Vaissnavi Shukl
Medical Tourism is a rapidly growing industry that has emerged out of people’s need to travel across country borders to access medical treatments and procedures. In order to understand this global movement, we need to understand the reason for travel, the destinations that attract individuals and the web of factors that shape this global industry. With the support of the Graham Foundation for Advanced Studies in the Fine Arts, we have with us today Dr. Valerie Crooks, who is a health geographer and a professor at Simon Fraser University in Canada. For more than a decade, she has been qualitatively studying the ethical and equity impact of medical tourism in countries such as Jamaica, Barbados, India, South Korea, Cayman Islands, to name a few.

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.

Valorie, you’ve done more than a decade of research on medical tourism. And so the risk of my question sounding small and shallow today I want to begin by tracing the origin of medical tourism, if they mean, when did the idea of travelling for treatment first emerge?

Valorie Crooks
Well, people have travelled for care or to improve their health for a long time before the phrase medical tourism even arrived into our vocabulary. So I mean, you can trace back very historic practices of the temporary or permanent movement of people in order to access care or to go into environments that they felt were more health promoting or healing and so you know, we have a history of people moving between countries and even moving between continents in order to improve their health status or to search for a better sense of well being. And so medical tourism, which I mean, you know, in today’s conversation right now, between us we can think of more as an economic sector. This has emerged on through the recognition that there are deficits in some health systems and there are assets and others that some patients will be motivated to travel for, for various reasons, and also just building off of that recognition that we have a long standing history within particular regions or between countries of people moving in order to access improved care. And so the actual sort of economic sector of medical tourism and the phrase “medical tourism” has existed with us for a few decades, and it’s grown out of a few different kind of recognitions in particular destination countries. So oftentimes, an early prompt for moving into a medical tourism sector is underused or unused capacity within a health system and so either sometimes strategically as part of the health system approach or sometimes on a case by case basis and a particular facility or hospital or clinic, recognition or interest in trying to fill that under used or unused capacity through bringing in international patients. There are also various kinds of very specialised procedures, where the local population in a particular country will not be large enough to sustain the practice of that procedure. And so that’s also a reason why we see people sometimes moving between countries and then there are various other reasons for the emergence of the sector and so outside of destinations where there’s unused or underused, existing system capacity, we have other countries and other sectors that I often refer to as kind of medical tourism to Plato because the emergence really comes from what I was just talking about in terms of, you know, health systems and countries strategically developing the sector in order to use that use up the space or the capacity within the unused or underused health system. You know, beds that are empty surgeries that are being unfulfilled, often within regional movements. That phrase that I just said medical tourism, I often think about, as you know, destinations where we have actually seen the emergence of purpose built facilities, specifically for international patients. And you can imagine that those two origin stories are very different. So whether it’s a country’s public or private or hybrid health system that has under or unused capacity that was originally intended for domestic patients or for patients where there could be some sort of small scale regional movements, and the kind of recognition that hey, we could sort of expand this to the international market and fill this are very different than the origin of a sector in a particular destination, where facilities have been built from the ground up with the intention of attracting international patients. They’re very different types of destinations, very different intentions behind who it is that you’re going to be seeking as a patient group, different motivations for why people may travel to those sites, as well as very different thinking in terms of the economic strategy behind that. So that’s something that I would say in terms of sort of the origin or that the arrival of medical tourism as a sector is that we have these two very different sort of stories of how we have seen this, this emergence and so you may go to a hospital. For example, I’ve visited hospitals in Chennai, India. Where thier hospitals that were, you know, clearly an originally built for domestic patients, but there will be a wing or floor where you see more international patients coming. So that sort of follows that first type of origin story that I mentioned. But I’ve also been, you know, throughout my travels in the Caribbean region where I’ve spent a lot of time doing work and in smaller countries within the region that are looking to diversify their tourism economies. I’ve been to many very small purpose built clinics, or small scale hospitals that were from the outset designed to attract international patients.

Vaissnavi Shukl
So this is the perfect point to end on. A couple of weeks ago during the Thanksgiving weekend. This one image became very popular in public media. It was the flight chart of all the travel people did for Thanksgiving in North America and I was I was wondering while looking at that in terms of, you know, if we were to make a flight chart of travellers commuting around the world for medical tourism, what are some of the places that emerge on top both in terms of outbound patients but also the geographic locations where people end up going was in terms of giving and receiving treatment and of course, you mentioned Chennai and we in India very, very familiar with, you know, having an influx of patients depending on what part of the country we are in and the treatment that those specific cities offer. But you also look into countries like Mexico and Barbados. What do you think overall and because you study human geography, what do you think that flight path looks like?

