COSMETIC TOURISM Kelly A. Harrison School of Hospitality & Tourism Management University of Guelph ABSTRACT Societies shallow perceptions of beauty have been increasingly facilitated through media exposure. Beautification, and the constant strive for physical perfection has made way for a new form of tourism, cosmetic tourism. As a subsector of medical tourism, cosmetic tourism is travelling abroad for the sole purpose of obtaining cosmetic surgery, most commonly at a discounted price. Safety issues and a general lack of industry knowledge are top concerns for potential candidates, but can be improved though the appeal of discounted cosmetic procedures combined with a relaxing and restorative holiday has made cosmetic tourism an increasingly sought after form of tourism. Keywords: cosmetic tourism, medical tourism, cosmetic surgery, healthcare Introduction It is the unfortunate truth, but society has become increasingly persuaded by media brainwashing. Billboards, magazines, television commercials and many other forms of advertising have set standards for beauty that have relentlessly facilitated an unhealthy, superficial body image. But what happens when cosmetic products, new diets, and trendy clothing are just not cutting it? The mainstreamed societal standard of beauty has made way for a new type of tourism, cosmetic tourism. Cosmetic tourism, a subsector of medical tourism, involves travelling for the purpose of undergoing medical procedures for enhancing one’s physical appearance. Altering one’s physical appearance to mimic society’s perception of beauty is a very controversial issue; meanwhile undergoing a cosmetic procedure to better one’s quality is a separate issue. North American cosmetic procedures are amongst the highest in cost. Candidates that would otherwise not consider undergoing surgery are now considering cosmetic surgery in other countries due to the substantial decrease in cost. Europe, Asia, The Middle East, South America, Africa and the Caribbean are among the most popular dental & cosmetic tourism destinations according to the Medical Tourism Association (Medical Tourism Association, 2012). Prices can range from 20 percent to 70 percent less than North American prices (McLymont, 2010). A standard facelift in the U.S is approximately $15,000 compared to just $5,000 in Mexico, whereas breast implants ring in at about $10,000 on average compared to just $2,700 in Thailand (Medical Tourism Association, 2012). Although the primary reason for undergoing cosmetic surgery is to alter the physical appearance, this type of travel is most usually constructed as a restorative and relaxing experience (Bell, Holliday, Jones, Probyn & Taylor, 2011). Whether it is vacationing to Mexico for dental veneers or Thailand for a nose job, cosmetic tourism is definitely on the rise. Exact patient numbers and procedure statistics are hard to validate because cosmetic tourism is considered ‘Medical Tourism’ for the most part. However, in 2013 the medical tourism industry, including cosmetic; is projected to reach over $100 billion making it one of the fastest growing sectors of the health-care industry (McLymont, 2010). Realizing the market potential of cosmetic tourism, health insurance companies have began to partner with accredited hospitals to provide coverage and usually at a lower rate than traditional health insurance (McLymont, 2010). The credibility of the hospitals facilitating cosmetic procedures for international travelers is among the most important when considering surgery. For example, UK citizen, Claudia Aderotimi died in a Philadelphia hotel after receiving a ‘toxic’ buttock augmentation (Bell, Holliday, Jones, Probyn & Taylor, 2011); serving as proof that medical malpractice is not exclusive to solely ‘budget’ destinations. There are many horror stories about the danger associated with travelling abroad for cosmetic procedures, which could easily be a result of patients failing to conducts thorough industry research prior to travel. The Medical Tourism Association is an American non-profit organization comprised of top international hospitals, medical travel facilitators, healthcare providers, and insurance companies aimed at promoting the highest level of quality healthcare to patients in a global environment (Medical Tourism Association, 2012). Cost, quality, service, and access are all determining factors of choosing a cosmetic tourism destination (Bell, Holliday, Jones, Probyn & Taylor, 2011). As the industry expands, so does the degree of invasiveness of cosmetic procedures; therefore, it would be in the best interest of the patient to perform thorough research and make sure the hospital and practitioners are credible. Historic Perspective Cosmetic tourism may seem like a relatively new trend; however, travelling for the purpose of ‘health’ is not. The ancient construction of spa resorts in Rome and seaside sanatoriums most commonly associated with Victorians could be considered to have laid the foundation for modern European tourism (Bell, Holliday, Jones, Probyn & Taylor, 2011). From the majestic healing powers of hot springs in the West to the therapeutic, holistic alternatives popular in the East, medical tourism can be observed in many forms all over the world. Medical tourism has been defined as “a form of niche tourism, links leisure travel, the act of seeking fun, pleasure, relaxation and bodily escape from the stresses and strains of daily life, with purposeful escape to medical interventions, such as cardiac surgery, stem cell injections, organ and bone marrow transplants, body enhancements and dental care”(Buzinde & Yarnal, 2012). Initially only wealthier