Vaissnavi Shukl
In our last episode, we got a wonderful overview of medical tourism around the world and the key factors that drive people to travel from one country to another for medical treatments and procedures. Today, we’ll take a closer look at some of the medical tourism hubs along with a very specific geographic area. That is the US Mexico border. epidemiologist and cultural anthropologist Vivian Clements research focuses on the macro and micro effects of health and environmental policies and politics on under source and under research communities. with the support of the grand Foundation for Advanced Studies in the fine arts. We speak to Vivian about Mexican cities that we use to American patients for a variety of treatments.

I am Vaissnavi Shukl and this is Architecture Off-Centre, a podcast where we discuss contemporary discourses that shape the built environment, but do not necessarily occupy the centrestage in our daily lives. We speak to radical designers, thinkers and change makers who are deeply engaged in redefining the way we live and interact with the world around us.

The first thing I wanted to talk about was the fact that when it comes to medical tourism, and we’ll open with this, it used to be that people from poorer nations or so called Developing nations or third world nations used to go to the so called developed countries or advanced countries for treatment. And what is happening right now is what we initially spoke about, and you kind of call it appropriately as reverse medical tourism where people from countries like the US are going to Mexico for medical procedures. How has the medical tourism industry boomed along the US Mexico border and can you point out some key factors responsible for this and then we’ll carry on with the nitty gritties of what is happening along the US Mexico border. Absolutely.

Viviane Clement
So for a long time, you’ve mentioned people did travel to quote unquote affluent countries because access to technology access to quote unquote, better health care systems. However, with the advent of sort of like the late 20th century people are, especially with the globe of the internet, people are able to access information about how healthcare is working elsewhere, right. They realise that people can speak English outside the United States and that healthcare is not necessarily subpar. In other places the majority of us look, a good chunk of the US healthcare system is really staffed by immigrants, workers, nurses, doctors. Compare that with the fact that healthcare in the US is becoming so expensive and out of touch. With a lot of people. Things like medical, dental, and they’ll be like towns where there’ll be deserts in deserts like there’s no health care clinic nearby. There’s no dental nearby. And even with insurance, a lot of people are finding themself priced out of the healthcare system. And so now you have the Internet where you’re able to get on and access information about, you know, travelling to Mexico to get your dental health care done. Travelling to Turkey to get this proper cosmetic done. Travelling to Dominican to be able to access IVF care, for example, people are comparing those price points and realising that you can actually afford quote unquote afford right. These healthcare services are much lower prices. And then you can also afford them at a really good customer service aspect because a lot of those governments are often really catering towards foreign patients realising that there’s a gap within healthcare systems with affluent nations, that they’re able to fit in and jump in and fill those gaps at a lower price point. And then you have consumers who are willing to now access those health care services because they realise that one healthcare service abroad is very good, that you can get really good, really quality healthcare services for a much lower price point. So there’s a lot of comfort now, given that the world is more globalised that there’s access to information and paired with the fact that a lot of people are being priced out of the healthcare system within the US even with insurance.

Vaissnavi Shukl
And I think what, correct me if I’m wrong, what also probably would have contributed to this particular exchange in terms of medical services would would have been the fact that geographically Mexico is the closest to the United States in terms of travel right? Because goes, when I talk about the Global South seats, it’s as close as it gets and as cheap as it gets without paying for travel to countries a little farther away.

Viviane Clement
After the US-Mexico border is right here and then with the fact that, you know, southern US Mexico, southern US states tend to have higher incidence of clinical desert healthcare deserts and lower healthcare quality and Mexico is literally right there. So if you look up online, like patient testimonies, there’s a lot of like, Oh, I just parked here for $10 and walked into Mexico. spent the day there for like a day trip got my, you know, what would have cost me three four to 510 $1,000 in the US cost me a couple of 100 bucks. I got really good Mexican food. And then at the end of the day, I walked across the border back to the US. I got into my car and went home. So it was the convenience of the fact that the US Mexico border is right there for a lot of the states where you can just park, walk in, have a day in Mexico, get your healthcare, healthcare services taken care of and then walk right back into the US side of the border and go home. The convenience of it is very much attractive to a lot of American consumers healthcare to healthcare consumers.

Vaissnavi Shukl
So this is a two part question because you touched upon both of them. One was about how you said people go get the teeth done. So within the field of healthcare, what are some of the areas at least along the US Mexico border that invite people to travel across so if he or dental is one what would be some of the other things and if you could also talk about the Mexican cities, which are on the receiving end of all the medical tourism.

