebranddrugs.Althoughlawsuitshave securedaccesstotheseexpensivemedicineselsewhereinLatinAmerica,this judicializationoftherighttohealth(Petryna2011)createsenormousadministrative andfiscalburdensonpublicsystems,andcontributestoworseninginequities.Thiscooptingoftherighttohealthdiscoursewithinaneoliberalexpansionofpharmaceuticals underfreetrade,isparticularlyinterestinginthecontextofLatinAmerica,wheresocial medicineandsolidarityhavebeensoimportant. Patientswithintheprivatesectorareviewedbyphysiciansasdemanding,entitled orspecialascomparedtopatientsintheCaja.Onephysiciansaid, Well,thethingwithprivatepatients,theyare,uh, special [laughs].You havetoanswerthephoneatanymoment,forjustanything.Sometimes, itslike2aminthemorningandtheycalltosaymyhairhurtsdoctor, whatcanItake?Andyoucannotjustsayareyoucrazy?!?Youhaveto saydontworry madame ,everythingisgoingtobejustfine.Youknow, thingslikethat...itsbecauseoftheprice.(38) ContrastthiswithaCajapatient,asdescribedbyapublicsectornurse, whoissilent,tolerant,heputsdownhishead,heplaysdumbwiththethingsthat aredonetohimorwiththethingshesees...TheCajaclientalsopays,butwesee itasiftheydontpay(44).Withintheprivatesector,usersareoftencalled clientsorcustomers,whereasinthepublicsector,theyarereferredtoas patients.Privatesectorpatientsareseenasactiveagents,takingcontroloftheir

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125 health,whilepublicpatientsareseenaspassive,inertlywaitinginlinefortheir care,andrelegatingtheirhealthcareneedstotheinefficientandprescriptivestate. TheLoveHateRelationshipwiththeState Theneoliberaleconomicprinciplesunderwhichprivatizationandmedical tourismareoccurringinCostaRicaaffectthewaythatpeoplethinkabouthealthcare. ButthewaysthatCostaRicanshavebeenintegratingtheseprinciplesintotheir understandingsofhealthcareis,inmanyways,alignedwiththeirhistoryofsocial medicine.Theresistancetoneoliberalreformsandprivatization,inparticular,revealthe degreetowhichthewelfarestateinCostaRicaisfundamentaltonationalidentityand healthcitizenship.Theco-optingofarighttohealthdiscourseinaccessingprivate facilities,andindemandingcertainmedicinesandphysiciansisalsoinlinewiththe foundationalbeliefthatallcitizensshouldhaveaccesstohealthcare.Eventhe justificationformedicaltourism,whichwillbediscussedinmoredetailinthetwo chaptersthatfollow,isbuiltatopthenationalbeliefintherighttohealthforall. ThesuccessfuldevelopmentofthesocialsecuritysysteminCostaRicawas effective,inthatitmadepeoplebelievethathealthcareisaright.Theresistanceto neoliberalreformshasdemonstratedthevaluethatCostaRicanshaveplacedinstatesponsoredhealthcare.ThecurrentdisenchantmentwiththeCajaisnotacritiqueof socialmedicine,butratherpublicdissatisfactionwiththechippingawayofthesystems socialfoundations.AsSeligson(2002)says,Ironicasitmayseem,thesuccessofstaterunenterpriseshasresultedinanegativeevaluationoftheCostaRicanstatebecauseof itseffortstoscalebackordissolvetheseenterprises.Thestateiswithdrawingwhere CostaRicansbelieveitshouldremainstrong.CostaRicansseemtobeinvolvedina

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126 lovehaterelationshipwiththestate.Thoughtheneoliberalblueprintisthesame,the waythatneoliberaldiscoursetakesshapeinCostaRicaisnovelinthatitisundermined byastrongbeliefinsocialmedicineandsolidarity.

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127 CHAPTER6:LOCALEXPERIENCESOFMEDICALTOURISM MedicaltourismwasdeclaredanactivityofnationalinterestbytheCostaRican governmentin2008(undertheAriasadministration)becauseofitspotentialtobring revenueintothehealthsectorandbolsterauxiliaryindustriesliketourism,transportation, hotelsandrecoveryhomes.TheMinistryofTourism(ICT)estimatesthateachmedical touriststaysinthecountry11daysandspendsbetween$6,500and$7,000,morethan fourtimeswhataregulartouristwouldspend(Brenes2011).Thisdeclarationhas resultedingovernmentpromotionofmedicaltourismlocallyandabroad,emphasison internationalaccreditationforprivatehospitalsandclinics,supportforinternational agreementswithinsurancecompaniesandemployers,andforeignandnational investmentinthemedicalinfrastructure.Italsomeansthatthegovernmentresponds morequicklyinmatterswheremedicaltourismorforeigninvestmentinhealthfacilities areconcernedasingivingvisasorresidencytoforeigners,fast-trackingpermitsfor healthfacilities,andcuttingthroughsomeredtape,asoneparticipanttoldme.It meansthatthereisaspecialcommitmentofallpublicinstitutionstoworkwiththe privatesectorinthisfield(16). NationalActorsandtheHealthCareCluster CostaRicaformedahealthcareclustertopromotemedicaltourism,as prescribedbytheMedicalTourismAssociation(seeChapterOne),tojoinbothpublic andprivatesectorentitieswithavestedinterestintheindustry.Thereisalsoanational medicaltourismpromotionagency,PROMED(theCouncilforInternationalPromotion ofCostaRicanMedicine),establishedin2008torepresentthecommoninterestsofthe stakeholdersinthemedicaltourismindustry,communicatewiththepublicsector,and

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128 ensuresustainablegrowthoftheindustry.Thehealthcarecluster,aslaidoutbytheexMinisterofCompetitivenessandRegulatoryImprovement,JorgeWoodbridge(whowas instrumentalinthedeclarationofmedicaltourismasanactivityofnationalinterest) includesasignificantroleforgovernmententitiesandpublicuniversitiesinsupportof themedicaltourismindustry. AccordingtoBillCook,MTAmember,andoperationsmanagerforthe internationalpatientdepartmentof ClnicaBblica ,thegovernmentsroleisthatofa refereeandsupporter:guaranteeingthatqualitystandardsaremaintained,definingthe rulesofthegame,andeliminatingpotentialbottleneckswithregardtohumanresources, technology,infrastructure,andimmigrationthatcouldhinderdevelopment(Cook2008). Specifically,theclustercallsforanaggressivegovernment-sponsoredmarketing campaigntobelaunched,aswellasattentiontothehumanresourcecapacitythatis neededtoexpandtheindustry. TheCajaandpublicuniversitiesaretaskedwiththeformationofhumanresources tosupporttheindustry,whilethegovernmentsroleistopreparethecountryfor medicaltourism.Thisincludesinstitutingqualitymeasuresforprivatefacilities,working withthenationsuniversitiestoencouragethemtofocusonspecialtiesthatareindemand bymedicaltourists,preparingmorebilingualnursesanddoctors,andencouragingpostgraduatetrainingintheUnitedStatesorinEuropetoprovidethem[healthcareworkers] withthecharacteristicsandtrainingthattheinternationalmarketdemands(18).One governmentofficialsaid,Withoutthetriangleofthepublicsectorprivatesectorand universities,themedicaltourismmasterplanwouldnotwork(16).Thefollowingtwo

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129 figuresillustratethewayinwhichthehealthcareclustersupportsprivateclinics,andthe expectedrolesofthegovernmentwithintheindustry. Figure13:Thehealthcarecluster,whichsupportsandpromotestheCostaRican medicaltourismindustry(MinisteriodeProduccin2010).

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Figure14 :Theroleofthegovernmentinsupportingthemedicaltourismindustry. ( AdaptedfromMinisteriodeProduccin2010 Mostinterviewparticipantswerepleasedthatthegovernmentwasatleast attemptingtoorganizeandpromotetheindustryandtheimageofCostaRica.Beyond thisgeneralrole ,however, involvementinthemedicaltourismindustry. privatedivide,as anextensionoftheneoliberalbeliefthatthestateshouldnotget involvedinpriv ateindustry thosewhoprofitedsignifica reasonthat thegovernmentshou sortstospend timeandresourcespromotingaprivateindustryinsteadofcaringforthe CostaRicanpopulation,whichisthes Thoughit wastypicallydeniedthat medicaltourism,t heCostaRica :Theroleofthegovernmentinsupportingthemedicaltourismindustry. AdaptedfromMinisteriodeProduccin2010 ) Mostinterviewparticipantswerepleasedthatthegovernmentwasatleast attemptingtoorganizeandpromotetheindustryandtheimageofCostaRica.Beyond ,however, they feltthatthegovernmentshouldhaveverylittle involvementinthemedicaltourismindustry. Thiswastypically relatedtothepublic anextensionoftheneoliberalbeliefthatthestateshouldnotget ateindustry .Notsurprisingly,thisviewwasexpressedmoreoftenby thosewhoprofitedsignifica ntlyfrommedicaltourism.Butothers hadamoresocial thegovernmentshou ldnotbeinvolvedbecauseiti saconflictofinterestof timeandresourcespromotingaprivateindustryinsteadofcaringforthe CostaRicanpopulation,whichisthes tatesresponsibility. wastypicallydeniedthat thegovernmenthadmuchinvolvementin heCostaRica ngovernmentsponsorstheWorldMedicalTourism 130 :Theroleofthegovernmentinsupportingthemedicaltourismindustry. Mostinterviewparticipantswerepleasedthatthegovernmentwasatleast attemptingtoorganizeandpromotetheindustryandtheimageofCostaRica.Beyond feltthatthegovernmentshouldhaveverylittle relatedtothepublic anextensionoftheneoliberalbeliefthatthestateshouldnotget .Notsurprisingly,thisviewwasexpressedmoreoftenby hadamoresocial saconflictofinterestof timeandresourcespromotingaprivateindustryinsteadofcaringforthe thegovernmenthadmuchinvolvementin ngovernmentsponsorstheWorldMedicalTourism and

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131 GlobalHealthCongress(WMTGHCthetradeconferenceoftheMTA),andpromotes theindustryandtheimageofCostaRicathroughotherevents,andmagazines.Medical tourismisalsoadvertisedthroughtheMinistryofTourism(ICT),whosenewslogan, Herewecureall,attemptstohighlightCostaRicasreputationasamedicaltourism destination.ThemostcostlyformofsubsidythatthegovernmentandtheCajaprovide, however,isthepubliceducationandtrainingofthehealthcareworkersthatsupportthe medicaltourismindustry.Despitethesecontributionstothegrowthoftheindustry,the publicsectorandtheCajareaplittlebenefitfromit. EmergingIndustryActorsasGatekeepers Privatehospitalphysicianstoldmethatmedicaltourismhasbeenhappeningina moreinformalsensefordecades.Oneexampleoftheseunofficialnetworkscamefroma plasticsurgeon,whotookoutasmalladvertisementinthe TicoTimes (anEnglish languagenewspaperinCostaRica)andhadawomanfromCaliforniarespondtothead andcometohimforafacelift15yearsago.Shewassopleasedwiththeresultsthatshe hascontinuedtobringpatientsfromherlargereligiouscongregationdowntoCostaRica afewtimesayearforprocedureswithhimeversince(andhasreceivedseveralmore proceduresofherown).Anotherplasticsurgeonsimilarlybuilthispracticefromwordof mouth,andexpressedannoyancewiththedevelopmentoftheindustry,saying, Thisisnotanewexperience.Themediaaretryingtomakeitseemlikeit is,likeitisthisboom,butbeforetheinternetwasanactivetoolforusto findthesepatients,maybetenplasticsurgeonsfromhere,includingme, andsomephysiciansinotherareasworkedinmedicaltourism.Nowthis industrytheyaretryingtomakeitseemliketheydiscoveredwarm watertherearealotofpeopletryingtodobusinessfromthis,butthisis somethingIvebeendoingforyearsnowIhavepeopleconstantly comingtometellingmetheywanttoworkwithme,asan intermediaryeveryonewantstomakemoneyofftheworkofothers.

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132 Theytrytoinventthingsthatalreadyworkandtheyjustinsertthemselves inthemiddle.(15) Thenationalagendatopromotethemedicaltourismindustryhasmeantthatmore actorsarebecominginvolvedinmedicaltourism.Inadditiontointernational associations,facilitatorcompanies,insurancecompaniesandotherglobalactors discussedinChapterOne,thereareseveralnationalstakeholdersemerginginCostaRica. PROMEDworkswiththebigthreehospitals,smallerprivateclinics,and providersinthetransportation,accommodation,aftercare,andtourismindustriesto ensurethatregulatorystandardsaremet,andtocompriseaunifiedfrontforpromoting theindustry.ThegrouprecentlydevelopedaPROMEDsealofapprovaltosignalquality oftheproviderswhomtheyworkwith.ProvidersinCostaRicapayPROMEDtogo throughthisprocess,justastheypayfeestobecomeaccreditedhealthcarefacilities,to becertifiedbytheMTA,ortobepartofaphysiciangroupwithinthemedicaltravel industry.Ontopofthesecertificationandaccreditationfees,therearealsomembership feestobepartoftheseorganizations. TheCostaRicanMedicalHoldingCompany(CRMHC)alsoemergedinrecent years,startedbyaplasticsurgeonwhoworkswithmedicaltourists.CRMHC(affiliated withPROMED)isaconsortiumofprivatephysiciansfromthebigthreemedical tourismhospitals,whoalsopayfeestobecomemembersofthegroup.Theconsortium thenpromotesmedicaltourismintheUnitedStatesandformalizeslinkswithinthe industry,includingaccommodations,transportationandtoursformedicaltourists. Thebigthreehospitalsallhaveinternationalpatientcoordinatorsor internationaldepartmentswithinthehospitaltohelpwiththespecialneedsofmedical touristsincludingcoordinatingtheiraccommodationsandtoursanddealingwith

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133 internationalinsuranceagencies.Eventhoughtheinternationaldepartmentsarewithin thehospital,theyareoperatedasseparatecompaniesandarepaidbythehospitalfor attractingmedicaltourists. Inpopularperception,organizingandpresentingaunifiedfrontformedical tourismisimportant,butmostfeelthattheseactorsdoverylittle,inpracticalterms,to advancetheindustry.Liketheplasticsurgeonabove,manyphysiciansinvolvedin medicaltourismseetheseorganizationsasgatekeepers,whoinventfunctionsandinsert themselvesintotheindustry,workingtoprotectthefinancialinterestsofasmallgroupof stakeholderswhoprofitfrommedicaltourism.Afewquestionsintoaninterviewwithan orthopedicsurgeon,helaughedandsaid, Oh,okay,youwanttoknowthe real business?Theseguys[industry actors]aretryingtocontrol everything .Theyarelikeoctopusesinthe middle,tryingtocontrolallthebusinessandallthemoney.Itsincredible, onecompanytriestoabsorbtheotheraccreditations,associations, facilitators,Imean,whatdoallthesepeople do ?ImetaladyintheUnited Stateswhoownedsomeinternetnamethathadmedicaltourisminthe title,shehadsometinybusiness,andsomeonecameandboughtitfrom herforfivemilliondollarshejustwantedthename.Itsjustbigbusiness thatsgoingon.Andnowtheinsurancecompaniesarecomingdownfrom theStatesandwe[physicians]arethelastpartofthechain.Thereisthe patientatoneend,andwedoctorsatthisend,andthenallofthese companiesinbetween.Thatisgoingtoincreasepricesanddecreasethe qualityofattention.(9) Oneyoungphysiciansaidthatshepaidnearly$3,000tojoinCRMHC.When askedifshehadreceivedanyforeignpatientsthroughthegroup,shesaidwitharollof hereyes,Zero.Absolutelynothing(38).Anotherprivatesectorphysicianremarked that,eventhoughPROMEDisanon-profit,theycansay,Iminthegroupandifyou wanttocomeinthenIwantsomethingfromyou.Theycanmovetheirchipssoyou cannotbeinthegroup.Itisverypolitical(10).