Valorie Crooks
So I’m actually gonna take a step back because the question that you just asked is a very logical question and I get asked that all the time. And the companion question that I asked to that. So you’re asking, where are people going to and where are they leaving from? So the companion question is numbers, how many people are going how many people leave particular countries? How many people arrive to other countries? And so these are very local questions. When talking about medical tourism. And so the answer that I’m going to give you me feel not quite satisfying, but this is the truth. And this is what we have to think about. Medical Tourism falls into what I call the triple use of global health care, mobility or transnational mobility, mobility, untracked and traced unregulated. So if somebody is listening to this podcast today, and they think about the last time that they went abroad to a particular country or that they return to their home country, when you’re going through that immigration check in, did you indicate whether or not you access health care abroad? My guess is going to be no. And so this is just a demonstration of the fact that we don’t have reliable population level tracking. And so you know, it’s not something that’s come up as a significant priority. And it’s not something that we can really track or trace. It is as I said, a triple U. I’m tracked and traced and righted at least at the sort of global or transnational level, in terms of regulation. And so, you know, just thinking about people’s own lived experience when they think about travelling, they haven’t been asked. So if we expand that into thinking about medical tourism, you can understand actually why all numbers are pretty much wrong. Some are useful. So most of the numbers I see around medical tourism, so whether they’re numbers that would inform kind of a flow map, like what you were talking about, or whether they’re numbers that just help us on abroad to a particular destination. Typically, those numbers are based on modelling. modelling, mathematical modelling is spatial modelling. They’re they’re based on assumptions, educated assumptions, not guesses. They’re based on assumptions to help us to sort of understand what the reliable numbers could be like based on a certain number of sort of assumptions. built into the model. And so pretty much the numbers that you’re gonna see, they’re all wrong. And so who’s telling you the numbers tell the story as to the numbers you’re gonna see? And so you know, if a particular destination is trying to report numbers where they’re doing so to kind of help this sort of build the fabric of their medical tourism sector, they may over report and it may not be an intentional reporting. It may simply be, how they understand what the practice is. So I’ve seen reporting of the number of medical tourists and also capture within those numbers, the friends or family members who have travelled abroad with the patient exam can say, why would you do that? But if you think of medical tourism as diversification of a tourism sector, then you could imagine the driver for capturing those. I’ve also seen numbers that report the individual procedures if someone has access as opposed to the numbers of patients. So you could have somebody going for a series of treatments. Somebody could go for a serious agnostic treatment, gamble, in addition to some preventative care, someone may access five different services, six, potentially even more, and so they’ll be captured that many times by the hospital. Or a clinic that’s recording. Now, is that hospital or clinic setting out intentionally to be deceptive or to give a false impression as to how many patients are coming? No, that’s not what I’m here to suggest. That’s probably their way of recording. But I’m giving you these different examples so that people can understand that actually, the basis for finding reliable numbers around how you are travelling abroad is very challenging. Also, it’s a highly privatised sector. And so what is the motivation for hospitals or clinics that are thriving to share that information widely, with their competitors potentially seeing it especially if they feel like they’ve broken into a new market? Maybe they really wanted to attract patients coming from the Middle Eastern region, and they were successful at doing so? Do they want their competitors to know? So unless governments are very reliably requiring reporting, and that reporting is coming forward, then you can see why numbers are part of a story. We should always stand back and say, who generated these numbers and what’s the perspective that they’re coming from? And so you know, that is what I would say in terms of the response to the question about a flow map. One thing I will comment on and this comes from my experience of doing research on this sector for a very long time, is that I think that there can be a very strong focus on sort of the more sensational stories so the idea that, you know, a dissatisfied patient, local here to where I am in Vancouver, Canada, will look for care abroad and they will end up maybe where you geographically are in a city in India in order to access that care. So the idea that people are travelling far and wide going to destinations they’ve never gone to before travelling to places that, you know, members of their family have never even heard of, in order to access care and in a very remote context, when actually we know that a lot of the travel is regional and so you know, something that doesn’t get talked about quite often but something I know very much from my work is that there’s also a very strong connection to diaspora populations. So people who may be first second third generation Caribbean Canadian, who is going back to visit over the upcoming holiday period while they’re there, they accessed on time. You know, so this is somebody who would be in this in this particular concept Canadian National so they are going abroad, they’re not going abroad with the intention Slee of accessing care, but they’re doing so well. There there. There are all different kinds of groups of people who end up becoming medical tourists. And just something that I just want to add just for the sake of clarification in our conversation is that when I’m talking about medical tourism, I am talking about instances where the care is intentional. So I’m not talking about an ill or injured vacation or I’m talking about somebody accessing care with intent. Typically, they’ve gone abroad for the purpose of accessing care, but there are also and this is another reason why it becomes very hard to track. We also see the emergence of certain kinds of medical tourism destinations, where they’re trying to kind of capture the local tourist market. So with cosmetic procedures or dental procedures that may be minimally invasive for myself, I in my work in the Caribbean region. I’ve been at many cruise ports where within you know 100 metres of the cruise port, you can have many clinics that are offering dental care or minimally invasive cosmetic procedures to people who are on board. And so in that instance, the person may not have travelled from the outset with the intent of accessing care, but still their access to that care is intentional. It’s not that they broke a crown in their mouth while they were on the cruise and they went for emergency dental care. So I want to make sure that that intentionality comes across because this is another reason why we can also see some challenges in interpreting the numbers that get reported around medical tourism because sometimes Ill or ill or injured vacationers actually get captured in these numbers and then another sort of distinction that we can make our people who are travelling abroad based on their own decision to go abroad and are doing so within Thailand versus somebody that it their domestic health system has actually covered the costs of them travelling abroad. So that would be arranged cross border care where that happens all the time, where there are countries where you know, that’s part of their their health system. So it may be a small country, it may be an under resourced country, or it may simply be even in Canada for example, we do have the potential for portability outside of the country. If a procedure is available abroad, and somebody is enduring kind of extensive pain and tissue damage, then they can request to have that. So these are two very different types of travel. And so when I’m talking about medical tourism, I’m talking about that individual who has made that decision on their own not by referral, not by approval of their domestic health system, where they are paying out of pocket and they are accessing intentional care abroad. I want to share that just you and I are on the same page for our conversation, but also all those different kinds of patient movements that I just mentioned. They often get to collapse together to report the number of international patients that have been in a particular destination. And then what will happen is somebody in the medical tourism sector that is looking to kind of talk very positively about a destination will say, look at all of the medical tourists that come but meanwhile, you know, a large number of them are people who broke their leg on on a, you know, on a waterfall in a popular spot in a tourist destination and ended up in the hospital in order to remember that something that you mentioned right now is actually happened with my own mother. I was interning in Sri Lanka and my parents had come to visit me and my mother was getting a picture click on one of the tourist spots, and she tripped over backwards and literally broke her elbow. And then of course, we had to you know, we were exposed to the entire healthcare system because there was a fracture and then we had to fly her back but, but I know what you mean. Something that I do want to get a little bit into the detail is you mentioned that you know when you fill the immigration form, and they ask you about receiving medical care, will would usually answer no if I just want to clarify, they don’t ask you. Like, they don’t ask you okay, that’s that was the point I was making. So typically, when you are entering a country, when you’re returning home, for example, you’re typically not on if you access to healthcare abroad. So you’re asked, you’re often asked if you’ve been on a farm because there’s concern about the spread of zoonotic disease. You’re often asked if you’re carrying over X amount of currency with you, because we want to kind of have a sense financially of of what people are coming in with and any concerns about that. So the point with that, that I’m trying to make is that people aren’t, so it’s not being recorded. Well, exactly. And so this is the point that I was trying to make by using that example is that this is exactly why all numbers are wrong. Because if we are not asking people when they return home if they ask intentionally Access to Care abroad, we will never know we don’t ask them when they leave the country in order to go back home and we don’t ask them when they return home nor typically we asked them when that when we arrived. There are a few exceptions now but that’s just not the norm so understood.