people could afford treatment overseas, however, the economies of scale theory has proven itself in the medical tourism industry as the consumption of cosmetic procedures increases. According to Jonathan Edelheit, Medical Tourism Association president, claims that “Medical Tourism is the only thing in health care that has hard dollar savings”, and that “if people actually start to use it, health care costs will start to go down”(Moody, 2007, p.114). For example, a heart bypass, not covered in the U.S will cost on average $144,000 as opposed to $27,000 in Mexico, a total cost savings of $117,000 on average (Medical Tourism Association, 2012). Initially medical tourism procedures were for the most part minor and only undertaken because they were excluded from traditional health insurance programs (Moody, 2007). Another attractive feature of medical tourism is the avoidance of long waiting periods, which is a common complaint in North America (Mclymont, 2010). Primarily in the U.S, waiting periods can be extremely lengthy and costly due to the lack of universal healthcare, and can adversely result in life-threatening circumstances for many critical patients. A reported excess of 45 million Americans are uninsured according to Moody (2007). Patients now have the availability to travel and receive medical attention abroad without remortgaging their house or claiming bankruptcy. Another attractive feature besides low surgical costs is the ease and affordability of airfare to many cosmetic tourism destinations. For example medical tourism facilities such as the Bumrungrad Hospital in Thailand have created packages targeted at medical tourists and have partnered with airline companies to offer reduced flight rates (Buzinde & Yarnal, 2012). The evolution of the rapidly growing medical tourism industry has sprouted the cosmetic subsector. In many developed countries more lenient vacation time, increasing salaries and a less focused ‘need’ based society have all made way for the new genre of medical tourism deemed cosmetic tourism. “In a media environment increasingly saturated with images and narratives of makeover and transformation, a cosmetic surgery makeover is becoming a prevalent fantasy and a growing reality, and in affluent societies, work on the body has now become a ‘project of the self’"(Bell et al, 2011, p.150). As perceptions of beauty have become a mainstreamed focus of society, cosmetic surgery is on the rise. A relaxing and restorative holiday experience combined with shorter wait periods and attractive pricing drives the demand for cosmetic tourism (Hall, 2011). For example, Rhinoplasty; more commonly known as a nose job, will ring in at roughly $8,000 in North America compared to just $4,500 in Costa Rica, a gross savings of 45% (Medical Tourism Association, 2012). A North American facelift procedure will cost on average $15,000, but travelling to India for the same procedure would cost around $4,000 on average, a 74% savings (Medical Tourism Association, 2012). Many popular destinations have realized the market potential for cosmetic tourism, several of whom officially recognize the industry as an export and receive government tax breaks (Bell et al, 2011). “Many governments, international agencies, private health providers and even some medical practitioners see it as a means of economic development that may cross-subsidize domestic health access” according to Hall (2011, p.9). Tourism is seen as an export for numerous countries; thus, the inflow of cosmetic tourism provides a source of much needed revenue for many local economies. Aside from the health care professionals involved in taking care of the patient, local restaurants, hotels, transportation, attractions, and local shops can also benefit from the increasing inflow of tourists due to cosmetic tourism. Bell suggests that “Such workers, and the economic and social processes in which they are implicated, are not incidental to the phenomenon of surgical holidays; they in part help to constitute it” (Bell et al, 2011, p. 145). The number of tourists seeking cosmetic makeovers has continued to expand rapidly in many parts of the developed world. It is estimated that over 500,000 Americans travelled abroad to receive medical treatment in 2006 (Moody, 2007). Travelling for the purpose of ‘health’ and well-being has been around for hundreds of years, however, in more recent years the medical tourism industry has experienced rapid growth especially in the cosmetic subsector (Bell et al, 2011). Breadth of Impact to Date Unfortunately travelling abroad for medical services has had some negative publicity. Horror stories of tourists having surgical procedures done by fraudulent and uncertified doctors have flooded the news. One horror story that surfaced was the case of a hospital on one of the Greek Islands forgetting to administer pre-operation medicine to pre-operational patients (Bell et al, 2011). One story about a woman who traveled to South America for a tummy tuck that went horribly wrong received so much attention that it aired on television. This woman experienced intense pain for several weeks, with multiple infected, open lacerations while the foreign surgeon refused to take responsibility for his botched surgical procedure. Quality of care and qualified medical practitioners are a common concern for hesitant adopters of cosmetic tourism. Many foreign health centers have achieved international accreditation from organizations such as the Medical Tourism Association and the Joint Commission International both of which rate and review foreign hospitals and healthcare centers for tourists. In order to avoid surgical complications