Viviane Clement
Some dental is definitely a big one. And if you look across like if you go on Google and you type in dental clinics in Mexico, and you sort of any populated with like dots across it, you see the majority of it is concentrated alongside the border, so we call them border towns. So most of the majority of the majority, majority of places where health care services exist, are right along the US Mexico border like really close by and you can see a high concentration of it right next to the custom borders. Another big one besides Dental is medication. Um, there’s some people who go to Canada to get insulin but a lot of people can also cross over to Mexico and get insulin. Another one is fertility services. And those are the three case studies or we looked at dental fertility and medication access. So those in the medical services that really offer ranges from something as simple as you want to go and buy your insulin or you want to get a particular medication at a lower price points to dental care, which I’ve looked at or something a little bit a little bit more involved, like hip replacements that kind of mentioned IVF. Other ones would be like knee surgeries like really outpatient surgeries that exist. You can access those in Mexico pretty pretty easily. And again, like I mentioned, information is easily available online. We can find patient testimonies or the clinics or our catering their marketing towards foreign patients so you can get a good idea about what it would look like for you to cross into Mexico to get these services who you’re going to talk to who your doctor is who your nurses and canteen is and how you care will sort of be tailored towards you for the duration of your medical care. So like I’ve mentioned, one of the cities are majorly like border cities. This is the major one for the Motor City which is the major one for dental care.

Vaissnavi Shukl
Talk to me about smaller cities. Why does the city get such a name?

Viviane Clement
I don’t know, maybe it’s famous, maybe it’s famous but what’s the story behind it is super famous. So I think I can see the numbers. There’s like a ridiculously large number of dental clinics that exist in quote unquote Molar city. I think it has the highest density of dentists and dental clinics of any city that exists. Yeah, they sit in that small town, the population is about 6000 but there’s about 350 to 500 dentists in that small concentration of town. If you pull up pictures of patient testimonies of people doing vlogs and going over to the Molar City you see like five or six dental clinics just like back to back just next to each other. You have like street vendors dressed in more costumes, like they look like T-shirts and holding up signs. There’s a lot of entertainment, a lot of a lot of things, just catering towards foreign. It’s a fun place to be there’s music, entertainment, just come get your teeth done. And just to come out and have good food is good music. It’s just very much the space is tailored towards this tourist attraction paired with medical services. Yeah, it’s just such a high concentration of dental clinics and a high concentration of dentists in this really small small town which is greatly pushed up against the border of US and Mexico.

Vaissnavi Shukl
Are there many of these around the border or do you think this is for?

Viviane Clement
Teeth that’s the one like if you want to go for Teeth that’s Molar City, but there’s this other cities alongside the Mexico US border I did focus on Motor City because that was the most interesting one to me. But the other cities alongside the border that really attract tourists, healthcare tourists.

Vaissnavi Shukl
So this is interesting because while we were doing some very primary research on medical tourism, and especially along the US Mexico border, we found that there were a lot of middlemen agents who would plan your trip who would connect to the right hospitals, doctors figured out your travel stay hotel food, everything and it seems like it replicates the model of what planning a normal holiday would be like, except you’re going there with an agenda. And it really made me think about all these different nodes that come together in order for a person to go get something done. I was wondering if you could talk a little bit about how people find these agents, what drives the selection of a particular city, particular hospital. I also read somewhere just like planning your stay for a vacation. There are different kinds of packages. So like you would stay in a five star hotel, there are some premium luxury packages. There are some budget packages. What does the process look like? Especially in your project, you’ve looked at Digital ethnographies and you’ve looked at blogs and you’ve looked at tweets and you look at YouTube testimonials know people talk about how they found a particular doctor and what their process or journey was like.

Viviane Clement
So a lot of like the YouTube testimonials I think that’s what a lot of good people go on there. There, you can search for, you know, dental clinics in Mexico or Motor City or IVF care in Mexico or you can search Whatever your healthcare needs are in Mexico. And when you go to YouTube, you have two sets of videos or shops. One that shows up is people sitting in their living room in their bedroom and sort of giving their testimonies of this is my doctor this is how I found him this how much I paid him. This is my overall experience in a blog style sit down kind of conversation and the other set of videos where you find these the agents that you were talking about the middlemen, right where they actually give you information about coming to our clinic. We are fully fluent in English. These are the patients that we have. These are the success rates that we have. These are the packages that we offer. And so you can get like real life video testimonies on YouTube, but you can also find blogs where people write about their day in Mexico getting their root canal or the day in Mexico or their week long vacation in Mexico while they got their egg transferred and their medications done. So again, the internet really web 2.0 really offered this citizen communal way of sharing information. They have such a huge access to really good quality information of people who want to go to Mexico and get these health care services taken care of and they’re fine and they’re coming back and saying yeah, my doctor spoke English. He was very easily accessible. There was really not an issue for me and I feel okay and they also have the agents who will give you good level information about what you can expect when you come here or when you go to Mexico for your health care needs. And I think a lot of it is done to assuage people’s feelings like don’t worry like we are