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134 CreatingSpecialSpacesforMedicalTourists Despiteageneralbeliefthatthegovernmentshouldhavelimitedinvolvementin theindustry,onephysician,whoranhisownphysiciangroup,toldmethathehopesthat thegovernmenttakestheircommitmenttopromotingmedicaltourismevenfurtherby creatingspecialconsiderationsfortravelingmedicaltouristslikeskippingtothefront ofcustomslinesandpriorityboardingonairplanestoreturnhome.Weneedspecial spacesforthem,(35)hetoldme. Indeed,medicaltouristsdoenjoyspecialspacesinCostaRica.Thebigthree privatehospitalsoffersleek,modernaccommodationsformedicaltourists,andseveral amenitieswithinandoutsideofthehospitals. HospitalHotelLaCatlica ,whichusedtoberunbynuns,waspurchasedbya privateinvestmentgroupofOscarArias,whichrenovatedtheformerconventintoa colonial-stylehotelformedicaltourists.Ofthispurchase,aUCRprofessorsaid,itisnot invainthatonebeginstoassociatefreetrade,theopeningofthesemarkets,andArias declaringmedicaltourismanactivityofnationalinterestandthenyoucangoaround likethatandputtogetherthepiecesofthepuzzle(7). Adjoiningthehospitalpartof LaCatlica ,acobblestonepathway,linedwith candles,openstoalargecourtyard,linedwithprivatehotelrooms.Amarblefountainis featuredprominentlyinthecenteroftheyard.Patientsstayingatthehotelcanchooseto taketheirlunchfromtheon-siterestauranttothepatioiftheyarefeelingupforit. JustoffthecourtyardareaPilatesstudio,anutritioncenter,andatrioof hyperbaricchambers--thelargestofwhichresemblesthefuselageofanairplaneandcan seatuptoeightpatientsatatime.Thechambers,whichallowpatientstobreathepure

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135 oxygentoassistwithrecovery,eachfaceatelevision,andanattendantmonitorsthe patientswhiletheyusethechambers. CIMA ,locatedinasuburbofSanJosthatissometimescalledLittleAmerica becauseitishometosomanyexpatriates,issandwichedbetweentwoAmerican-style hotelsaMariottononeend,andaHolidayInnontheother,strategicallylocatedfor increasingpatientpopulations(40).Botharebrandnew.Justoutsidethehospital,there isaparkforpatientstowalk,anIMAXTheater,and AvenidaEscazu, arowofhigh-end retailstoresandrestaurants.Theexpansiveandpolishedlobbyofthehospitalhousesan upscalerestaurant,aninternationalinsuranceclaimsoffice,andaUnitedStatesVeterans Affairsofficerightinthelobby.Ophelia,CIMAsinternationalpatientcoordinator,takes careofallarrangementsforinternationalpatientsincludingsettinguptourstoseeCosta Ricanvolcanoes,beaches,orotherattractions,inaddition,ofcourse,tocoordinatingthe patientsmedicalneeds. Anothershiningexampleofthesespecialspacesis ClnicaBblica ,theoldestand largestprivatehospitalinCostaRica,foundedbyevangelicalmissionariesin1921,and purchasedbyagroupofentrepreneurs(ASEMECO)in1968.Ithasbeenprogressively expandingsinceitwaspurchased,andmostrecentlyaddedthemodernOmegaTower in2003. Furnishingsin LaBblica areminimalandcontemporary,thoughbothdoctorsand nursesdressintraditionalgarb(doctorsinmonogrammedwhitecoats,andnursesincrisp blueandwhiteuniformswithatraditionalnursescap).Insidethehospital,patientscan findafoodcourt,abank,asalonandbarbershop,coffeeshop,internetcaf,and pharmacy.Thereareraisedcoveredwalkwaysbetweenthehospitalsbuildings,making

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136 italmostunnecessarytoleavethehospital.Apianoplayerplaysinthelobbyduringthe busiertimes.Thereisaninternationalofficeandpatientcoordinatorhereaswell,who takecareofallaspectsofapatientsvisit,includingtransportationtoandfromtheairport andhospital. Thepatientroomsineachofthesehospitalsareprivateandwellappointed,with amplefurnitureforpatientstounpacktheirbelongings,aplaceforfamilytositorsleep, flatscreentelevisions,andpersonalbathrooms.Therearealsosuitesavailable,which typicallyincludeasecondsittingandsleepingroomforpatientsandtheirguests.Nurses andphysiciansarefriendly,nicelyuniformed,andspeakEnglish.Calmingmusicplaysin thehalls,whicharequiet,andinsomecases,seemnearlyempty.Waitingareashave televisions,magazines,leathersofasandarmchairs,andlocalartworkadornsthewalls. Theseprivatemedicalspacesarea very sharpcontrasttothecrowded,chaoticscenesthat IwitnessedinCajahospitalsandclinics. Post-surgery,medicaltouristscanchoosetorecoverinnearbyhotelsorrecovery homesthataredesignedwithrehabilitationinmind,whichtypicallyincludeallmealsand amenitiessothatguestsrarely,ifever,havetoleavethepremises.Attendantsatthese facilitiescookandclean,runerrands,takepatientstoandfromfollow-upappointments, changebandages,andsometimesactastherapists,helpingpatientstohealbothmentally andphysically.InonefacilitythatIvisited,aplasticsurgeonkeptanexamroomatthe recoveryhomesothathecouldstopthereonhiswayhomefromthehospitaltocheckup onseveralpatientsatonce.Therearealsoaftercarecompanies,likeacompanycalled Homewatch,whichisaffiliatedwiththeMTA,whichwillcareforthepatientoncetheir

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137 Figure15:Thespecialspacesofmedicaltourists.Clockwisefromtop:CIMASanJose building;thewaitingareaofaprivateplasticsurgeonsoffice;entrancetoHospitalHotel LaCatlica;theMarriotHotelatCIMAHospital,withaparkinforeground;lighted walkwaytotheOmegaToweratClnicaBblica(HorizonPacific2012);thecourtyardof LaCatlica.(Allphotobutoneisbyauthor).

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138 surgeryiscomplete.Theyoffersimilaramenitiestotherecoveryhomesshouldapatient opttostayinahotelinstead. Thesearethespecialspacesofmedicaltouristsgleamingandmodernwith everyamenity,carefullypurifiedofThirdWorldconditionsthatareincompatiblewithin theidyllicCostaRicanimagethattheindustrypromotes,andthatmedicaltouristsexpect. Thesespacesareglobalspaces,andmedicaltouristsareprotectedfromthelocal surroundings.Aroundthemsitthedirty,crowded,pot-holedstreetsofSanJos,andthe barredwindowsoflocalshopsandhomes.Thisisaquiteliteralcontrastinthecaseof ClnicaBblica ,whichsitsdirectlyindowntownSanJos.Violentcrimeandpovertyare ontherisehere,asintherestofCostaRica,andtrashdisposalandenvironmental degradationhavebecomewidespreadproblems,despitethenationsgreenimage.These negativedevelopmentsarecauseforconcernamonglocals,whoareworrythatCosta Ricaexceptionalismmaybeeroding,andthenationisbecomingmoreandmorelikeits CentralAmericanneighbors(e.g,Ordoez2007;Seligson2002) TheStateoftheMedicalTourismIndustryinCostaRica MedicaltouristscometoCostaRicaprimarilyfromtheUnitedStates,whichis viewedastheprimarytargetfortheindustry.ThoseseekingcareinCostaRicaare,for themostpart,uninsured,underinsured,orseekingaprocedurethatinsurancewillnot cover.AlthoughCAFTAopenedtheinsurancemarkettointernationalcompetition,anda fewinsurancecompanieshavebeguntocovermedicaltourismoptions,thebulkof medicaltouristspayoutofpocket.Thisislikelybecauseelectivesurgeries,which insuranceplanswillnotcover,remainthemostpopularprocedures.Americanmedical touriststendtochooseCostaRicabecauseofitsgeographicproximity,successfulhealth

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139 caresystem,nationalimageofbeingpeaceful,happy,andgreen,andbecauseitsnatural beautymakesitaniceplacetorecuperate.The puravida 25 attitudeofCostaRicansis alsoadrawforAmericanswhodesiretoescapetheinjusticesofU.S.healthcaretothe competence,kindness,andleisurelypaceofCostaRicanmedicine(Ackerman2009). Liketheglobalmedicaltourismindustry,inconsistentdefinitionsandmethodsfor collectingandreportingindustrydatamakeitextremelydifficulttoprovideanaccurate estimateofthenumberofmedicaltouriststravelingtoCostaRicaforhealthcare. Nationalestimatesvarywildly,fromjustover2,200patientsperyear,toasmanyas 100,000(e.g.,AreadeTurismoReceptor2009;Arce2011b;Arguedas2009;Brenes 2011;MinisteriodeProduccin2010;PROMED2010).Therealityisprobably somewherein-between,andthemostoftencitedfiguresareintheareaof30,000medical touristsannually.Whenadvertisingtheindustry,over-reportingnumbersofvisiting medicaltouristsisaverycommonpractice,asistheunderreportingofpatientnumbers amongprivatefacilitiestoavoidpayingtaxes.Inherstudyofplasticsurgerytourismin CostaRica,Ackerman(2010)wastoldthatplasticsurgeonstypicallypayincometaxon onlytenpercentoftheirprivatepracticeearnings.Thisunderreportingcallsintoquestion theneoliberallogicofindustrybenefitsthatproposesthattheindustrybenefitstheCosta Ricangovernment,andtheCaja,throughanincreasedGDPthattricklesdown. InLatinAmericaingeneral,andCostaRicainparticular,medicaltourismcenters onelectivesurgeries,primarilyplasticsurgeryandcosmeticdentistry.However,these procedurestendtobetheleastprofitableforhospitalsbecausetheyareoftenperformed 25 Puravida isauniversallyknownCostaRicanexpressionthatisusedtodescribethelaidback CostaRicanattitude.Itliterallytranslatestopurelifeorplentyoflife,butisusedcommonly asagreeting,orinresponsetothequestionhowareyou?

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140 onanoutpatientbasis;thephysiciantypicallyprovidesnecessaryequipmentand supplies,andthepatientrecuperatesinarecoveryhomeinsteadofatthehospital. Consequently,theindustryisattemptingtoexpandthemarketfororthopedicprocedures, bariatricandweightlosssurgeries,liberationtherapyformultiplesclerosis,andcorporate wellnessexams,andotherproceduresconsideredtobemorenecessary,andmore profitable. UntilJuneof2010,CostaRicawashometoastemcellclinic.TheInstitutefor CellularMedicine(ICM),ownedbyanArizonaentrepreneur,operatedoutofCIMA HospitalforfouryearsbeforeitwasshutdownbytheMinistryofHealth.Thereason citedforitsclosingwasalackofevidencethatstemcelltreatmentswereeffective,with theMinisterofHealthstating,Thisisn'tallowedinanyseriouscountryintheworld (vila2010).ThemedicaltourismindustryinCostaRicawantsverymuchtobetaken seriously,andtoprotectitsreputationamongstAmericansinparticular.Inclosingthe ICM,theMinistryofHealthshoweditsdeferencetoU.S.biomedicalvalues,signaling againthattheindustryisonparwithAmericanqualitystandards.Whileitwasopen, about400patientsweretreatedatICM,withtreatmentsrangingfrom$5,000to$30,000. Afteritsclosing,thepatientloadwasmovedtoanotherfacilityinPanama(Carroll2010). LocalHopesforMedicalTourism Sinceitsdeclarationasanactivityofnationalinterest,thecountryhasbeen preparingforalargenumberofmedicaltourists,andmanyhaveveryhighhopesforthe futureoftheindustry,thoughthesehavenotyetbeenrealized.Duringtoursofprivate hospitals CIMA and ClnicaBblica ,Iwastoldthatthehospitalswouldliketohavean entirefloordedicatedtomedicaltourism,staffedwithEnglish-speakingphysicians,

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141 nursesandadministrators.TheinternationalpatientcoordinatoratCIMAshowedmean emptyfloorinoneofthecomplexsrecentlyconstructedbuildings,whichfacedthe HolidayInnthatwasunderconstruction,andsaidwearewaitingformoremedical touriststocomefillit. Anorthopedicsurgeonatoneoftheprivatehospitalstoldmethattheindustryis planningspecificallyforbariatricsurgery,orthopedicsurgery,anddentalprocedures. Thosearegoingtobetheones,hetoldme,anditisincrediblehowtheyare preparing.HetoldKarinaandmethathehadreceivedtwoemailsandtwointerview requeststheweekthatIspokewithhimfromphysicianswhowereinterestedininvesting inthesefields.Theydontwanttoopenanofficehere,hesaid,theywanttoopen hospitals here.Whenaskedwheretheywerefrom,herespondedTheStates!Of course.IaskedhimifhethoughtthattheCostaRicangovernmentwouldbeconcerned aboutsuchexpansion,andheansweredMaybe20yearsafterwards,butnotrightnow. Becausetheyregoingtomakemoney,thefacilitieswillpaytaxeseveryoneisgoingto behappyaboutitatthe beginning (9). Inmakinghiscaseformedicaltourism,MinisterWoodbridge(n.d.)summarized theanticipatedbenefitsforCostaRicaasfollows: Increasedflowsofdirectforeigninvestmentandexportofservices; Moreandbetteropportunitiesforprofessionalsinmedicine; HighlycompetitivehealthcarepricesforCostaRicans; Higherstandardsandcontinuousimprovementofhospitalstandards(notonly forforeignpatientsbutalsonationalpatients); Higherprofitsforthehealthcareindustryanditsvaluechain(hotels,restaurants, travelagencies,airlines,pharmaceutical,equipment,doctors,etc.); CreationofaCorporateSocialResponsibilityFundfinancedbyprivate institutionstodevelopsocialhealthprojects.

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142 Theseargumentsinsupportofmedicaltourism,whicharequitesimilarto standardendorsementsprovidedbyproponentsoftheglobalindustry,aremainly neoliberalinnatureandoperateontheassumptionthatincreasedrevenueand competitionwillimprovetheconditionsofthecountryandcomplementpublichealth efforts.Theextenttowhichthisisactuallyhappeningisaddressedlaterinthechapter. MoststakeholdersIinterviewed,especiallyintheprivatesector,hadhighhopes forthegrowthofmedicaltourismandtheopportunitiesthatitpresentsforthecountry, sharingtheMinisterWoodbridgesoptimismaboutthepotentialfortheindustryto improvestandardsofliving.Oneplasticsurgeon,withsubstantialstakesintheindustry, describedmedicaltourismasavaluabletoolforhelpingCostaRicabecomeadeveloped country.Hesaid, Ireallyliketodream,becauseIamanexampleofthatdream.Icamefrom alower-middleclassfamily,wenttopublichighschoolandpublic universityandnowadaysIamonthetopofmedicaltourisminCosta Rica,soCostaRicaisacountryofopportunities...ThisisCostaRicas planforthefuture.Wereallybelievethatmedicaltourism,becauseofthe levelofincomeforthecountry,isthemaintooltobecomeadeveloped country,whichwehavebeenwaitingforformanyyears. Itwillprovidenotonlymoneytothegovernment,butalsohopeforthe schoolsystem,forthestudents,becauseifyouhavearichcountryand higherincome,theywillhavemoreopportunities.Andobviouslywedont wanteverybodytobecomeadoctororanurse,butmedicaltourismand globalizedmedicineinvolves everything hotels,recoveryfacilities, pharmaceuticals,transportation,food,hospitals,infrastructure, entertainment,safetyandsecurity,communications;itinvolves everything!Sotheglobalizedmedicineproject,asacountry,meansthat therewillbeopportunitiesforeverysinglesectorinthecountry. Plusitissustainable,ecologicallyfriendly,andsociallyresponsible. Thepatientnotonlyreceiveslowcost,highqualitycare,butwarm treatmentbystaffandtheknowledgethattheyaresupportingacountry thatbelievesinpeace,healthandeducation.(35)

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143 Inasubsequentdiscussion,thisparticipantevenstatedthathethoughtmedical tourismwouldreduceviolence,prostitutionandsextourisminCostaRica,bygivingthe tourismindustrysomethingprestigiousandlegitimatetofocuson. Thoughnotallstakeholdersinterviewedhadsuchloftygoalsformedicaltourism, mostdidseeatleastsomepotentialadvantagesofpromotingtheindustryatanational level,themostoft-citedofwhichwasincreasednationalrevenue.Currentnational figuresprojectsthatmedicaltourismbrought$288milliontoCostaRicain2010(Brenes 2011),thoughduethedatacollectionissuesmentionedabove,thisisdifficulttoconfirm. Eventhoughincreasedrevenuewasrecognizedasaprincipalpositiveeffectofmedical tourism,noneoftheparticipantsinterviewedofferedevidenceofanydirectbenefittothe Cajaorpublicsystem.Thelogicismerelythatarisingtidewillliftallboats. LocalAnxietiesaboutMedicalTourism Competition InternationalCompetition Opportunisticmoves,liketherelocationofthestemcellclinicfromCostaRicato Panama,arenotuncommonwithintheindustry,andmanywithinvestmentsinmedical tourisminCostaRicaworryaboutbeingundercutbyneighboringnationsandlosingthe industryaltogether.Aswithotherformsofoutsourcing,thishascreatedanatmosphereof competitionamongstLatinAmericancountries,whichknowthattheycannotcompete withthemuchlowercostsofhealthcareinAsia,but,becauseofgeographicproximity, theycancompeteforAmericansagainstotherLatinAmericannations.Competitionisa keyprincipleofneoliberaldiscourse,whichassumesitwillreducecostsandincrease efficiency.Ifonedestinationcountrywillnotundertakeaprocedureorifpricesaretoo