abroad, potential candidates to conduct thorough research prior to traveling. As the cosmetic tourism sector develops further, the pool of available information for potential candidates is likely to expand in size and validity. It should be a top concern for tourism industry organizations to further research ‘accredited’ medical centers as well as preform audits on medical practitioners abroad to minimize medical malpractice. Having the procedure preformed at a recognizable hospital and ensuring the surgeon is a qualified professional can avoid horror stories such as the ones mentioned above. However, the candidate must realize that using non-accredited surgeons abroad may still be qualified, but may not necessarily have the quality of training North American and other well-developed countries provide. Increased bio-security becomes a concern for cosmetic tourism because patients deliberately travel to medical environments, which have the potential to expose themselves to new pathogens and microbiologic flora and fauna (Hall, 2011). Aside from the obvious health concerns associated with medical tourism lies a notso-evident socio-economic byproduct. Sadly, in many countries with a medical tourism industry, the treatment of foreign patients often comes before locals. If the medical center is privatized, then the surgeon is setting the price and booking their own appointments, resulting in the prioritization of patients with the highest willingness to pay. This can be seen in other forms of tourism. For example, there are strict regulations enforced by the Mexican government in order to prevent locals from ‘disrupting’ foreign tourists and to secure the demand for tourism; a major driver of economic wealth. Medical tourism is a lucrative business for many periphery nations because it has the potential to “increase gross domestic product, upgrade services, generate foreign exchange and create a more favorable balance-of-trade situation, and boost tourism”(Buzinde, Yarnal, 2012, p.784). Unfortunately, this is commonly at the expense of the locals in the host country. The “availability of health care resources for local people; inequalities within the health care systems of host nations; human resource allocation, relating to the percentage of educated local people who service local communities versus those who cater to foreign clientele; and lastly, economic and social benefits to host nation versus socio-economic exploitation” are all negative byproducts of medical and cosmetic tourism (Buzinde, Yarnal, 2012, p. 785). The questions surrounding morality surface surrounding the issue of exporting medical services while local populations remain suffering with little or no medical care (Hall, 2011). Clearly there are many moral issues surrounding cosmetic tourism in postcolonial regions such as Costa Rica, Thailand, Mexico; the most popular dental and cosmetic destinations (Bell et al, 2011). On the other hand, international medical professionals may seek additional training in the United States, which could not only facilitate the demand for cosmetic tourism but also increase the quality of care for local people. Although there is much negativity associated with exporting cosmetic medical service and local communities may lack sufficient healthcare, inbound cosmetic tourists are still providing economic stimulation. The destination image also has the potential to improve a destinations image. If international tourists are willing to put their health in the hands of foreign practitioners, then that destination is likely to improve their brand image, in the medical subsector specifically. Other forms of tourism may benefit as well because cosmetic tourists receiving medical attention often plan their trip to include more traditional types of tourism. For example, patients receiving dental implants in Mexico are likely to stay post or pre surgery to experience the destinations beauty and visit popular attractions such as the Mayan Ruins. Multi-purpose types of tourism therefore can become very hazy. Travelling for the purpose of receiving cosmetic surgery may be the initial driver of cosmetic tourism, but providing the holiday experience is still a crucial driver of GDP for many post colonial countries. Anticipated Future Evolution & Impact There is always going to be negative publicity regarding traveling abroad for the purposes of undergoing a cosmetic procedure because the topic itself is extremely controversial. The trends surrounding the increasing emphasis media places on “flawless beauty” in societies such as North America will continue to trigger people’s obsession with being perfect. Unfortunately many patients still fail to conduct the necessary research surrounding accredited healthcare facilities qualified medical professionals, which result in exaggerated media negativity towards cosmetic tourism. Since price has always proven to play a major factor in consumer’s buying decision, people will research the availability of different price points for the particular procedure(s) they are interested in; naturally this will lead them to discovering the large cost savings available in foreign countries. Shorter waiting periods in postcolonial countries have also attracted cosmetic tourists. As the industry develops regulations surrounding local welfare and foreign medical policy are likely to become increasingly stringent. As a result, the commoditization of the cosmetic tourism industry will allow opportunities for developing countries to strengthen their tourism industry and allow them to capture a larger share of the tourism industry. 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