Vaissnavi Shukl
certified. It’s not a scam. You’ll come back right, we could do the cares.

Viviane Clement
And a lot of you know if you pair that with like the competition run brain brain, brain drain of like actual healthcare professionals going abroad and again, the healthcare services and coming back to Mexico coming back to the homelands and and opening up these private clinics, you see that the training and the certification is oftentimes there so that worry is this there’s no need for that worry is that at least for those patient testimonies and agents are saying is that we’re safe? We’re certified. You’re okay here. Oh, and by the way, you can hang out. You can eat good food, you can be entertained. This can be a vacation mess. It was a beautiful piece of calm and relaxed. So there’s this pairing between both of your healthcare services that can be taken care of at a really good quality, but you can be stressful and beyond vacation here.

Vaissnavi Shukl
I wanted to talk a little bit about the city per se, any which one you want to pick? What does this kind of tourism do to the visual culture of the city? I mean, an architecture at least most of us have graduated knowing of the last weakest phenomenon and how last week is became the city where the boom of the hotel industry and tourism really commoditized or catalysed the whole place right so if you were driving down a road, there’s this constant fight of which hotel grabs your attention, and it’s this attention economy of making sure that the Bellagio is known more than the luxury or your MGM and everything that comes on your way when you go down the strip. So it’s this cacophony of all these visual signs really hitting you in the face. And we speak a lot about it in architecture and what you know, branding signage, do to the city at least like the public sphere of it. And while looking at all these cities, whether it’s huge as Juarez Tijuana, any of the ones which are very popular for medical tourism, there was of course, a direct recollection of what was happening last week is in terms of the advertisements across the roads, the branding of the city. And I was also wondering if at all got a chance to look at how the tourism industry the medical tourism industry has shaped different aspects of the city, whether it is public transportation, transportation of any sorts, hospitality, if, of course I’m sure because they had so many people coming down from the US what does it do to the kind of food that is served in restaurants, you know, what does it do to the kind of hotel setup? What does the overall real estate around these medical centres or hubs use? If you could speak to that a little bit?

Viviane Clement
Yeah, I think I think that’s I’ve never know but the Las Vegas phenomena

Vaissnavi Shukl
The book is called Learning from Las Vegas and written by a stellar architect couple called Robert Venturi and Denise Brown. I’ll send you a link.

Viviane Clement
Yeah, please do because I think there’s a lot of parallels there, right because I was talking earlier about how Motor City is so hyped up around dental tourism and attracting foreign foreign patients to come in. So a lot of it is again, like the person who’s dressed it as a teeth, waving a flag around come to this particular clinic if you go on YouTube NBC did like a clip about Motor City and they’re walking around they followed a couple of patients who came from the US over to the to Motor City. And this video documentary from NBC really shows what it looks visually like somebody dressed in a tooth and waving a flag like come to this clinic don’t go to the no or like our clinic is better we speak English or there’s food and entertainment is good vendors down the road. There are people selling souvenirs. Yes, that’s the one Yeah. People selling souvenirs. And what’s really interesting is a lot of these workers and migrant workers but once upon a time in the US and for one reason or the other will either be deported or were able to go back to Mexico and be able to make living in these very hubs of legacy the horrors of Tijuana Motor City. So yeah, visually it looks like it is very crowded. You hear languages mostly, you hear attractive languages in English, but there’s also Spanish being spoken. The real estate is multiple clinics back to Bacary. You can have one blog where there are several dental clinics just factor back. You can have, you know, people dancing music down the road. So it’s just like if you look at that video, you’ll get a really good sense of what it is like visually and what it sounds like because again, everything is very tailored towards tourism and attraction. And look here. Come here. We’re the best and especially this multiple clinics and there’s this competition of coming to this clinic versus that clinic and, and the more outrageous the more the more entertaining it is. Or you’re able to attract people who are looking to be entertained but also look into health services.