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144 high,thenextoneinlinewill.Amongthosewithinvestmentsinmedicaltourism,thereis aprevalentfearaboutbeingoutcompetedandlosingbusinesstoaneighboringcountry ifthegovernmentdoesnotactquicklytopromotetheindustryanddecreaseregulatory barriers.Onemedicaltourismfacilitatorurged, They[thegovernment]mustseetheopportunityrightnow.Because Panamaisgrowing,ColombiaisgrowingColombiahasacleanerimage yearafteryear,andPanamahasenoughmoneyandinfrastructure,butthey havealackofJCIhospitalsandphysicians,butfiveyearsfromnowthe situationwillbeabsolutelydifferent.(35) Anotherphysicianadded,Lookhowdangerousthefuturecouldbewedont knowhowmuchlongerCubawillremainCommunist.IfCubaopensup,everythinggoes tohell.EvenNicaragua,whatifthingscomebacktolifethere,andtheypromotemedical tourism?MyGod,theywillbeatusdefinitely(42).Othersspokeoftheficklenature ofthetourismindustryandworriedthat,afterallofthisinvestmentinmedicaltourism, theboommightbeoverinafewyears.ACajaphysicianasked,Willourcountrybe theEden,orwillitbesomewhereelse?Therearesomanytouristspotsthatwerepopular tenyearsagoandareabandonednow.Itisunpredictable(23). Fearoflosingbusinesstoneighboringcountrieshasresultedinvariouschangesto medicaltourismpracticesinCostaRica.Physicianssometimesfeelpressuredby facilitatorcompanies,physiciangroups,orhospitalstoreducetheirpricestoremain competitive.Whilesomeseepricereductionasaneffectivestrategyforpromoting medicaltourisminbulktoreceivealargervolumeofpatients,othersfeeltaken advantageofbycontinuallybeingpushedtoreduceprices.Oneprivatesectorsurgeon said: Ihavebeenworkingwithfacilitators,andtheyarealwayssaying,wewill bringyoupatients,buttheproblemisthepricesIthinktheyaretrying

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145 toprostituteourpractice.So,forexample,ifIdoasurgery,thehospital reducesthepricesalittlebit,butmostlyitisus,thephysicianswhydo wehavetogolowerandlower?Imeantheonlypeoplewhochangetheir pricesforthisisthedoctor,thesurgeon.Whatabouttheothers?We cannotImeanthisisthelowestwecando.Idontknow,Ithinkits prostitution.(38) NationalCompetition Thereisalsointernalcompetitionamongstthebigthreeprivatehospitalsto attractpatients.Althoughtheindustryattemptstopromotethecountryasawhole,and presentaunitedfrontinattractingmedicaltourists,oncethetouristscome,theprivate sectorhastocompetetocapturethem.Atthatpoint,itisallself-interest(5).Thoughall threeofthehospitalsareJCIaccreditedandattractmedicaltourists,onseveraloccasions, Iwastoldthatthereisinferiorqualityatthe other privatehospitals,thatpricesaretoo high,orthattheirpracticesarenottransparent.Tryingtoundercutcompetinghospitals andphysiciansiscommonpractice.OnephysicianatCIMAeventoldmetogoandtell ClnicaBblica tostopsayingbadthingsaboutuswhenIwastherenext(40).Withthe openingoftwonewprivatehospitalsinSanJossince2010,andmorefacilities scheduledtobeopenedinotherpartsofthecountry,theinternalcompetitionbetween hospitalstryingtoattractmedicaltouristsislikelytoheatupevenmore. IndividualCompetition Evenwithinprivatehospitals,physiciansaresometimespittedagainsteachother toreduceprices.Themedicaldirectorofoneofthebigthreehospitalstoldmethat, whenamedicaltouristcontactsthehospital,hechoosesthreephysiciansandasksthem togivepricequotesforthedesiredprocedure,andthenoffersthetouristthecheapest priceofthethree.Andthenlaterweexplaintotheothertwodoctorswhywedidnot

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146 choosethemtomakethepointthat,ifanAmericancomeshere,itistolookforthe cheapestprice,nottopaythesameasintheUnitedStates(12). Thoughmostwhowereinvolvedinmedicaltourismtoldmethatpricesfor proceduresarefixedanditdidnotmatterwhetheritisaCostaRicanoramedicaltourist seekingtheprocedure,thisisnotalwaysthecase.Toattractalargervolumeofmedical tourists,somephysiciansofferlowerpricestoforeignersthantoCostaRicans.Others, however,feelthatmedicaltouristsareabletopayhigherpricesforproceduresandthat theydemandmoreattentionandaftercare,sohadapolicyofquotingpricesonacase-bycasebasis,dependingoncircumstances,whichtypicallyresultsincharginghigherprices forthetravelingpatients.Eitheroneofthesestrategiesraisingorloweringprices strictlyformedicaltouristsillustratesthatmedicaltouristsaretreateddifferentlythan CostaRicans.IfpricesarecutforAmericans,whocanaffordtouseprivatecaremore thanCostaRicans,thisisethicallyquestionable.Ifpricesareraisedformedicaltourists, thishasthepotentialtodrivethecostsofprivatecareup,decreasingaccessforlocals. Theywouldconsideritveryexpensive,onegovernmentofficialstated.Imean someonefromtheStates,theymightthink$5,000forasurgeryischeap,butforaCosta Rican,itisvery,veryexpensive(27).AretiredCajaphysiciansaidthisisoneofhis mainconcernsthatafterfocusingonmedicaltourismforafewyears,thecostofprivate medicinewillgoup, Wemighthavefourorfiveyearswiththisboomofpatients,andsowe raisethecostsofprivatecare,andthisisgoingtoreduceaccessforTicos. Becausewearealmost5millionpeople,butnoteven1millionofuscan payforprivatemedicine.Ifmedicaltourismisasmallbusiness,Ithink thatisbetter.Itisbettertojustcontinuewithaccessibleratesformedicine andlivewiththat,ratherthantotryandtakeallthemoneyforwhat? Fiveyearsandthatsit?Andafterthat,what?Imreallyconcernedabout

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147 that.Mostofmycolleagues[physicians]theywanttotake everything and takeit now. Butthisismedicine.Thisshouldnotbelikethat.(32) Capacity AninternationalmedicaltourismexecutivewhomIspokewithsharedinthe hopesforindustrygrowth,butatthesametimehadconcernsthatitmightbea fieldof dreams scenario,asking,Whatifwebuilditandthey[themedicaltourists]dont come?Thisisofparticularconcernamongstakeholderswhoarebuildingandinvesting somuchintheindustryduringthecurrenteconomiccrisis.Onephysiciantoldmethat, beforethecrisis,hewassaturated,doingallofthesurgeriesthatIwantedtodo,butnow ithasgonedown,down,down(19).Ahospitaladministratorsaidthattheyhadhopedto attractaround80patientspermonth,andarecurrentlygettingonlyabout30medical touristsatmost. Thefactthatthereare47millionuninsuredAmericanscameupnumeroustimes ininterviewsasanindicationthatmedicaltourismwouldgrowinCostaRica.One privatesectorphysicianstatedhopefully: Imean,thereareplentyofpatientsinNorthAmericaforallofus.We donthavespaceavailableforallthepeoplethatneedhelpinthe Stateswearestillnotevenapproaching0.001%ofthosepatientsthat needmedicalservicesintheU.S.(9) HiscommentnotonlyillustratesCostaRicans'expectationsfortheindustry,but alsotouchesonaquestionraisedbyotherparticipants;whetherCostaRicahasthe capacitytoaccommodateamedicaltourismboom.CostaRicaisacountryof4.5 millionpeoplemarketingtoapotentialpopulationof47million.Atthetimethatthis researchwasconducted,therewereonlythreeJCIaccreditedprivatehospitalsinCosta Ricaworkingwithmedicaltourists.Althoughmorefacilitiesthattargetmedicaltourists

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148 areintheworks,someparticipantswonderedifCostaRicacouldsupportasizablesurge offoreignpatients.Justasthereisanxietyaboutwhatwillhappeniftheydontcome, thereisconcernaboutwhatwillhappenifthey do come: Ifyoubringmeonepatientforagallbladderremoval,thatisfine,a privatesectorphysiciansaid,butifyougiveme100,andtheyallcomein thesamemonth,youdfloodme.Thatwouldshutdownmyoperation.I couldntseeanyoneelsebutthat.Itisveryeasytooverwhelmthese structures.Theyarenotdesignedforvolume.(34) Especiallywiththeentryofprivateinsurancecompanies,whichmayincitea highervolumeofpatientstravelingtoCostaRicaforprocedurescoveredontheir insuranceplans,manyworryaboutwhetherCostaRicahasenoughfacilities, infrastructure,andhumanresourcestoaccommodatesubstantiallymoremedicaltourists. Evenifitdoes,willthisaccommodationcomeattheexpenseofCostaRicanresidents? MedicalTourismDevelopmentinGuanacaste Ananswertothesequestionsmaycomewiththerealizationofalargemedical tourismundertakingintheGuanacasteregionofthecountryonthePacificcoast,anarea knownforitsbeautifulbeachesandtourismdevelopment.TheLiberiaairport,closeto Guanacaste,recentlyexpandedtoaccommodatemoreflightstothispopulartouristarea. Twoofthebigthreeprivatehospitals,CIMAand ClnicaBblica plantoexpandto openhospitalsthere,andthethird, HospitalHotelLaCatlica ,intendstoopenaclinicin theregionaswell. ClnicaBblica sfacilitywillbepartofalargedevelopmentproject whichincludeshotels,agolfcourse,shops,restaurantsandaretirementcommunityfor foreignerswhowouldliketoretiretoCostaRica,wheretheirpensionswillgofurther (Taborda2011). ClnicaBblica spartneronthisprojectisanAmericaninvestor.Unlike theexistinghospitalsinSanJos,whichattractCostaRicansaswell,theGuanacaste

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149 facilitieswillcateralmostexclusivelytomedicaltouristsandresidentsoftheretirement community.CostaRicaisbeginningtoheavilypromoteitselfasaplaceforelderly Americanstoretire,whichisincreasinglybecominglinkedtomedicaltourism developmentsinthecountry.TherehasevenbeendiscussionaroundprovidingMedicare servicesforthispopulationofAmericanretirees.InadditiontoGuanacaste developments,sinceIcompletedthisresearch,anewprivatehospitalhasopenedinSan Jos,andtwomorearescheduledtoopenby2013.Whiletherearemanyhopesand expectationsforthesemulti-milliondollardevelopments,therearealsodoubtsamong thoseworkingintheindustryaboutwhethertheywillcome. SomeinterviewparticipantsworrynotaboutwhethertheGuanacaste developmentwillbeaprofitableventure,butwhethertheprojectwillworseninequities inthearea,andcontributetothedevelopmenta"local-free"zone.Guanacastehas becomeaconspicuousexampleofhighlyinequitabletourismdevelopmentinCostaRica. Theregion,oneofthepoorestinthecountry,developedrapidly,withoutaclearplanfor sustainability,andtodayisrifewithdisparitiesgolfcoursessitnexttolocal communitieswithoutaccesstocleanwater,all-inclusiveresortshaverisenin communitiesofprimarilyimpoverishedfarmerswholacktheeducationtoworkinthese facilities,andtourismdevelopmentscontinuetoexcludelocalsfromaccesstoprivate beachesandland. Thesetouristfacilitieshavevirtuallynorelationshipwiththesurrounding communityinGuanacaste,andmanyareall-inclusive,whichprohibitsprofitsfrom benefittinglocalGuanacastecos.Theresultisthatforeignowners"areimportingpeople fromothercountriesorfromthemetropolitanarea(NotiCen2007)aslocalsareforced

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150 intolower-payingjobsandthecostoflivingandrealestatepricesskyrocketbecauseof tourismdevelopment.MauricioCespedes,executivedirectoroftheGuanacasteTourism Chamberstatedthat"asocialbreachisopeningeverwiderbetweentheaverage GuanacastecoandthepeoplewhocomefromSanJose"(NotiCen2007). MedicalTourismandInequitiesinCostaRica Justasindustrysupportersargueforforeigninvestmentasthemajorsolutionto poverty,theCostaRicantourismindustrystandsasanexampleofthiskindofinvestment workingagainsttheinterestsofthepoor.Thenationsbeachesandrainforestsare becomingsaturatedwithforeign-ownedresorts,hotelchains,andAmericanexpatriate communities,butlocalsareleftoutofthisprocess,andtheresultingprofits.Anacademic attheUniversityofCostaRicacautionedagainstfurtherexacerbatingsuchasituation withmedicaltourism,stating: Mypointisthatwecannotopentheissueofmedicaltourismifwerenot openingitwithavisionthatisregulatedresponsibly,withclearlydefined policies,butalsoinawaythatengages"productionchains"thatservice communities,sothatthesituationthatweveseeninGuanacasteisnot repeatedanymore.Ithinkitisaterriblelessonlearnedthere,andyetit stillcontinuestoberepeated.(7) TheexampleofGuanacastehighlightsthepotentialoutcomesofinequitable tourismdevelopmentthatexcludeslocals,anddrawsmonetaryandhumanresources awayfromthelocalandpoor,intothehandsoftheforeignandwealthy.Although medicaltourismmaystillbetooyoungasanindustrytotrulyunderstanditsimpacts,this researchillustratesthepotentialoftheindustrytocontributetounequalsystemsofhealth careandawideninggapinhealthcareaccess,muchlikewhathastakenplacein Guanacaste.

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151 FinancialResources DespiteconsiderableconcernsabouttheeffectsofmedicaltourisminCostaRica, participantsdidacknowledgethattheremightbeconstructivewaysinwhichtheindustry couldimpactlocalhealthsystems,typicallythrougheconomicdevelopment.Atthis point,however,thesebenefitsseemtobelittlemorethanhypothetical;todateitis impossibletoidentifyanydirectbenefitforthepublichealthsystem.Thisisespecially noteworthysincetheCostaRicangovernment,theCaja,anduniversities,areallviewed ashavingaroletoplayinthepromotionandsupportofthemedicaltourismindustry(see Figures13and14).TheCorporateSocialResponsibilityFundthatMinister Woodbridgesuggestswillconnectmedicaltourismtosocialhealthdoesnotexist,and therearenoplansforittohappen.Ofthesupposedbenefitsofmedicaltourismforthe CostaRicangovernment,onephysiciansaid, Itsusuallyaforeignpersonthatcomesinwiththeidea,paysthecosts, andmakesallthemoney.Someofthemusethemoneyhereorlivehere, butsome,likethehotelchains,wellusuallytheytakethemoneyoutside thecountry.Eighty-eightpercentofthecountryshotelchainsarenot managedbynationals,theyareallrunbyforeignersormultinationals.So, asabusiness,IthinkthattheCostaRicanstateandgovernmentarenot goingtomakemuchmoneyfrommedicaltourism. Thisisabusinessofonlyafewpeople,andthegovernmentisgoingto putthemoneyintomaketherules,topromoteit,butthemoneythenjust goestotheprivateclinics,whopayverylittletothegovernment.Andthe hospitalswell,CIMAhospitalisnotCostaRican,itisAmerican. La Catlica isownedbyaprivategroupoftheformerpresidentofthe country,thatiswhyallofthishasbeendonethatisthereasonwhy medicaltourismwasdeclaredofnationalinterest.Itssimplysothe governmentcanspendthemoneyforthesepeopletomakeevenmore money. LaBiblica istheonlyhospitalthatisCostaRican,butitisalsoa foundation,so45%ofwhattheymake,theyinvestbackinthemselves, andtheydontpayhightaxes,sothereisnotmuchforthegovernmentto makefromthis.Andtheyshouldnthavethefalseillusionsthattherewill bemoneyforthestate,becausethatwillnothappen.(32)

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152 Medicaltourismisnottaxeddifferentlythananyotherindustry,thoughsome thoughtthatprofitsshouldbesomehowredirectedtothestate,andthataspecialtaxon medicaltourismwouldbeappropriate.Onenursefeelsthatneglectingtoredistributethe earningsfrommedicaltourismgoesagainstthesocialsolidarityofthecountryandtakes advantageofsubsidizededucation.Shesaid, Ithinkit[medicaltourism]shouldhaveatax,andifnotatax,wellthena percentageofearningsshouldbedesignatedforthenationalhealth system.Thereshouldbecompensationinthatrespect,because,intheend, thedoctorswhoareparticipating,theyhavebeenformedbythesame government,thesamecountry.Inthepublicinstitutions,trainingadoctor oranurseisnotcheap,itrequiresinvestment;thecountryhasinvestedin thathumanresource,andnowthatresourceislookingtogenerateahigher positionforthemselves,withoutthinkingabouttherestofthepeople.(41) Anotherinterviewee,aMinistryofHealthofficial,believedthatthereisaneed forthegovernmenttotakeastrongerregulatoryapproachindealingwithmedical tourisminordertomaximizepotentialadvantagesandminimizeharmfulimpacts: Ithinkthatthegovernmentshouldregulateit[medicaltourism]more thegovernmentshouldhavesomepartofwhatmedicaltourism generates,intermsofmoneyanddistributeittothepeoplewhoreally needittoputitintosocialprogramsthatreduceinequity.Themoney shouldbedistributedinabetterway,butallthemoneyisstayingwith thehospitals,andnobodyisthinkingaboutit.Oratleastnobodyinthe government.Ofcoursethereisalotofmoneyinvolvedhereitisa verygoodbusinessandmanypeopleWellitsveryniceforthemto keepitquiet.Tonotdosomethingwithit.(13) WhilethegovernmentandtheCajaprovideanunacknowledgedsubsidyofthe medicaltourismindustry,thebenefitstheyreceivefromtheindustryarevirtuallynonexistent,andtherearenoplanstoamendthis.Atbest,publicbenefitfrommedical tourismwillbedistal,asprofits(thatarenotredirectedtoforeigners)gototheCosta Ricanelite,slowlymakingtheirwaybacktothepublicsectorthroughgeneraltaxation andin-countryspending.

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153 InternalBrainDrain Intheory,theinstitutionalizedpublicmedicalformationenablesnewlytrained physicianstofeedintothepublicsystem,wheretheyremainforthedurationoftheir careerscaringfortheCostaRicanpopulation.Inpractice,manynewphysiciansare beginningtosplittheirtimebetweenthesectors,orpracticeexclusivelyintheprivate sector.ThisisduetoincreasedprivatizationwithinCostaRica,andchallengestothe publicsystemthatmakeitundesirableforthemtoremainemployedsolelyintheCaja. Thephenomenonknownas"internalbraindrain,"whereinphysiciansopttopracticein themoreprofitableprivatesectoroverthepublicsector,isofconcernwithregardtothe continuingdevelopmentofmedicaltourisminCostaRicaandthefurtherdivergenceof publicandprivatehealthcare. Particularlyincertainspecialtiesthatareindemandintheprivatesector,theCaja hasseenmajorshortagesduetothenumberofphysicianswhobreaktheircontractand moveintoprivatepractice,wheretheycanmakemoremoney.Thepublicsubsidization ofphysicianswhoeventuallyenduppracticingexclusivelyintheprivatesectoris worrying,especiallyinasystemthatisalreadyfinanciallystrained.Severalparticipants expressedthisconcern.OneCajaadministratorwhobelievesthatmedicaltourismwill impacttheCajathroughthelossofhumanresourcesstated,theamountofprofessionals thatareintheprivatesectorareenough,thatcamefromour[public]classrooms(42). Anotherparticipant,anacademic,expressedasimilarfrustration: Andonthesubjectofhumanresourcesinthehealthfield,thisis creatingabigconflict,becausewithmytaxesandallofuswhopay taxeshereinCostaRica,wearepayingforthetrainingofmedical specialistsandmanyofthesemedicalspecialistsarenotevengoingto workinthepublichealthsystem!Theywillworkintheprivatesystem

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154 wherewagestandardsarevery,verydifferent,thaninthepublichealth systemImean,mycolleagueshaveconfessedtomeandsaid,'Look, IgaveupworkingforthesocialsecuritysystembecauseevenwhenI had25yearsofworkingwiththeCajaandIwasalmostreadytoretire, mysalarydidnotexceed$2,500,soIprefernottocontinuewiththis salarybutinsteadtoearninprivatepractice$20,000permonth.'This reallychangesthings.(7) Inordertoretainitsphysicians,theCajamustnowcompetewiththeprivate sector.Thismeansthatthepublicsystem,alreadysofinanciallystrainedbytheinternal andexternalforcesdescribedinpreviouschapters,mustsomehowmanagetoraisethe salariesofitsemployeesinordertoincentivizethemtostay.Thiscouldleadtowage inflation,ashasbeenthecaseinThailand,wheremedicaltourismhasbeenindictedasa majorcontributortoaphysicianshortage(NaRanongandNaRanong2011).Asthe governmentpromotesThailandasaninternationalmedicalhub,localpatientscontinue havepooraccesstoqualityhealthcare,andpublichospitalsfaceaseverebraindrainof healthcareworkerswholeavefortheprivatesector.In2005,thegovernmentofThailand trainedonly1,300physicians,while700resignedduringthatsameperiodmanyto workintheprivatesector(Chambers2011). ThisinternalbraindrainseemstobeoccurringinCostaRicaaswell.Medical tourismexacerbateshumanresourcemigrationbyofferingnewopportunitiesfor physicians,increasingpatientvolumeswithintheprivatesector,andprovidingeven higherremunerationthanworkingwithCostaRicansintheprivatesector. Itisconsideredprestigiousforphysicianstoworkwithmedicaltourists,because theytendtobethemosteducated,well-traveled,andskilledphysicians.Iaskedinmy interviewsiftherearespecificrequirementsforphysicianswhoworkwithmedical tourists.ThegeneralconsensuswasthattheyhadtospeakEnglish,havereceivedsome

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155 trainingwithintheUnitedStatesorEurope,andbecertifiedwithintheirspecialtybut theyalsomustbeconsideredofhighenoughcaliber.Duringaninterviewwithoneofthe privatehospitaldirectors,hesaid, R:Thereisafreemarketofferforphysicianswhowanttoworkwith medicaltouristsinmyhospital.Weestablishsomespecificrulesand standards,andthenweevaluatewhethertheyarewhattheythinktheyare. Theymustinformusabouttheirdegrees,thecoursestheytake,the congressesorseminarstheygoto.Theymustconvinceusthattheyare capableofworkingwithmedicaltourists. I:Andaretheremanyphysicianswhowanttoworkmorewithmedical tourists?Whowanttogothroughthisprocessofprovingtoyouthatthey arecapable? R:Ohyes,yes,yes,ofcourse.Andsometimes,therearedoctorsthat wellwearenotsosurethatwewantthemtoworkwithmedicaltourists, sowekindlyaskthemnotto.Thatisaprivilegeinthestatusofour doctors.(6) ThemajorityofphysiciansIinterviewedwork,orhadworked,inbothsectors, andmanyhopedtoeventuallymoveintotheprivatesectorexclusively,wheretheycould earnmoreincome,andhavecontrolovertheirtime.Thefactthatthesamephysicians workinboththesectors,andcanflowrelativelyfreelybetweenthetwo,makesitfairly easyforaCajaphysiciantoleavefortheprivatesectorifpatientvolumeisthereand medicaltourismcontributestopatientvolume.Mostwhospecializeinservicesthatarein demandbymedicaltouristssaidthattheywouldprefertoworkwithmedicaltourists, primarilyforthesalaryboost.Iaskedaninfectiousdiseasespecialistabouttheissueof internalbraindrain,andheresponded, Yes,ithashappenedallready.ManydoctorshavefledfromtheCajato workinthesespecialties,andthatiswhyweneedsourgently, anesthesiologistsandorthopedicsurgeonsjustoneorthopedicsurgeryis extremelyexpensive.SeveralyearsagoIhadapatientthathadtoundergo orthopedicsurgery,andjustwiththesurgery,nottakingintoaccountthe wholesetofdaysthatshehadtobeinsidethehospital,withjustthe surgery,thepartofmybillwasbiggerthanthreecompletemonthsoffull Cajasalary.Butbythen,itwasalreadytoolateforme[laughs],Iwas

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156 alreadyaninfectiousdiseasesspecialist,Ihadntthoughtofbecomingan orthopedicsurgeonatthatpoint!(20) Beyondtheprestigeofworkingwithforeigners,physicianswhoworkedwith medicaltouristsoftenfeelthattheyarefreelypracticingmedicinebecausethereareno constraintsonthem,likeintheCaja.Theyhavelotsoftimetospendwiththeirpatients, ontraining,andconductingresearch,andmostimportantly,didnotfeelfinancially constrainedtheyareabletoperformwhateverproceduretheywant,andusewhatever medicinestheywant,regardlessofthecost. Thereisnolimittowhatthesepeoplewillpay,onesurgeontoldme. TwoweeksagoIhadapatienthere,anAmerican,averyrichguy,and wefoundoutthatheneededamediationheneededtwoccsofa coagulantcalledFactorVII.Andits$15,000foreachone.Theguysaid dontworry,bringit!Ittookoneday.Inthepublicsectorthatwould neverhappen,andevenintheprivatesector,theCostaRicanpatient wouldntbeabletoaffordthat,sotheywouldprobablygetsenttothe Cajaanyway.(28) PracticingmedicineinCostaRicaisbecomingsynonymouswithadvanced technology,medicines,andfacilitiesandistransformingintotreatmentoffewerpatients inamorespecializedway.Treatingmedicaltouristshelpsphysiciansfeelthattheyhave thefreedomtopracticeunrestrainedmedicine,asopposedtoworkingintheCaja,where theymustworkwithlimitedresources. Themigrationofphysiciansintotheprivatesector,andintospecialtiesthathave moredemandwithintheglobalmarketplacefurthercontributestotheshiftawayfrom carethatiscenteredonpreventivemedicine,primarycare,andlocalpatients.Agroupof medicalstudentsIspokewithsaidthat,justafewyearsago,itwasfrownedupontoeven considerspecializing,andthattheCajaencouragedallphysicianstobetrainedfor cough,diarrheaandmucusandthatwastheideaofoursocialsystem;ourresponsibility

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157 asdoctors.Nowwearegoingintoadifferentkindofmedicinewearemedical scientists.Weworkbasedonevidence,wedocomplexsurgeries,wewanttoknowthe lastreceptorinthebrainthatmakesthismedicinework(43). CostaRicanphysiciansarebecomingmoreandmorespecialized,withsomesubspecializingorevensub-sub-specializing.Thereislittleincentiveforthesephysiciansto stayintheCaja,wherephysiciansarepaidbasedonseniority,andwheremasscaretends tobepromotedoverhighlyspecificcare.ThishasalsobeenseeninThailand,where doctorsarenowbecomingsosuper-specializedthattheynolongerworkinprimary careatall. Asanotheraspectofinternalbraindrain,physiciansaremorefrequentlyoptingto remaininurbanareas,particularlyinandaroundSanJos,whichconcentrateshealth resourcesintheseareas.Thenationsprivatehospitalsareallcurrentlylocatedwithin SanJosonly,sophysicianswhowouldliketopracticeinbothsectors,orwhodesireto buildaprivatepracticegradually,muststaynearthecitytodoso.Thisislikelyoneof thereasonswhymedicalresidentswentonstrikein2010,objectingtotheirplacementsin ruralareas. Eventhoughspecialiststendtofleetotheprivatesector,industrystakeholders maintainedthatitwasthegovernmentsresponsibilitytomeettheindustrysneedfor specialiststhatmedicaltourismdemands.Onemedicaltourismpromotersaid,the numberofspecialistswearegoingtoneedforthisprojectishuge,sothatisabigtask thatthegovernmentofthecountryhastofaceinorderformedicaltourismtobe sustainable.Becauseifnot,wecannotgrowandwecannotfullyreceiveforeignpatients (16).So,althoughthegovernmentdoesnotbenefitfromthespecialistswhomtheytrain,

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158 anddoesnotreceiveanydirectprofitfrommedicaltourism,theyarenonetheless consideredresponsibletoinvestinthetrainingofhealthcarepersonnelwhoworkinthe industry. Itseems,fromthisresearch,andcasestudiesconductedelsewhere,thatmedical tourismdoesmoreharmthangoodtopublichealthcareprovision.Itsiphonsresources monetary,human,andtechnologicalfrompublictoprivate,ruraltourban,andgeneral tospecialized.Itencouragesafocusonproceduresandareasofmedicinethatarein demandbytheglobalmarket,anditcontributestoawideninginequalitiesbetweenpublic andprivate,richandpoor,foreignandlocal.Thewaysthatthissiphoningofresources contributestoanemergingdualtrackofmedicalcareinCostaRicawillbediscussedin thenextchapter.

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159 CHAPTER7:MEDICALTOURISMANDCOSTARICASCONTRADICTING VISIONS Thisisacountrythatisprivilegedintermsofhealthcare.Thatisthe wonderofuniversalhealthcare.Onlyafewcountries,ifnotonlyinCosta Ricahaveahealthsystemthatissogood.Theproblemthatweexperience isfromtheupsanddownsofthepoliticalandeconomicalideologiesin thewholeworldthataffectthesekindsofsystems. Ourgovernmentobeysinternationalpoliciesandbowstointernational economiesthatrestrictthesekindsofuniversalhealthsystems,andin response,theydeteriorate.Butitisnotbecauseuniversalsocialsecurity systemsarebadthatiswhattheyinworldpowertrytotellusthatwe shouldenduniversalsocialsecuritybecauseitiswhatishurtingeconomy, butitisnotbecauseofthat.Itisbecauseofinternationalpressuresthat demandthatthesetypesofsystemsstopexisting. Sothesystemdeterioratesandtheywantustobelievethatitis deterioratingbecausethesystemitselfisbad.Butitsnotitisa marveloussystem.Hopefullythewholeworldwouldhaveasystembuilt onsolidaritylikewedo,becausethereareothercountrieswhereifyouget sick,youwilljustdieifyoudonthavemoney. Cajanurse(44) On-the-groundconsequencesofneoliberalreformshavebeenwelldocumented, buttherehasbeenlessattentiontotheimpactthatsuchreformshaveonnotionsofhealth citizenshipandsocialsolidarity.Overarchingthemoretangibleimpactsthatmedical tourismhasonthehealthcaresystem,aretheethicalandideologicalimplicationsthatit hasinacontextsuchasCostaRica.Thischapterexploresthejuxtapositionsthattoday existinCostaRica,takingasitsprimaryfocusthecontradictoryideologiesthatgive spacefortheemergenceofmedicaltourism,anindustrysoseeminglyatoddswith principlesofuniversalhealthcoveragesubsidizedbythepublicsector,andthewaysthat thisindustryischanginghowthatCostaRicansthinkabouthealthcareandstate responsibility. CostaRicasContradictions IamgladyouchoseCostaRica,butIfeelsorryforyou,becausewe arecomplicatedcreatures.Wearevery,verycontradictory.Andwedo

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160 everythinghalfwayuntilwegetcaught.Andthenwegoatwarpspeed andwereallyexertourselvesandtrytofixwhathasbeendone,butitis toolate.Thatshowitis,Iamsureyoufinditverypeculiar.(34) TheinvestigationofCostaRicanmedicaltourismrevealsthecontradictionsofthe currentpoliticalandhistoricalmomentamomentofsystemicfluxwithregardtohow thesocialcontractbetweenstateandcitizenisconceptualized.CostaRicaisacountry thatrepeatedlyrejectsneoliberalprinciplesinitshealthcaresystem,yetadoptsthemin thesigningofCAFTA;thatresistsprivatizationoftheCaja,butprovides unacknowledgedsubsidyoftheprivatesector,anddeclaresmedicaltourismanindustry fullyentrenchedintheprivatesectoranactivityofnationalinterest.CostaRicais strugglingtofinditsnicheintheglobaleconomy,whileatthesametimefervently defendingthesocialprinciplesuponwhichitisfounded. MedicalTourismandOpposingIdeologicalValues Indiscussingthemedicaltourismindustryinthiscontext,therearetwopolar conceptionsofhealthsystemsatplayheresocializedhealthcareatoneend,inwhich healthisasocialrightandthestateistheguarantor,andaneoliberalmarketsystemon theother,inwhichhealthisacommoditytobepurchased.Whenthesocialmentality aroundhealthcarethatexistsinCostaRicaispositionedalongsideamodelofprivate, for-profithealthcare,messagesofsocialsolidaritygetconvoluted.Onepublicsector nursesummarizedthispointwell,statingthatitisnotthefinancialorhumanresource impactsofmedicaltourismthatconcernheratpresent,buttheincrementalshiftsin thinkingthatitrepresents: Ithinkthatwhatishappeningnowwiththistypeoftourism,isthatits makingtheprivatesectorgrow.Theyarebuildinghotelsrightnextto thesehospitals,orinthehospitalsandwell,youcanseetheconnection.