Vaissnavi Shukl
So we’re wondering, ever thought that you could comically use I don’t know what the word is for something that’s health related. And when I saw that image is like there’s standing with a sign and it says Welcome to Motor City. It’s humanising in a certain way, but it also kind of feels a little detrimental, you know, like you’ve commoditized health care to a certain extent . It’s weird.

Viviane Clement
It’s a very it’s responding to something that is real, right? It’s responding to people being locked out of healthcare services, and having to go elsewhere. Like it’s very, like if you look at it from the US healthcare system. It’s very sad that people are being locked out of the healthcare system, that now they have to go to somebody else’s place. They have to go to a different country to have their healthcare be met. And it’s also sad on the other side of the border to think about how all this effort and energy is being put towards attracting foreign workers and foreign healthcare seekers to come in. And you wonder, okay, if I am a mom of three kids who live in a city and all these services are really geared towards attracting foreign patient. What does it look for? What does it look like for me to access these spaces? So that I can get the healthcare service as a citizen of this country, where the majority of the healthcare now is being really tailored to attracting other consumers that are not citizens of this particular country? So you get you get like a really weird mix of Oh, great. If I’m if I’m coming from the US and I’m living in a dental desert, I have insurance but my insurance doesn’t cover anything and I have this root canal that really needs to be taken out. I can just go to Mexico and pay $300 out of pocket and I’ll be okay. I don’t think verifies if I’m a Mexican citizen who works as food vendor or whatever the case may be $300 out of pocket that becomes a lot.

Vaissnavi Shukl
So this is where I think we should talk about being priced out of your own healthcare system. And in our discussion, I realised that things that do attract people, at least in the US Mexico scenario, are essentially healthcare items that are not probably life threatening and which is why they have been able to kind of lighten the atmosphere a little bit. Take it in a slightly jovial fashion. I wonder if you’ve also come across instances where the more complicated aspects of healthcare, whether it’s neurological, whether it’s cardiac, whether it’s cancer related, has also seen a certain movement in terms of travel from the US to Mexico. I mean, I’m only asking because I wonder if this has happened because they trust Americans more when it comes to complicated surgeries or things that are life threatening versus things that are more cosmetic aesthetic, more plastic, in that sense, is that the case but then again, IVF doesn’t count as something that’s cosmetic. In fact, it doesn’t but the US Mexico scenario I don’t remember seeing there being any travel for the chemotherapy or radiation I mean, that people still want to do it with their trusted doctors or the university hospitals or the large large groups.

Viviane Clement
That’s very true. That’s a very true observation that I’ve seen. I’ve not seen travelling to Mexico travelling abroad for, quote unquote, much more serious health care conditions. But I wonder if it’s also Yeah, that’s a great observation. I’ve not seen a lot of instances of people travelling for cardiac or brain surgery or chemotherapy into Mexico. I wonder if that has to do a lot more with longevity or the long term careness that comes with more chronic diseases, right? Something that would require multiple visits or require more long term care you honestly are. You have to be where you are. Right? You have to be in the same home because you have to go to chemotherapy multiple times in a week. There’s no way you can travel multiple times to Mexico, at least not with the infrastructure as it said, these aren’t in the comfort is there yet or the type of visit like your family has to be around you when you are, you know, going through much more serious much more long term chronic illness that requires a lot more intensive care with multiple visits. So yeah, there is nothing much travel and tourism around much more chronic, much more serious life threatening concerns when it comes to health. But I wonder if that’s because again, the couple mentioned is that those particular health care needs are much more frequent, much more consistent and require a long, long term sort of address of that health issue. But also

Vaissnavi Shukl
because maybe people’s insurance might cover all of these right maybe they have employers who have already paid for employee insurances or whatever student insurance or your and maybe these are things that are not covered by insurance, and that exposes a large gap in a country’s insurance system or your healthcare system where all these one stop procedures are not as widely covered as the more serious conditions and that I mean, I think in this case, what we discussed earlier on about reverse medical tourism doesn’t hold true because you still see people from the global south people from the so called Developing countries still going to the US still referring to the Mayo Clinic and sending their reports for expert opinions when it comes to something that has to do with your cardiac health or your neuro condition or something. So of course, I think we need the role of research and research plays a huge role in terms of where universities have more funding to undertake your drug trials or experimental procedures and, you know, publish those kinds of studies and we live in countries don’t have those kinds of resources because you’re still really grappling with maintaining a healthy population and so you don’t invest as much in research at least that’s what I’m sure there’s a lot of research still coming out but it’s not at the at the at the scale and which is why I think when people start coming in for a certain kind of procedure, the local population gets priced out of it. Any thoughts on what this medical tourism has done to medical education in Mexico in terms of how people train for doctors, and if they already know that there are people coming in for dental procedures, maybe there’s been an uptick in the number of people becoming dentists. And moving to the smaller towns are people opening fertility clinics or people becoming cosmetologists or institutions because they’re able to do things like plastic surgeons? Any any stats on that?