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161 Sotheprivatehospitalsarefocusingongrowth,butitisonlyforacertain groupthathasacquisitivecapacitytodoit,andhasforeigncapital. Inacertainway,IdontknowifIcansaythatitisallnegative,but thisbringschangestoourculture.Becausemedicaltourism,sinceitisfor peoplewithhigherincome,andaboveallforforeigners-itchangesthe idiosyncrasies,theindividualcharacterofourculture ,aswellasthe determinedspacesmeantforcertainsectors.Itbecomesmoreelite focusedandthingshappenthatareforthisotherpopulation,notfor CostaRicans.Sothereareculturalchangesthatalsocomewiththis process,anditisveryimportanttotaketheseintoaccount.(41) TheseincrementalchangesinCostaRicaaretakingplacemuchinthesameway thatprivatizationingeneralhasbeencreepinginthereislittleacknowledgementof whatthesechangesmeanwithinthestate-dominatedsystem.AlthoughmanyCosta RicansseethemselvesasagainsttheneoliberalvaluesthattheUnitedStatesrepresents, theydonotalwaysrecognizethecurrentchangesthatareoccurringaspartofthespread ofthosevalues.Rather,itisperceivedasanaccolade,provingthatthedeveloped countriesoftheworldrespectCostaRicashealthsystem.ItisseenasawayforCosta Ricatoachievenationaldevelopmentandnegotiateaplaceintheglobaleconomy.An internistwhomIinterviewedtoldmethatmedicaltourismactuallyprovedthatCosta RicawasbetterthantheUnitedStates,saying, Actually,Ilikeit[medicaltourism].Youknowwhy?Becausetheres anideathat,intheStates,theyarethebest.Andactually,Ihavemetalot ofAmericans,andIhavedonesurgeriesonalotofU.S.patientsandI knowthatthisisnttrue.YoudontgetthebestmedicineintheStates.So inopeningthismarket,IthinkeverybodywillknowthatCostaRicais reallygoodprobablybetterthantheUnitedStates.(10) MedicaltourismhasbecomeanewsourceofpridewithinCostaRica,andaway fortheworldtorecognizeitsaccomplishments.Thisisparadoxical,inthattheindustry embodiesprinciplesofprofit-drivenhealthcarethatCostaRicansloatheintheU.S.

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162 systemwhichisseenasunfair,inefficient,andeveninhumane,puttingprofitsabove thewellbeingofitscitizens. InadditiontocriticizingtheU.S.systematlarge,CostaRicanphysiciansbelieve thatAmericandoctorsarenottrulyfreetopracticemedicineasitwasintended,because ofthismodelofhealthcareasabusiness.TherearesomanyregulationsintheUnited States,adermatologisttoldme,Youcannot,asaphysician,beveryfreeyouare boundbytheinsurancecompany,andwhattheywillpay,ornotpay.Andsoitsnot reallyyourmedicaldecision,theinsurancecompanytakesthedecisionfromyou.Thats notrealmedicine(25).Atthesametime,however,CAFTAhasopeneduptheprivate insurancemarketwithinCostaRica,andthereisanoteworthytrendtowards privatization,aswellasagrowinginclinationforphysicianstomovetotheprivate sector,wheretheywilllikelyfacesimilarconstraintsontheirpracticesastheprivate sectorgrows. Thedemandingpatients,andmedico-legalclimateoftheUnitedStatesisalso citedasadifferencefromtheCostaRicansystem.Onephysician(whodidrecognize medicaltourismasadifferentmodelofhealthcarefromsocialmedicine)saidthat, Medicaltourismisadouble-edgedsword,becausehereweareusedto adifferentkindofmedicine.TheUnitedStatesareallprotocols,informed consents,whatiswrittendownitisjusttakethis,fillthis,iftheres anyquestion:readthis.Soitisverycold.Idonotlikethatkindof medicine.Itgivesmealittlebitoffearifapatientcomesformedical tourismbecauseinAmericatheytendtodemandeverything.Itrained, theyclaimitdidnotrain,sotheysue[laughs].Butmedicaltourismhas beeninsertedinCostaRicawiththesamemodelofdoctor-patient relationshipasintheUnitedStates.Soforme,it'sashock,Idonotknow ...itsthecultureorsomething.(30) ItiswellrecognizedwithinCostaRicathattheU.S.systemisfailing,andthisis whymedicaltouristsseekcareoutsideoftheirborders.Yet,atthesametimethatCosta

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163 RicansboastaboutthefoundationsoftheirsocialsystemandcritiquetheU.S.system, medicaltourismistoutedasaformofglobalprestigeandawayforwardforthecountry. Likethemaintenanceofthepublic-privatedivide,thereisdenialatworkhere,asCosta Ricansfailtoacknowledgetheinterconnectednessbetweenmedicaltourismandthe neoliberalmodelofhealthcare.Thisfurtherexposesthesocialsystemtoharmfrom outsideandopensthedoorforadualsystemofhealthcare,asthecost,quality,and accesstopublicandprivatehealthcareprovisioncontinuetodiverge. CompetingVisionsofHealthNationalism ThepopularCostaRicannotionofexceptionalism,rootedinthenationssocial pastisnowincompetitionwithaverydifferentvisionofhealthnationalismbasedon caringforforeigners.Withinthisemergingvisionofhealthcare,theprivatesectoris increasinglyequatedwithwealth,efficiency,andaprogressive,andnimbleway forwardforthecountry,whiletheCajaisviewedasanimmovable,outdatedsymbolof CostaRicaspastglory.Theseconflictingvisionsrequireareworkingofmedicine,from aprojectofnation-makingandsocialinclusion,tohealthcareascommerce. LastNovember,avisitingLatinAmericanjournalist,AndresOppenheimer,gave aspeechinSanJosinwhichheadmonishedCostaRicaforbeingobsessedwiththe past,whileothercountriesarelookingtowardsthefuture(Williams2011).Histalkwas followedwithanappealbythepresidentoftheCostaRicanMedicalHoldingphysician group,forthestrongerpromotionofmedicaltourismwithintheUnitedStates,asameans foreconomicdevelopmentandmovingforward.Therhetoricofmedicaltourismas progressforthenationisprevalent,especiallyamongthosewithstakesintheindustry.

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164 Evenatop-rankingCajaofficialtoldmethatCostaRicamustgetonthetrainofchange tomoveforward,referringtothepromotionofmedicaltourism(42). Physiciansarebecomingmoreattractedtopracticingmedicinewithintheprivate sector,wheretheyfeelthattheycanlocatetheprestigeandcareeradvancementthatthey desire.TheyseetheCajaasstiflingthisadvancementthroughitsfocusonmassmedicine anditspromotionsystembasedonseniorityratherthanskillorambition.Increasingly, theCajaisbeingseenaspreventingCostaRicafrommovingforward,andisimplicated inthecurrentfailuresofthehealthcaresystem,butexcludedfromitssuccesses. ThepurifiedspecialspacesthathavebeencreatedwithinCostaRica,described inthepreviouschapter,alsoembodythevisionofCostaRicasglobalfuture,withtheir state-of-the-arttechnology,modernstyling,andhighlyspecializedphysicians.The struggleoverthefutureofthenationalhealthsysteminCostaRicaremainsdisconnected fromthesespaces,andfromphysiciandecisionstoleavefortheprivatesector. DistinguishingBetweenForeigners Anotherinterestingdistinctionthatismadebetweenthepastandfuturevisionsof CostaRicaliesinthemarkeddifferencesinopinionsaboutNicaraguanimmigrantswho usethehealthsystemversusmedicaltouristswhousethehealthsystem. WhileNicaraguansareoftenseenassocialpariahs,medicaltouristsand Americanexpatriatesorretireesarewelcomed,andseenasasignofglobalprestige.In theCostaRicanimagination,medicaltouristsarealignedwiththefuturevisionofthe nation,whileNicaraguansrepresenttheerosionofCostaRicanexceptionalismanda returntoCentralAmerica(Ordoez2007).Participantsinthisresearchhadalmost

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165 oppositefeelingsaboutthesetwogroupsofforeigners,andwerecleartodistinguish betweenthem.Inaninterview,onephysicianstoppedabruptlyandsaid, Maybethereisaneedfordifferentiationbecauseatouristthatcomes fromtheUnitedStates,togetsurgery,hehasitdoneintheprivatesector. HewontgototheCajatohavethesurgery,sohewontbetakingthe placeofaCostaRican.Thatisfine.Ontheotherhand,peoplewhocome fromNicaraguatoworkhereinCostaRica,theyreceivecareintheCaja, so,inthatcase,itisaforeignerwhoistakingaTicosspot.(37) Thoughthereareotherimmigrantgroupsthatenterthecountrytowork,the numberofNicaraguanspermanentlylivinginCostaRicahasincreaseddramatically, makingupaboutsixpercentofthecurrentpopulation(Muiser,etal.2008).Thereare manymoredaylaborers,whocomeintoCostaRicatoworklowleveljobs,andthen returntoNicaragua.Nicaraguansarethetargetofmuchanti-immigrantsentiment,and areoftenblamedforthecurrentsocialillsofCostaRica,suchasreemerginginfectious diseases,poverty,crime,prostitution,environmentaldegradation,andlowwages. TheCajaisasiteofsignificantanti-Nicaraguansentiment,asimmigrantsare accusedofusingexpensivecarewithoutcontributingtothesystem.Asopposedto medicaltourists,whoareseenasliftingthecountryoutofpovertythrougheconomic development,NicaraguansareequatedwiththedeteriorationofCostaRicasinstitutions, andareviewedasdirty,andaspollutingtheracialpurityofthenation(seeChapterTwo onthewhitelegendofCostaRica).Iinterviewedafemalephysicianintheprivate sectorwho,whenaskedheropinionoftheCostaRicanhealthsystem,responded, Iloveit.Becauseifyouaresick,yougotothehospitalandyouget whatyouneed.Theproblemisimmigrantpeople.Likeforexample,there wasthisNicaraguangirl,shejustcrossedtheborderaweekearlierand thenshewentintochildbirth.Sofirst,nowwehavenowanewCosta Rican,andthatpopulationisgettingbiggerandbigger,andalso,they didntpayanyinsurance,sothatisthething.AndweCostaRicans,we

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166 pay,butwiththemoneywespend,wearepayingforimmigrants.AndI mean,itisexpensive.(38) WhenIaskedthissamephysicianwhetherCostaRicanshaveanynegative feelingsaboutmedicaltouristsusingtheCostaRicansystemforcare,sherespondedOh no,weliketourists!Wehaveasayinghere-alwayssmiletoatourist. Medicaltouristsarepositionedwithintheprivateglobalfuturevisionofthe country,whileimmigrantsarepositionedwithinthepublicnationalpast,whichis increasinglyequated,too,withpovertyandcharitycare. MedicalTourismUnderaSocialSystem WhilemanyAmericansenvisionthemselvesasresistingtheimpersonalcapitalist U.S.healthcaresystembypartakinginmedicaltourism,theyarenotoutsideofthe neoliberalmodelofhealthcare.Byseekingcareelsewhere,thesetouristsare,infact, utilizingtheindividualresponsibilityandentrepreneurialspiritthattheneoliberalsystem taughtthem. Similarly,inCostaRica,justificationsformedicaltourismoftenalignwith nationaldiscoursearoundsocialmedicine.Thoughapowerfulglobaleconomicmodel, neoliberalismisnotalwaysenactedinauniformmanner,orabsorbeduncriticallyin destinationcountries.Thereareoftenlocalresistancesthatpushbackonglobalprocesses (Scott1998),andglobalizationcanbeaninherentlylocalizingprocess(Appadurai1991). ThewaythatCostaRicadoesmedicaltourisminmanywaysiscoloredbytheirsocial past.Primarily,theriseoftheCaja,itsachievements,anditsprominentroleinCosta Ricannationalidentity,havebeeneffectiveinconvincingCostaRicansthathealthcareis abasichumanright.

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167 ThewaythatCostaRicansrationalizemedicaltourismisindicativeofthisbelief insocialmedicine.Onnumerousoccasions,Iwastoldthatthebenefitsofmedical tourismarenotjustingeneratingincomeforCostaRica,butalsothattheindustryisan opportunityfortheU.S.healthcaresystemtobeabletoprovidehealthcareforallof theircitizens.ItisachanceforindividualAmericanstogainaccesstohealthcareasis theirhumanrightwhentheUnitedStatesfailstoprovideitforthem.Onephysician said,MedicaltourismrepresentsethicsandmoralsbecausewearegivingAmericans healthcarewhichtheydonothaveathome(35). InthemindofmanyCostaRicans,medicaltourismtakesonanaltruisticform, compatiblewithsocialprinciples.Manyjustifiedprivatizationinthesameway;ina conversationwiththreemedicalstudentsattheUniversityofCostaRica,they thoughtfullytoldme, A:Wellprivatizationisntgoodifyoudoiteverywhere,butIthink thathavingprivatemedicineandmedicaltourismcanhelptheCaja becausethepeoplewhocanpaywillgotoprivatehospitals,andthis meansthatthepeoplewhoreallyneedthecheapercarewilluseit. Becauseifyoucanpayforprivatecare,thenpayyourtaxesandgotothe privatehospital,butdonttakethespotsawayfromthepeoplewhocannot payforprivatehealthcareandarestandinginlineattheCaja.Some peoplewouldsaythatsunfairbutthatishowitshouldbe,ifyoucan pay,pay.Theoneswhocannotpayforit,theyhavenootherchoice.You haveachoice. B:Yeah,ifyouhavethemoney,youcanchoose. C:Itsawayforyoutohelpsomeonewhocant.Itisnotjustabout payingtaxesandputtingthemoneyintothesystem,itisaboutawhole wayofthinkingthatwehave--tosupporteachother,andtheoneswho candosomethings[payforprivatecare],dothem,sotheywillleave spacefortheoneswhocannottakeadvantageofprivatecare.Formethat iswhyprivateexpansionisokay,butyoucannotlosethatobjective,that pointofview.(43)

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168 Inherdiscussionoforgantransplanttourism,NancyScheper-Hughes(2002) arguesthatcapitalizedeconomicrelationsthatinvolvebodiesareoftenmaskedin altruism.Inthenewglobaleconomy,shestates,theconflictbetweennon-malfeasance (donoharm)andbeneficence(themoraldutytoperformgoodacts)isincreasingly resolvedinfavorofthelibertarianandconsumer-orientedprinciplethatthoseableto brokerorbuyahumanorganshouldnotbepreventedfromdoingso(2002).Inthese situations,anindividualsrighttohealthtrumpsallotherpotentialimpactsandbecomes thefinalword.Inanalyzingmedicaltourism,therhetoricthathighlightsaltruismand benevolencefitswithinaCostaRicanmentalityofsocialsolidarityandhealthasahuman right.However,itcanobscuretheharmfulimpactsofthispracticeandfurthercontribute toinequitiesinthemedicalsystem,whichgoesagainstthesesocialprinciples. MedicalTourism,DistributiveJusticeandMoralPluralism Theemploymentofaltruismasajustificationformedicaltourismnotonlymasks itsimpacts,butmasksmoralpluralismandethicalimplications,asmedicaltouristsare oftenaffordeddifferentstandardsofcarethanlocals.Forexample,intheCzech Republic,localsmustbeundertheageof38toreceiveIVFtreatments,whilemedical touristsmustbeundertheageof51(Whittaker2010a).InCuba,aforeignpassportis requiredtoaccesswell-stockedpharmacies,whilelocalsaredeniedallbutthemostbasic medications(Brotherton2008).InCostaRica,medicaltouristsutilizethespecialspaces oftheprivatesector,whileCostaRicansmustwaitinlineforcareatthecrowdedpublic facilities.Theseareexamplesofmedicalpluralisminmotion,withinmedicaltourism destinationcountries(Pennings2002),andillustratepost-colonialnotionsofthevalueof bodies,asbodiesoftheThirdWorldaretaskedwithtakingcareofbodiesoftheFirst

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169 World,whichareseenasmoredeservingandinneed.Inmanyways,theCostaRican stateisperpetuatingthedoublemoralthatexistsbysimultaneouslypromotingmedical tourism,whileatthesametimestrugglingtocareforitsowncitizens. Somescholars,andparticipantsinthisresearch,feelthatmedicaltourismis,atits core,anunethicalorexploitivepractice,inthatitpromotestakingadvantageoflower healthcarecostsinCostaRica,ratherthanfixingtheproblemsofthehealthsystemsfrom whichmedicaltouristsarecoming,andtakesawayfromcareforlocals.Oneparticipant, anacademic,said: Idontlikemedicaltourism.Idontknow;Idontlikeit.BecauseI thinkitismakinguseoflowercostsherethaninthecountrywherethe peoplearefrom.Idontknowifthatisfairifyoutakeresources awayfromCostaRicans,thenyouaredoingsomethingwrongandyou justdoitbecausethosepeoplecomingherecanpaysomuchmoney well,youknow,theysaythatiseconomicdevelopmentIguess.ButI dontthinkso.(22) Somewonderedwhethermedicaltourismwouldleadtoadual-trackhealth system,withthepublicsectorcaringforthepoormajority,andtheprivatesectorcaring fortheCostaRicaneliteandforeigners.Thereisevidencethatmedicaltourismis contributingtosuchasplitsysteminbothCubaandIndia. InCuba,wheremedicaltourismisbeingpromotedthroughthestate, Brotherton(2005)hasillustratedthatamedicalapartheidisoccurring,wherein medicaltouristsaccessseparate(public)facilitiesthatrequireaforeignpassport andforeigncurrency.Thesefacilitiesarelesscrowdedandbetterstockedwith medicinesthantheonesthatCubansaccess.HildaMolina,aphysician,refusedto complywiththegovernmentsdecisiontoturnherNeurologicalCenterintoa

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170 tourist-onlyhospital,demandingthatCubansbetreatedequally,andwasbanned frompracticingmedicine(Vincent2004). InIndia,theprivatesectorholdsthelargemajorityofphysicians, technologyandspecialists(Thomas2010)andonlytheverypoorusepublic healthcarefacilities.Seventypercentofhealthspendingisprivateandout-ofpocket,whileonlyfourpercentofgovernmentspendinggoestohealth(World HealthOrganization2000).Yet,thegovernmentheavilysubsidizesthemedical tourismindustryandmedicaleducation,whilethevastmajorityofIndians struggletoaccesstohealthcare.Forevery100,000people,thereare60 physiciansinIndia,comparedwith279intheUnitedStates(Meghani2010).An outspokencriticofmedicaltourismstatedthateverytimeamedicaltourist comestoIndia,theyarereducingthechancesforanIndiantoreceivecare (Thomas2010). Thesecasestudiesillustrateinequitiesproducedbymedicaltourism,and someareconcernedthatifCostaRicacontinuesonitscurrenttrajectory,similar dualtrackhealthsystemswillresult.However,becausemedicaltouristsarenot usingtheCaja,whichiswheremostCostaRicansgofortheircare,thisideaof takingawayfromCostaRicansisnotasobviousordirect,andmanywhomI spokewithdidnotfeelthatmedicaltourismdetractsfromlocalcare.Duringone interview,justafterdiscussingtheroleofthegovernmentinpromotingmedical tourism,creatingregulations,andgivingprioritytotrainingspecialiststhatarein demandbytheindustry,Iaskedonemedicaldirectorwhatthedisadvantagesof medicaltourismmightbeforthecountry.Heresponded,

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171 Disadvantages?No,inreality,Idontseeany.Becauseitisrevenuesthat arenotbeingtakenawayfromanybody.Thecountryhasaninfrastructure thatisbeingunderexploited,Imeanhereinthishospital,wehaveten surgeryroomsandatthisverymomentyoucansaytomethatyouwantto operateontwopatientsandIwouldsayyes(12). Thisisrelatedtothediscussionofthepublic-privatedisconnectandthe viewpointthatthepublicandprivatesectorsdonotshareconnectedresources.In thecaseofCostaRica,wheretheveryphysicianswhotendtomedicaltouristsare sharedwiththeCaja,itisdifficulttomakethisargument.Despitethedenialby manyparticipantsthatthepublicandprivatesectorsshareresources,therewere somewhoIspokewithwho did feelthatmedicaltourismencouragedpoor distributivejustice,withthemajorityoftheresourceslocatedinthewealthy privatesector,whilethepoorgetwhateverremains.Meghani,whoexamined medicaltourismfromanethicalperspective,citedseveralwaysinwhichmedical tourismcouldbeconsideredanunethicalpractice,stating,ratherbluntly,thatthis practiceis,inessence,thehavestakingfromthehavenotsandanagentof harm(2010). Theideaofexcesscapacity,mentionedinthequoteabove,isprevalentwithin theprivatesector.Thisisanextremecontrastwiththepublicsector,wherefacilitiesare alwayscrowdedwithpatientswaitingtobeseen;waitlistsaresometimesoverayear long,andphysiciansarerequiredtoseeasmanyas40patientsperday.Somemedical tourismadsevendrawonthisfalsecapacitywithintheprivatesector.Oneadstates, Eventhoughcurrentlyoverburdenedbyneedycitizens,theCostaRican healthcaresystemisbeingutilizedatlessthan100%.Theexpensive medicalequipmentandhightechoperatingroomsstandidleeveryday aftermid-afternoon.WhilewealthierCostaRicansandsomeforeign residentsmakeappointmentswiththeirprivatephysicians,theirnumbers arenotgreatenoughtokeeptheprivateofficesandclinicsoverlybusy.

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172 Thereisnoticeableslackinthesystem,anditisthisslackwhichserves theforeigntouristinterestedinthefullspectrumofhealthcareservices offered(Underwood2005). Thiselucidatestheneoliberaldiscoursearoundhealthcare,whereinhealth isviewedasacommodity.Theslackinthesystemmeansthatthereismore supplythandemandinCostaRica;theyareseekingmoreclients.Butthereis plentyofdemandforhealthcarewithinCostaRica.Itjustoccursinthepublic sector,becausethemajorityofCostaRicanscannotaffordprivatecare. InatalkentitledMedicalTourisminIndia:PrivateProfit,PublicPain, anIndianphysician,Dr.GeorgeThomas(2010),spokeaboutthisconceptof excesscapacitywithintheprivatesector,whichIndianmedicaltourism facilitiesoftenuseintheirpromotionoftheindustry.Thiscapacityisfalse,he argues,becauseitarisesoutoftheinabilityoflocalcitizenstoaffordprivate healthcare.Heequatedthisargumenttosayingthatthereisanoverabundanceof foodsimplybecausepeoplecannotaffordtobuyfood.Thisonceagain illustratesthedividebetweenconceptionsofhealthcareasacommodityversus healthcareasahumanrightandsocialgood.Medicaltouristsarebeing encouragedtoreceivehealthtreatmentsthatoftentimestheydonotneed, meanwhilelocalpopulationsstruggletoaccessbasiccare. TheShiftingRoleofSocialResponsibility MedicaltourismindicatesanerosionofsocialresponsibilityonwhichtheCajais founded.Physicians,whoplayedsuchaprominentroleinthenationalhealthsystemat thetimeofitsdevelopment,areleavingfortheprivatesectorandavoidinganysocial responsibilitytocarefortheCostaRicanpopulation.Amongsome,socialresponsibility

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173 hasbecomemoresymbolic,volunteeringaportionoftheirtimetotheCaja,oragreeing totakeonCajapatientsonoccasion,ascharitycare.Oneplasticsurgeon,wholeftthe Cajatoworkwithmedicaltourists,toldmehowhefulfilledhissocialresponsibilityasa CostaRicanphysician,whilepracticingfull-timeintheprivatesector: Inmycase,oneofthemostinterestingsurgeriesthatIwasinvolvedin attheCajawasbreastreconstructionsurgeries,soIdecidedtostartmy ownprivateprogramforbreastreconstructionhereinmyprivatepractice, outofsocialcommitmentWhentheprogramstarted,Ididonesurgery everyfourmonths,thenIwasabletodooneeverythirdmonth,thenone everysecondmonth,thenoneeverymonth,nowadayswearedoing almosttwoeverymonth,undertheprogram.ThatisthewayIkeepthe contactwiththeCajapopulationwhenIamhereinprivatesector.(35) Whilesuchinitiativesarecommendable,itisarguablethatservingsuchalow numberofpoorpatientscouldreplacethesocialserviceofanentirecareerwithinthe Caja.Thislimitedcharityworkishardlythevisionofphysicianascivilservantthat wasintendedwhentheCajawasfounded. Thissubstitutionofcharityworkforsocialresponsibilityhasbeendiscussedfrom anethicalperspectiveinIndia,wheremedicaltouristhospitalgroupsareinitiatingcharity programsforthepoortogivebacktoIndia.Inthatcaseaswell,itisquestionable whetherthepatientsservedonacharitybasiscanjustify,notonlythelossofpublic physicians,butalsothemoneythatthegovernmentspendspromotingandsubsidizing medicaltourismtoattractcitizensofwealthiernations(Meghani2010).ACajanurse commentedontheerosionofsocialresponsibility,saying, Ithinkmedicaltourismwouldbefine,aslongasthenationalhealth problemsaregettingsolved,butthecountryhasapileofproblemstobe solved.Andthisisanindustrywherealotofdoctorsareleavingto practiceintheprivatesector,becausetheyknowthatitmeansdollars. Truly,thisoughttomakeusre-thinkwhether,ethicallyandmorally,this iswhatweweretrainedfor--fortreatingapopulationfromanother countryandimproving their conditions?Ithinkitisdifficulttosaythat

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174 youaretotallyinfavorofthis.Andtheethicalandmoralpartofhealth professionalsisnttakenintoaccount--wegiveanoathtoprotectthelife andhealthofthepeoplewhoweattendto,andinrealitywearegoingona differentpathnowMaybepeopledoneedprivatehealthcaretoo,butnot inthesamewaythattheyneedthenationalhealthsystem.(41) Morethanjustindividualphysiciansandnurses,thereisanexpectationthatthe privatesector,asalargerentity,shouldgivebacktothepublicsector.Thereisnothingin place,todate,thatensuresthiswillhappen.Somedohope,however,thatsomethinglike thiswillbeinstitutedinamoreformalway.OneparticipantfromtheCajatalkedabout theroleofthepublicandprivatesectorsinhealthcareprovision,saying; Theroleofthepublicsectorisunquestionableattentiontoall citizens thatarewithinournationalterritory.Thatmeansthatthepublichealth systemhastheobligationtoprotectthehealthofalltheinhabitantsofthe country,whoevertheyare.Thisisforhumanisticreasons,becausewe wereformedinthatmentalityandthatisthesystemthatwastaughttous sincewewerekids.So,ofcourse,itistheCajasobligationtobethe primaryinstitutionforallthehealthatanationallevel. ButIbelievetheprivatesectoralsohastogiveitscontributionaspart ofsociety--tocontributetothehealthsysteminsomeway.Forexample, maybeCIMASanJosearns--Idontknowhowmanyhundredsof millionsinsurgeriesfrommedicaltourism--welltheyshouldgivea certainpercentagetosmallconsultationsforpreventiveandcommunity medicineforthecommunitythatisbesidethehospital,Ithinkthatisa moralobligationofbeingpartoftheCostaRicansociety.(44) CostaRicaishometoamodelofcitizenshipdefinedbysocialistvaluesinan economyincreasinglydefinedbymarket-basedreforms.Despitethecontractionofthe Caja,whichhasmadeitdifficulttocarefortheCostaRicanpopulation,therehasbeen littlechangeinthebeliefthathealthcareistheresponsibilityofthestate.Althoughthe charityworksuggestedaboveisbetterthannothing,itislikelynotenoughtooutweigh theharmtotheCajathattheparasiticrelationshipwiththeprivatesectorcauses.

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175 RegulatingMedicalTourism Thereisnoregulationofthis[medicaltourism]inthecountry.Herein CostaRica,wedealwiththingswithtweezers.Wearenotexplicitin sayinglook,lookatwhatashamethisis,thatthisishappening,orcalling attentiontowhatisntworkingtotryandfixit. IrememberonetimethatIwasinvitedbytheMunicipalityofSanJose andthePanAmericanHealthOrganizationforaceremony.Itwasfor childrenprotectingtheenvironment.Medalsweregiven,andtherewas foodandacelebration.Istoodupandsaid,Look,Ihonestlyfeelverybad tobehere,andIamsurethatyouwontinvitemeagain,butIneedtotell youwhatIamfeelinghere.Iamappalledthatwerewardchildrenfor pickingupthegarbagethatadultsthrowaway.Itisatotallyappalling culturalpractice.Imeanwhyarewetofeelhappythatchildrenare protectingtheenvironmentthatwearepollutingasadults?Whyisthe attentionnotonthesourceoftheproblem?Thatisastorytoillustratehow CostaRicadealswiththings.Wewillnotregulatemedicaltourismuntilit istoolate.Andeventhenwewilljustusesometweezers(7). Medicaltourismrepresentsanewconfigurationofhealthcareprovisionina globalizedworldandthereiscurrentlyalackofconsensusaboutwhoseresponsibilityit istoensurethatmedicaltourismisregulatedinasociallyresponsibleway.Thegrowing standardizationonthesendingsideofthemedicaltourismindustryhasnotbeen matchedindestinationcountries,makingtheindustrysubjecttovaryingnational regulationsandcosts. Medicaltourismbringsuplargerquestionsaboutwhoistogovernglobal industries.Theindustryhasremainedmostlyunstructuredintermsofgoverning legislationformedicaltourism.Itwasclearfrommyinterviewswiththoseinvolved internationallyfeltthatitwasnottheindustrysresponsibilitytoregulatemedicaltourism inanyway,butthatitwastheresponsibilityofgovernmentsindestinationcountriesto ensurethatanyprofitswereredistributedfairly.Inapublishedarticleinamedical tourismtrademagazine,thepresidentoftheMedicalTourismAssociationwrotethatshe feltthatgovernmentsindestinationcountriesshouldreinvesttheirprofitsintofurther

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176 infrastructuretoaccommodateincreasedpatientflowsfrommedicaltourism.Shewent oninthearticle,tocalltheWorldHealthOrganization(WHO)andtheWorldTrade Organization(WTO)BigBrotherOrganizations,asking,Canyouimaginethefuture ofmedicaltourismheldinthehandsoftheWorldHealthOrganization?(Stephano 2009).Thisisclearlyadistastefulpropositionforstakeholderswhopreferforthe industrytoavoidanyinternationaloversightthatmightquashprofits.Thequestionstill remains,however,aboutwhoseresponsibilityitistoregulatemedicaltourism. Meghani(2010),inherethicalassessmentofmedicaltourism,findsthatitisnota governmentalissue,butratheranissueofindividualethics,anditisthetravelingmedical touristhimorherselfwhomustrefusetopartakeinmedicaltourism,knowingthatthis practicecausesharmtothehealthsystemsofdestinationcountries.Dharamsi(2010) thinks,instead,thatthelackofsocialaccountabilityandmoralcoreoftheindustryshould beaddressedthroughpracticingphysicians.Hearguesthatphysicianshaveaspecial professionalstatusthatrequiresthattheybevirtuousintheirpracticeofmedicine, particularlyincaseswheretheirmedicaleducationwaspaidforbythegovernment. Ashifttoneoliberalgovernmentality,inthecaseofmedicaltourism,prescribes nationalgovernancethatisunderminedbyinternationallawsandinterests.Thisshift awayfromsovereigntyleavesstatesweakerandwithlesspowertoenactpoliciesthat counteractglobalprocesses. Thegovernmentsofdestinationcountrieshavelaggedbehindindeveloping regulatoryframeworksthataddresstheindustry,andmanyofthesecountriesare developing,andill-preparedforthechallengesthataglobalindustrylikemedicaltourism posestotheirownhealthsystemsandlegalregulations.InthiscasestudyofCostaRica,

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177 theprivatesectorwasseenasmovingatamuchfasterpacethantheCostaRican government,whichdidlittletoregulatethemedicaltourismindustrybeyondensuring thatnationalstandardsforhealthfacilitieswerecompliedwith.Thequoteatthestartof thissectionillustratesthewaythattheCostaRicangovernmentisperceivedtodealwith itsproblems,usingtweezerstomakesmallcorrectionsinsteadofgettingtotheroot cause. AsmedicaltourismexpandsratherrapidlyinCostaRica,itislikelythatthese smallcorrectionswillcometoolate,aftertheindustryhasalreadydoneirreversible damagetothepublicprovisionofhealthcare.Institutingfirmerregulationofthe industry,orformalizingpathwaysinwhichtheprivatesectorisrequiredtogivebackto theCajamayhelptoalleviatesomeoftheburden,butgiventhattheprivatesectors primarymotivationisprofit,itisunlikelythattherewillbesubstantialvoluntary contributiontotheprovisionofpublichealthcareinCostaRica.Thepopularbeliefthat thattheprivatesectorisnotdetractingfromcarewithintheCaja,furtherinhibitsany formalregulationinwhichtheprivatesectorwouldbeobligatedtocontributetopublic healthcare. Medicaltourismisunlikelytodisappearanytimesoonand,inalllikelihood,will continuetogrow.Anyregulationthatatleastattemptstomaximizeitsbenefitsand reduceitsharmswouldbeastepintherightdirection.Market-basedreformsintheform ofSAPsandFreeTradeAgreementshavealreadyproventhattheyaredestructivetothe socialhealthcaresystemofCostaRica.Unregulatedmedicaltourismalongsidethe socializedsystem,especiallyasstate-runindustriesareopenedtotheglobalmarket,has thepotentialtobeextremelydetrimentaltoCostaRicaspublicsystem.