Viviane Clement
You know, that’s a really good question. That was one of the question when I was reading my article that came up and that was something that we are going to explore next is how does, how does we looked at it from the consumer end of it, how then how do we shift to look at it from like the worker employment, healthcare workers perspective, and one of the things that we were going to look at is we were we are planning to talk to like different dental hospitals or dental training schools within Mexico to see how exactly what you’ve mentioned how is how are they training their dentists now, when it comes to Yes, the actual training of dentists but also when it comes to what do you want to do post your education? Are you planning on staying in Mexico? Are you planning to go to the border towns and open up a clinic? Are deans and professors and training seeing more students coming in with the sole intention of going to these border towns to open up clinics? So that’s a really good question that you picked up on and that’s something that we were really applying to look at more so like training of healthcare workers training of dentals or training of the next generation of care providers. Where are they going? If there is, you know, we talk about brain brain drain, we talk about leaving a country completely fully. But is there a brain drain that is happening regionally or locationally? right within a country but moving towards cities or moving towards border towns to cater to a specific healthcare gap that exists?

Vaissnavi Shukl
So long question, Vivianne, you’re an anthropologist, and you’ve done this wonderful study. And of course, this paper was written during COVID or around the time. Yeah, it was around the time. COVID is, yeah.

Viviane Clement
So when I was reading it COVID was happening.

Vaissnavi Shukl
Yeah, because your research methodology was shaped up in a very interesting format where you had to look at digital resources and sources which were readily available in terms of testimonials, Twitter, Facebook, and YouTube, because I also wrote my dissertation during the lockdown and I had no access to a library. So a lot of it had to be prepared to make do with what you can find through open access journals. So now that it’s been a while since you’ve published the paper, any update on where the study has gotten if you’re still working on it, or how you would like to take it forward?

Viviane Clement
So yes, the study really came out of what I was thinking about in class. Especially important calmness, the word we were we studied multiple things. And for my project, I really focus on the medical industry because I have a master’s in public health. So that was, in part, something I really want to focus on and COVID was really happening and methodologically we need to grapple, especially within anthropology. What does fieldwork look like? Well, this observational study and ethnographies look like we can access bases and be there physically, even if it’s just thinking about ethnographies from the preliminary stage of how do you gather your data from secondary sources so that you’re much more important when you go to field studies. So that you collect data more by using non on site specific data? Exclusively, right? How do we retain secondary data, online data, web data, social media, which is becoming so pervasive in everyday people’s type of lives in our research study? And your question is, what do I see this project going forward? Correct. What I want to do methodologically at least again, it’s this idea that digital ethnography is not a replacement of onsite ethnographies. So once this luminary data that I’ve gathered with the patient testimonials with the videos and blogs might the next step the most, the most natural next step is to actually go to Motor City and interview people go to Motor City interview dentists, and actually be there in places see if what we have collected online, what fishing testimony looks like online, what the agents and commercialization looks like online, is actually what is actually continuously happening offline, within real day everyday in real life kind of conversations. So yeah, so best case scenario I’ll be in Mexico running this study and talking to dentists talking to the utility clinics, talking to pharmaceutical companies and also talking to students who are being trained in these fields about how they see medical tourism? Is it a negative thing? Is it a positive thing? Is it neutral in terms of just as a need and we’re filling it and how do we then not also exclude local patients from accessing their national health care services?

Vaissnavi Shukl
Lovely, thank you so much for taking the time off and sharing your work with us.

Viviane Clement
Absolutely. Thank you for having me. This is a fun conversation. It’s been a while since I talked about the papers. I really appreciate the time to jump back in and really think about it.

Vaissnavi Shukl
Special thanks to Ayushi Thakur for the research and design support, and Kahaan Shah for the background score. For guests and topic suggestions, you can get in touch with us through instagram or our website through our website archoffcentre.com, both of which are ‘archoffcentre’. And thank you for listening.