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178 CONCLUSION Medicaltourismrepresentsanewconfigurationofhealthcareprovisionina globalworldandhasmanypotentialimplicationsforthewaythathealthcareisprovided andconceptualizedindestinationcountries.Inthinkingaboutmedicaltourism,itmustbe notedthatthispracticeexistspreciselybecausetherearesignificantinequitiesbetween sendingandreceivingnations.Medicaltourismoccursacrosslinesofeconomicand socialclassdivisions,andinfactdependsuponthesedivisionsaswellasentrenched inequalitieswithinandbetweennationsforitsprosperity.Rationalizationsofmedical tourismoftenignorethepowerrelationsthatmakethisindustrypossible.Thepolitical economyperspectiveusedinthisstudyhelpstohighlighttheseglobalconnectionsand inequitiesandtodrawattentiontothecontradictionsthattheindustryrepresents. Atthemoment,medicaltourismisoperatedasabusiness,takingfromtheCosta Ricannationalhealthcaresystemwithoutgivingtoit.Thereisverylittlebenefittothe publicsystem,andinfact,thereisrealpotentialforharm.Beyonditsramificationsin drawingresourcesawayfrompublichealthcare,itisalsoimpactingthewaythathealth careisconceptualized,asnewideologicalencountersaroundhealthandhealthcare provisionareinitiated. Recentanthropologicalworkhaspromotedthedevelopmentofananthropology ofpolicy(e.gCastroandSinger2004;HortonandLamphere2006;ShoreandWright 1997)thatencouragesanthropologiststoweighinonpublicdiscoursesurrounding pressinghealthandsocialissues.Beyondmerelydocumentingtherelationshipbetween globalandlocalconfigurationsofhealthcare,theseperspectiveschallengeanthropology tobemoreinvolvedinhealthpolicyissuesthataretoooftenrelegatedtoarealmoutside

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179 ofthediscipline,wherehealtheconomistsholdhegemonicinfluence(Hortonand Lamphere2006).Thisresearchattemptstouncoverthecontextofhealthpoliciesthat encasemedicaltourism;policiesthatareshapedbyanumberoffactors,onlyoneof which,andsometimestheleastofwhichisaconcernwithpublichealth(Castroand Singer2004:xiii). Inordertomaximizethebenefitsandreducethenegativeimpactsofmedical tourism,itisimportanttoconsiderregulatorymeasuresandoversightoftheindustry. Thesemeasuresshouldensuresociallyresponsiblepracticesthatsustainthehealthcare achievementsthatCostaRicahasmadeinthepastcentury,ratherthandismantlethem. Examplesofsuchregulationcouldincludespecialtaxationonmedicaltourism, channelingapercentageofprofitsdirectlyintothepublichealthsector,monitoringand regulatinghumanresourceneedsandtheabilityofphysicianstomovefreelybetweenthe twosectors,requiringtheprivatesectortocontributetothetrainingofphysiciansthrough theCaja,orutilizingprivatesectorresourcestoeasethecurrentburdenonthepublic sector,whichprovidesforCostaRicans. Tothisend,morecriticalattentionisneededonthepracticeofmedicaltourism andthewaysinwhichitinteractswithandimpactsexistinghealthsystemsindestination countries.Particularlyforunderrepresentedpopulations,socialscienceresearchhasan obligationtoserveasacounter-voicetothehegemonicneoliberaldiscussionsthatare takingplacearoundmedicaltourisminthedevelopedworld.Amidstalloftheupbeat accountsofmedicaltourisminthemediaandpraiseforitspossibilities,thepotential harmsarewhatneedmoreresearchandattention.Powerfulstakeholdersintheindustry havemadetheirvoiceheard,butlocalsindestinationcountrieshavenotyethadthat

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180 chance.Ethnographicperspectivesareanimportantmeanstobringtolightlocal worldsthatareoftenovershadowedbypowerfulindustries.Thisresearchismeanttobe astepinthisdirection,voicingtheconcernsandexperiencesoflocalCostaRicansto broadenunderstandingoftheeffectsofmedicaltourismonlocalhealthsystemsand perceptionsofhealthcare. Anthropologyhasanimportantroletoplayingeneratingdetaileddatafrom specificlocalesthatcanbeusedbyprogramplannersandpolicymakersastheydesign programstotakeadvantagesofthebenefitsofmedicaltravelandaddressthe disadvantagescreatedbythisactivity.

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181 WORKSCITED Abada-Barrero,Csar 2012TheColombiaHealthCareReform:A"LivingLaboratory"ofGlobal Capitalism?SMA"TakeaStand"Statement:HealthInsuranceReform.March29, 2012. http://medanthro.net/research/cagh/insurancestatements/ Ackerman,Sara 2009OperatinginEden:CosmeticSurgeryTourismandthePoliticsofPublic andPrivateMedicineinCostaRica,DepartmentofAnthropology,Universityof NorthCarolina. 2010PlasticParadise:TransformingBodiesandSelvesinCostaRica's CosmeticSurgeryTourismIndustry.MedicalAnthropology29(4):403-423. AreadeTurismoReceptor 2009Nmero,PorcentajeYVariacinPorcentualDeLaCantidadDeViajeros QueLlegaronaCostaRicaPorVaereaPorMotivoDeSaludSegnAo. Aizura,ArenZ. 2010FeminineTransformations:GenderReassignmentSurgicalTourismin Thailand.MedicalAnthropology29(4):424-443. Aliano,David 2007CuringtheIllsofCentralAmerica:TheUnitedFruitCompany'sMedical DepartmentandCorporateAmer. In EstudiosInterdisciplinariosdeAmerica LatinayelCaribe:GraduateCenterofCUNY. AmericanMedicalAssociation 2008GuidelinesonMedicalTourism. www.amaassn.org/ama1/pub/upload/mm/31/medicaltourism.pdf Appadurai,Arjun 1991GlobalEthnoscapes:NotesandQueriesforaTransnationalAnthropology. In RecapturingAnthropology:WorkinginthePresent.R.G.Fox,ed.SantaFe: AmericanSchoolofResearchPress. Arbol,J. 2009CostaRicanEx-PresidentConvictedinHistoricalTrial.NowPublic. October6,2009. http://www.nowpublic.com/world/costa-rican-ex-presidentconvicted-historic-trial Arce,Sergio 2011aClnicasYHospitalesPrivadosCrecenEnElreaMetropolitana.La Nacion.October20,2011. http://www.nacion.com/2011-10-

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182 20/Economia/clinicas-y-hospitales-privados-crecen--en-el---area-metropolitana-.aspx 2011bCostaRicaIntentaAtraerAlTurismoMdicoCorporativo.LaNacion. May3,2011. http://www.nacion.com/2011-0503/Economia/NotasSecundarias/Economia2765557.aspx Arguedas,Jeffrey 2009CreceElTurismoDeSaludEnCostaRica.ImpreZona.May2,2009. http://www.impre.com/imprezona/2009/2/5/crece-el-turismo-de-salud-en-c107477-1.html Armada,Francisco,andCarlesMuntaneer 2004TheVisibleFistoftheMarket:HealthReformsinLatinAmerica.. In UnhealthyHealthPolicy:ACriticalAnthropologicalExamination.A.Castroand M.Singer,eds.Pp.29-40.walnutCreek,CA:AltamiraPress. Arsonheart 2006CostaRicaDice:NoAlTlc.MarchaContraElTlc,SanJosCostaRica, Octubre23,2006. http://www.youtube.com/watch?v=IbWXYxuWO4&feature=related Assembly,ColoradoGeneral 2007Bill07-1143. http://www.leg.state.co.us/CLICS/CLICS2007A/csl.nsf/BillFoldersAll?OpenFra meSet Bajgrowicz,Scotty 2010MedicalTourism:AVacationfromtheRealityofHigh-CostHealthcare. MedillReports.June8,2010. http://news.medill.northwestern.edu/WorkArea/linkit.aspx?LinkIdentifier=id&Ite mID=155917 Biehl,Joao 2006PharmaceuticalGovernance. In GlobalPharmaceuticals:Ethics,Markets, Practices.A.Petryna,A.Lakoff,andA.Kleinman,eds.Pp.206-249.Durham: DukeUniversityPress. 2007Pharmaceuticalization:AidsTreatmentandGlobalHealthPolitics. AnthropologicalQuarterly80(4):1083-1126. Biesanz,MavisHiltunen,etal. 1998TheTicos:CultureandSocialChangeinCostaRica:LynneRienner Publishers.

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183 Blyth,Eric,andAbigailFarrand 2005ReproductiveTourism:APriceWorthPayingforReproductive Autonomy?.CriticalSocialPolicy25(1):91-114. Bookman,Milica,andKarlaBookman 2007MedicalTourisminDevelopingCountries.NewYork,NY:Palgrave Macmillan. Brenes,CesarQuiros 2011TurismoMedicoDaFuertesLatidos:IndustriaVinculaUnas600 EmpresasUGener$288MillonesEn2010.ElFinanciero.June26,2011. http://www.elfinancierocr.com/ef_archivo/2011/junio/26/enportada2813943.html Brotherton,PierreSean 2003ThePragmaticState:SocialistHealthPolicy,StatePower,andIndividual BodilyPracticesinHavana,Cuba,Anthropology,McGillUniversity. 2005MacroeconomicChangeandtheBiopoliticsofHealthinCubasSpecial Period.JournalofLatinAmericanAnthropology10(2):339-369. 2008WeHavetoThinkLikeCapitalistsbutContinueBeingSocialists: MedicalizedSubjectivities,EmergentCapital,andSocialistEntrepreneursinPostSovietCuba.AmericanEthnologist35(2):259-274. BumrungradInternationalHospital 2012BumrungradInternationalHospital. http://www.bumrungrad.com/thailandhospital BureauofWesternHempisphereAffairs 2011BackgroundNote:CostaRica. www.state.gov/r/pa/ei/bgn/2019.htm#econ Carroll,Rory 2010CostaRicanHealthMinistryBansExperimentalStemCellTreatment. Guardian(UK).June7,2010. http://www.guardian.co.uk/world/2010/jun/07/costa-rica-stem-cell-treatment Castro,Arachu,andMerrillSinger,eds. 2004UnhealthyHealthPolicy:ACriticalAnthropologicalExamination.Walnut Creek,CA:AltaMiraPress. CCSS 2004ReglamentoQueRegulaLaFormacinDeEspecialistasEnCiencias MedicasDeLaCajaCostarricenseDeSeguroSocialEnLasUnidadesDocentes Autorizadas.L.J.D.d.l.C.C.d.S.Social,ed,Vol.171.SanJos:DiarioOficialLa Gaceta.

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190 Murray,Sarah 2009TravelSickness.FinancialTimes.December7,2009. http://www.ft.com/intl/cms/s/0/6b1f8380-dd54-11de-ad6000144feabdc0.html#axzz1oeRWbzkh Nader,Laura 1974UptheAnthropologist-PerspectivesGainedfromStudyingUp. In ReinventingAnthropology.D.Hymes,ed.Pp.284-311.NewYork:Vintage Books. NaRanong,Anchana,andVirojNaRanong 2011TheEffectsofMedicalTourism:Thailand'sExperience.Bulletinofthe WorldHealthOrganization89:336-344. Navarro,Vicente 1998WhoseGlobalization?AmericanJournalofPublicHealth88(5):742-743. 2007TheWorldHealthSituation. In Neoliberalism,Globalizationand Inequalities:ConsequencesforHealthandQualityofLife.V.Navarro,ed.Pp. 203-212.Amityville,NY:BaywoodPublishing. Neely,Elizabeth 2009ChronicHipPain?HipReplacementorHipResurfacingOverseasMayBe YourAnswer.ArticlesBase.April21,2009. http://www.articlesbase.com/healtharticles/chronic-hip-pain-hip-replacement-or-hip-resurfacing-overseas-may-beyour-answer-878703.html Noauthor 2007LaunchoftheMedicalTourismAssociation.PrivateHealthcareUK. August5,2007. http://www.privatehealth.co.uk/news/august-2007/medicaltourism-association-171/ Nordstrom,Carolyn 2007GlobalOutlaws:Crime,Money,andPowerintheContemporaryWorld. Berkeley:UniversityofCaliforniaPress. NotiCen 2007CostaRica'sProtractedProcessExposesCafta'sManyProblems.Central American&CaribbeanAffairs.January25,2007. http://www.allbusiness.com/caribbean/3991489-1.html Ordoez,Jaime 2007CostaRica:SteadilyComingClosertoCentralAmerica.SanJos,Costa Rica:RealInstitutoElcano. Ormond,Meghann

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191 2011MedicalTourism,MedicalExile:RespondingtotheCross-BorderPursuit ofHealthcareinMalaysia. In RealTourism:Practice,CareandPoliticsin ContemporaryTravel.C.MincaandT.Oakes,eds.London:Routledge. Palmer,Steven 2003FromPopularMedicinetoMedicalPopulism:Doctors,Healers,and PublicPowerinCostaRica,1800-1940.Durham,NC:DukeUniversityPress. Parke,S.,etal. 2010StemCellTourismandSpinalCordInjury:Perspectivesfromthe AdvocacyCommunity.InternationalConferenceonEthicalIssuesinMedical Tourism,Vancouver,BC. Pennings,Guido 2002ReproductiveTourismasMoralPluralisminMotion.JournalofMedical Ethics28(6):337. Petryna,Adriana 2009WhenExperimentsTravel:ClinicalTrialsandtheGlobalSearchfor HumanSubjects.Princeton:PrincetonUniversityPress. 2011PharmaceuticalsandtheRighttoHealth.AnthropologicalQuarterly 84(2):305-330. PROMED 2010ElTurismoDeSalud. http://www.acoprot.org/files/El_Turismo_de_Salud.doc .. Ratner,Caroline 2009WhoOwnsMedicalTourism?ReactiontotheMtaV.ImtaLegalAction. InternationalMedicalTravelJournal.February10,2009. http://www.imtjonline.com/articles/2009/mta-v-imta-legal-action-30018/ Robinson,William 2003TransnationalConflicts:CentralAmerica,SocialChangeand Globalization.LondonandNewYork:Verso. Rose,Nikolas 1999PowersofFreedom:ReframingPoliticalThought.Boston:Cambridge UniversityPress. Salas,KarinaValverde 2009PrivatizacinDeServiciosMdicosEnCostaRica,Sociology,University ofCostaRica. Scheper-Hughes,Nancy

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192 2002TheEndsoftheBody:CommodityFetishismandtheGlobalTrafficin Organs.SAISReview22(1):61-80. Scheper-Hughes,Nancy,andMargaretLock 1987TheMindfulBody:AProlegomenontoFutureWorkinMedical Anthropology.MedicalAnthropologyQuarterly1(1):6-41. Scott,James 1998SeeingLikeaState:HowCertainSchemestoImprovetheHuman ConditionHaveFailed.NewHaven:YaleUniversity. Seligson,M. 2002TroubleinParadise?TheErosionofSystemSupportinCostaRica, 19781999.LatinAmericanResearchReview27(1):160185. Sethna,Christabelle,andMarionDoull 2010AccidentalTourists:Women,MedicalTourismandAbortionTourism InternationalConferenceonEthicalIssuesinMedicalTourism,Vancouver,BC. Shaffer,EllenR.,etal. 2005HealthPolicyandEthics:GlobalTradeinPublicHealth.American JournalofPublicHealth95(1):23-34. Shore,Cris,andSusanWright 1997AnthropologyofPolicy:CriticalPerspectivesonGovernanceandPower. London:RouteledgePress. Soares,Rodrigo 2009LifeExpectancyandWelfareinLatinAmericaandtheCaribbean.Health Economics18(S1):S37-S54. Sobo,Elisa,etal. 2011SellingMedicalTraveltoUsPatient-Consumers:TheCulturalAppealof WebsiteMarketingMessages.Anthropology&Medicine18(1):119-136. Song,Priscilla 2010BiotechPilgrimsandtheTransnationalQuestforStemCellCures. MedicalAnthropology29(4):384-402. Speier,AmyR. 2011HealthTourisminaCzechHealthSpa.Anthropology&Medicine 18(1):55-66. Stephano,Rene-Marie 2009BigBrothersandLittleSisters.MedicalTourismMagazine. http://www.medicaltourismmag.com/article/big-brothers.html Taborda,Leonardo

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193 2011CostaRicaPromotingItselfasaMedicalTourismDestination. http://www.promedcostarica.com/blog/?p=135 Tatko-Peterson 2006TakingaVacationtoHaveanOperation:ForeignMedicalCareFillingthe GapforSome.U-TSanDiego.October11,2006. http://www.signonsandiego.com/uniontrib/20061011/news_1n11medtour.html Tllez,Rommel 2011CostaRica'sPublicHealthSysteminCriticalCondition.TicoTimes. April15,2011. http://www.ticotimes.net/Current-Edition/Top-Story/News/CostaRica-s-public-health-system-in-critical-condition_Friday-April-15-2011 ThirdWorldNetwork 2007ReferendumHeldinCostaRicaonItsUsFreeTradeAgreementThird WorldNetwork.October9,2007. http://www.twnside.org.sg/title2/FTAs/info.service/fta.info.service112.htm Thomas,George 2010MedicalTourisminIndia:PrivateProfit,PublicPain.International ConferenceonEthicsinMedicalTourism,Vancouver,BC. Turner,Leigh 2007"FirstWorldHealthCareatThirdWorldPrices""Globalization, Bioethics,andMedicalTourism.Biosocieties2:303-325. Turshen,Meredith 1999PrivatizingHealthServicesinAfrica.NewBrunswick:RutgersUniversity Press. Underwood,Ed 2005ToYourHealth:MedicineinCostaRica.CompleteCostaRica. http://www.cocori.com/library/life/med1.htm Unger,Jean-Pierre,etal. 2007CostaRica:AchievementsofaHeterodoxHealthPolicy.American journalofpublichealth98(4):636-43. UniversityofCostaRica 2006EncuestaNacionalDeSalud(Ensa).UniversityofCostaRica. 2012UniversityofCostaRica. www.ucr.ac.cr Unti,James

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194 2009MedicalandSurgicalTourism:TheNewWorldofHealthCare GlobalizationandWhatItMeansforthePracticingSurgeon.Bulletinofthe AmericanCollegeofSurgeons94(4):18-25. VargasSols,LuisPaulino 2004TlcConEstadosUnidos,CaerTroya? In TlcConEstadosUnidos: ContribucionesParaElDebate.M.Flrez-EstradaandGerardoHernndez,eds. Pp.347-376.SanJos:InstitutodeInvestigacionesSociales,Universidadde CostaRica. Venkatachalan,Deepa,etal. 2010TheBusinessofMakingBabiesforProfitatHomeandAbroad InternationalConferenceonEthicalIssuesinMedicalTourism,Vancouver,BC, 2010. Vincent,Isabel 2004ForCubans,aBitterPill.NationalPost,July7,2004. Waitzkin,Howard,etal. 2001SocialMedicineThenandNow:LessonsFomLatinAmerica.American JournalofPublicHealth91(10):1592-1601. WestVirginiaGeneralAssembly 2007GeneralAssemblyBill2841. http://www.legis.state.wv.us/Bill_Text_HTML/2007_SESSIONS/RS/BILLS/hb2 841%20intr.htm Whittaker,AndreaandAmySpeier 2010a"CyclingOverseas":Care,Commodification,andStratificationinCrossBorderReproductiveTravel.MedicalAnthropology29(4):363-383. Whittaker,Andrea,LenoreManderson,andElizabethCartwright 2010bPatientswithoutBorders:UnderstandingMedicalTravel..Medical Anthropology29(4):336-343. Williams,Adam 2011Oppenheimer:WhyIsLatinAmericaFailing?TicoTimes.November11, 2011. http://www.ticotimes.net/Business/Oppenheimer-Why-is-Latin-Americafailing-_Friday-November-11-2011 Wilson,Ara 2010MedicalTourisminThailand. In AsianBiotech:EthicsandCommunities ofFate.A.OngandN.Chen,eds.Durham,NC:DukeUniversityPress. Woodbridge,Jorge n.d.UnClsterMdicoEnCostaRica:Oportunidades,EstrategiasY Compromisos".

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195 WorldBank 2003ImplementationCompletionReport(Cpl36540)onaLoanintheAmount of$Us22MilliontotheRepublicofCostaRicaforaHealthSectorReform Project. 2012DatabyCountry:CostaRica. http://data.worldbank.org/country/costa-rica WorldHealthOrganization 2000TheWorldHealthReport2000-HealthSystems:ImprovingPerformance. Youngman,Ian 2009MedicalTourismStatistics:WhyMckinseyHasGotItWrong.IMTJ. September13,2009. http://www.imtjonline.com/articles/2009/mckinsey-wrongmedical-travel/

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196 APPENDIXA:EXAMPLEINTERVIEWGUIDE 26 InterviewGuideforPhysiciansandNurses ThankyouforagreeingtotalktomesothatIcanbetterunderstandwhatyouandyour clinic/hospital/companydo,andalittlemoreaboutmedicaltourismandhowitoperates hereinCostaRica,andyouropinionsaboutit. ThisresearchisfundedbytheNationalScienceFoundationoftheUnitedStates,andthe WennerGrenFoundation.ItispartofadissertationprojectinHealthandBehavioral SciencesandmedicalanthropologyattheUniversityofColoradoDenver.Thegoalof thisresearchistounderstandhowmedicaltourismoperatesinCostaRica,interaction betweenthemedicaltourismindustryandthepublichealthsystemandgovernmentin CostaRica,opinionsaboutmedicaltourism,andwhatimpact,ifany,itishavingonthe healthsystemandaccesstohealthcareinCostaRica. Yourinterviewwillbeoneofapproximately50-60interviews.Itwilllastuptoanhour andberecorded.Whatyousaywillbekeptanonymous,andyournameaswellasthe nameofyourhospital,clinic,orcompanywillnotbeusedinthewrite-upofthis research. Aswemeettoday,IhavearangeofquestionsI'dliketoaskyouaboutyourexperiences inthehealthcaresectorinCostaRica,andyouropinionsandperceptionsoftheheath systeminCostaRicaandofmedicaltourism.Ifatanytimeyouhavequestionsplease askme,orifyouwanttostopforanyreasonpleaseletmeknow. IsitallrightifItaperecordthisinterview? EmploymentandBackground Canyoutellmewhatyourpositionishereatthehospital/clinic? Howlonghaveyoubeenworkinghere? Howdidyougetinvolvedwiththiswork? Whatisyouremploymentbackgroundandeducation? Haveyouworkedinthepublicorprivatesector?Orboth? Whatisyourmedicalspecialization? Knowledgeof/Involvementwithmedicaltourism: Doyouhaveanyinvolvementwithmedicaltourism? Ifno 26 Intotal,Iusedeightdifferentinterviewguidesdependingontheparticipantsposition.Thisis anexampleofaguidethatwasusedwithphysiciansandnurses,translatedintoEnglish.

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197 Whatdoyouknowaboutmedicaltourismingeneral?InCostaRica? Whatisyouropinionofmedicaltourism? Wouldyouwanttobeinvolvedinmedicaltourism?Why/whynot? Ifyes WhatisyourinvolvementwithmedicaltourisminCostaRica? Howdidyougetinvolved? Doanymedicaltouristscomehere?Ifyes Howmany? Fromwhere? Forwhichprocedures? Istheredatacollected? Howdoyouattractmedicaltourists? WhataretheorganizationsthatyouworkwithregardingmedicaltourismhereinCosta Rica? Internationalorganizationsorassociations(MTA)? Facilitatorcompanies(specificallywhichones)? Governmentorganizations? Insurancecompanies? Anyothers? Whatistherelationshipbetweenyourhospital/clinicandtheseorganizations? Dophysiciansneedanyspecialskillsortrainingtoworkwithmedicaltourists? Dodoctorswhoworkinmedicaltourismneedmalpracticeinsurance? Generalinformationabouthospital/clinic: Whatkindofpatientsutilizeyouroffice/hospitalthemost?(Ageneralprofile) Ifforeign,wheredotheycomefrom? Whatarethemostcommonproceduresorsurgeriespatientsreceivehere? Isthisdatacollected? RelationshipbetweenPublicandPrivateSector Whydidyouchoosetopracticeinthepublic/privatesector?

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198 Whatdoyouthinkthegeneraldifferencesareforaphysicianworkinginthepublic versustheprivatesector? Salarydifferences? Employmentbenefits? Patientvolume(howmanypatientstheytreat)? Workingenvironment(bettertechnology?Nicerfacilities?Calmer environment?) Qualityofcare? Prestige--whichoneisconsideredmoreprestigious?Why? Doyouhaveanideaofwhatthesalaryrangeofphysiciansintheprivateversusthe publicsector? Asaphysician,doyouthinkitmoreattractivetopracticeinthepublicorprivatesector? Why? Whataboutphysicianswhotreatmedicaltourists?Whataretheadvantages/ disadvantages? Doyouthinkthereissufficientmotivationforphysicianstopracticeinthepublic sector? TheHealthSysteminCostaRica: WhatisyourgeneralopinionofthehealthcaresystemhereinCostaRica? WhatdoyouthinkarethemostpositiveandnegativeaspectsoftheCostaRicanhealth caresystem? Doyouusethepublicorprivatehealthsectorforyourhealthcare?Why? Haveyouhadanyparticularlypositiveornegativepersonalexperienceswithhealth careinCostaRicathatyoucantellmeabout? Whatdoyouthinktherolesandresponsibilitiesofthepublicandprivatehealthcare sectorsare?Howaretheydifferent? Doyouthinkthatprivatehospitalsandclinicsshouldpromotemedicaltourism?Why orwhynot? Inwhatwaysdoyouthinkthegovernmentisinvolvedinmedicaltourism? Inwhatwaysdoyouthinkthegovernment should beinvolved? Doyouthinkthatthegovernmentshouldpromotemedicaltourism?Whyor whynot? Whatdoyouthinkagovernmentsresponsibilityiswithregardtohealthcareforits citizens?Whatistheroleoftheprivatesector?

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199 Doyouthinkthatprivatehealthcareandmedicaltourism,aseconomicactivities,fit withthehealthcareideologyinCostaRicaandCajasprinciplesofuniversality, solidarity&equity? ImpactofMedicalTourism Wheredoyouthinktheprofitsfrommedicaltourismgo?Whereshouldtheygo? Ingeneral,whatdoyouthinktheadvantagesorbenefitsofmedicaltourismarefor CostaRica? Arethereanydirectbenefitstothehealthcaresystem? Probes Argumentsabouthowit could havepositiveimpact: Increasednationaltourismrevenue? Improvementstoinfrastructure? Physiciantraining? Newtechnologies? Betterstandardsofcare? Newphysicianspecialties? KeepingphysiciansinCostaRica? Ingeneral,whatarethedisadvantagesornegativeeffectsofmedicaltourism? DoyouthinkfocusingonmedicaltourisminCostaRicahasanynegativeimpactonthe publichealthcareforCostaRicans? Probes Argumentsabouthowit could havenegativeimpact: Isitcausingphysicianstospecializeinthingsthatarenotimportantfor localpopulations?(i.e.plasticsurgery/weightlosssurgeries) Isitdrawingattentionawayfromprimaryhealthcaretomore specializedprocedures? Isitdrawingphysiciansoutofthepublicsector? Isitcreatingasplithealthcaresystemwherethewealthyandforeigners getonekindofcareandotherCostaRicansanother? Future: WhatdoyouthinkthefutureofmedicaltourismwillbehereinCostaRica?Doyou thinkitwillcontinuetogrow? WhatdoyouthinkthefocusoftheCostaRicanhealthsystemshouldbemovinginto thefuture?(i.e.,shouldtherebeafocusonprimarycareoronnewhealthtechnologies andtertiarycare?) Isthereanythingelsethatwedidnotaskthatyouwouldliketoadd?Anyadditional comments? ***THANKYOUFORPARTICIPATING***

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200 Follow-Up: Dotheyknowanyoneelsewecouldcontactforaninterview? DotheyknowofanydatathatisavailableinCostaRicaonmedicaltourism? Isthereanydataavailableattheirhospital/clinicwecouldlookat? -Numbersofpatients,procedurestheycomefor,demographics(age,wherethey arefrom,etc.),physicianspecialtiesandproceduresperformed?Whererevenuesgo? Possibletotourfacility? Canwedistributesurveystopatientsattheirfacility?

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201 APPENDIXB:SURVEYGUIDE Buenosdas/Buenastardes MinombreesCourtneyLee,soydelaUniversidaddeColorado.Estoyaplicandounos cuestionariosconrespectoasusopinionessobreelsistemacostarricensedesalud.Mi asistenteestconmigo,ellasellamaSilviaRomeroyesdelaUniversidaddeCostaRica. SolicitamoselpermisoalHospitalolaclinicaparahacerestetrabajo.Ningunarespuesta escorrectaoincorrectayesabsolutamenteconfidencial. Encuesta 1. Profesin/trabajo: 2. readndevive: 3. Salariomensual(aproximado): Menosde150.000colonespormes Entre150.000y250.000colonespormes Entre250.000y500.000colonespormes Entre500.000y750.000colonespormes Msde750.000colonespormes Cualquiercomentario: SISTEMADESALUDCOSTARRICENSE 4. Engeneral,culessuopinindelsistemadesaludenCostaRica?Tomandoen cuentatantoelsectorpblicocomoelprivado. Excelente,nonecesitaningncambio Muybueno Bueno Promedio,necesitaalgunasmejoras Muymalo,necesitamuchasmejoras Cualquiercomentario: 5. Enunao,qutantousalosserviciosdeLaCaja? Msde20vecesporao 6-10vecesporao 16-20vecesporao Menosde5vecesporao 11-15vecesporao

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202 Cualquiercomentario: 6. Qutantousalosserviciosdesaludprivadosoparticulares? Msde20vecesporao 6-10vecesporao 16-20vecesporao Menosde5vecesporao 11-15vecesporao Cualquiercomentario: 7. CundousalosserviciosdeLaCajaycundousalosserviciosprivadosypor qu? 8. CulessuopinindelosserviciosdeLaCajaenlassiguientesreas? Cualquiercomentario:

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203 9. Culessuopinindelosserviciosprivadosoparticularesenlassiguientes reas? Cualquiercomentario: 10. CulesconsideraquesonlosaspectosmspositivosdeLaCajaparaCostaRica? 11. CulesconsideraquesonlosaspectosmsnegativosdeLaCajaparaCosta Rica? 12. Culesconsideraquesonlosbeneficiosdeldesarrollodelamedicinaprivada paraCostaRica?

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204 13. Culesconsideraquesonlasdesventajasdeldesarrollodelamedicinaprivada paraCostaRica? 14. Quinesmsresponsableconrespectoalasaluddeloscostarricenses? LaCaja Elsectorprivado Ambos,igualmente Personasindividuales Otro: 15. CreeustedqueCostaRicadebedaratencinmdicaalosturistasmdicosque vienenaCostaRicapararecibiratencinmdica? Si No Nos Cualquiercomentario: 16. CulessonlasventajasobeneficiosdelturismomdicoparaCostaRica? 17. CulessonlasdesventajasoimpactosnegativosdelturismomdicoparaCosta Rica? Muchasgracias!

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205 APPENDIXC:PARTICIPANTLIST Transcript#ParticipantDescriptionLocationofInterview 1 AdministratorofamedicaltourismassociationUnitedStates(phone) 2 AdministratorofamedicaltourismassociationUnitedStates(phone) 3 RegionalcoordinatorofamedicaltourismassociaionSanJos,CostaRica 4 MedicaltourismfacilitatorSanJos,CostaRica 5 AcademicSanJos,CostaRica 6 PrivatehospitaladministratorSanJos,CostaRica 7 CajaphysicianandacademicSanJos,CostaRica 8 Cajaex-administratorandphysicianSanJos,CostaRica 9 PrivatesectorphysicianSanJos,CostaRica 10 PrivatesectorphysicianSanJos,CostaRica 11 MinistryofHealthofficialSanJos,CostaRica 12 PrivatehospitaladministratorSanJos,CostaRica 13 MinistryofHealthofficialSanJos,CostaRica 14 AcademicSanJos,CostaRica 15 PrivatesectorphysicianSanJos,CostaRica 16 MinistryofCompetitivenessofficialSanJos,CostaRica 17 Privatehospitalex-administratorSanJos,CostaRica 18 PrivatehospitaladministratorSanJos,CostaRica 19 Privatesectorphysician(assistantwaspresentaswell)SanJos,CostaRica 20 CajaandprivatesectorphysicianSanJos,CostaRica 21 PrivatesectorphysicianSanJos,CostaRica 22 AcademicSanJos,CostaRica 23 CajaphysicianSanJos,CostaRica 24 PanAmericanHealthOrganizationofficialSanJos,CostaRica 25 PrivatesectorphysicianSanJos,CostaRica 26 CajaandprivatesectorphysicianSanJos,CostaRica 27 PROCOMER(ForeignTradeAgency)officialSanJos,CostaRica 28 Privatesectorphysician,retiredfromCajaSanJos,CostaRica 29 Privatesectorphysician,retiredfromCajaSanJos,CostaRica 30 CajaandprivatesectorphysicianSanJos,CostaRica 31 PrivatesectorphysicianSanJos,CostaRica 32 CajaandprivatesectorphysicianSanJos,CostaRica 33 CajaandprivatesectorphysicianSanJos,CostaRica 34 PrivatesectorphysicianSanJos,CostaRica 35 MedicaltourismfacilitatorandprivatesectorphysicianSanJos,CostaRica 36 MedicalresidentandCajaphysicianSanJos,CostaRica 37 Groupinterviewwith3medicalresidents/CajaphysiciansSanJos,CostaRica 38 CajaandprivatesectorphysicianSanJos,CostaRica 39 AcademicSanJos,CostaRica 40 PrivatehospitaladministratorSanJos,CostaRica 41 CajanurseSanJos,CostaRica

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206 42 CajahospitaladministratorandphysicianSanJos,CostaRica 43 Groupinterviewwith3medicalstudentsSanJos,CostaRica 44 CajanurseSanJos,CostaRica 45 CajahospitaladministratorandphysicianSanJos,CostaRica 46 CajaphysicianSanJos,CostaRica 47 CajaphysicianataCooperativeSanJos,CostaRica 48 MedicaltourismresearcherandacademicUnitedStates(phone) **Transcript#37and#43eachhadthreeparticipants,andonewaspresentatbothinterviews.Transcript #14wasofafollow-upinterviewwiththesameparticipantas#4.Removingduplicateparticipantsand addingtheadditionalparticipantsfromthegroupinterviews,thetotalparticipantnumberis50.