Vaissnavi Shukl
Can you speak to how certain places have really went up like certain medical specialisations. For example, a particular doctor and a hospital in my city became very famous for knee replacements. And because they advertised in a certain way to African countries and had a lot of African patients flying in. There is now an emergence in a number of hospitals in the city, which boasted about offering good knee replacement surgeries. Similarly, in Bangalore, there was a hospital that pioneered cardiac procedures had procedures. And so around that hospital there was an ecosystem of other hospitals which became very popular in offering heart related healthcare. What does this monopolisation look like at a global scale?

Valorie Crooks
If it does? Yeah, I mean, I don’t know that it’s necessarily a monopolisation. But you know, there’s a lot of networking among people are thinking about going abroad. So there are lots of chat rooms and discussion boards, for example, websites where patients are talking about their experience and when people are thinking about going abroad, oftentimes the look to those kinds of sources for information and so this is how you can build up a reputation of a particular destination. There’s a lot of reputational protection in the medical tourism industry. So you can have particular hospitals or clinics or even countries as a whole that are very much focused on what is their online branding, what is being discussed about them. I have been I’m aware of some clinics that even hire outside contractors to help to manage social media presence. And I’m not just talking about somebody that supports the content that’s going in but also looking at the comments that are made. Sometimes also generating the comments that are made so this is how it’s possible that you can build up a reputation for a particular kind of destination for a particular procedure. You know, most people that are travelling abroad are not going to be trained medical professionals because most people just aren’t trained medical professionals. And so it can be very hard to know how you pick a hospital or a clinic. You know, we often I hear in my work so often, you know, destinations looking to brand themselves. In my conversations with medical tourists, which have been numerous by this point in my career. I’ve very rarely come across somebody that picked a designation people are also very rarely picking a hospital or clinic. That might happen more if it’s a cosmetic type of procedure, something that’s minimally invasive, something where the clinic as a whole offers a single procedure and so that’s the only thing you’re gonna go for what people are typically going for, if you’re dealing with surgery is they’re going for a specific practitioner, and they’re going to where that person is based. So this is why I’m saying it’s not really a monopoly. It’s just simply that, you know, it doesn’t it doesn’t take a lot of research as somebody who might need a knee replacement like you’re talking about. To know that one of the things you want to see is an orthopaedic surgeon who has done a good volume of that particular procedure because the it’s very likely then the outcomes are going to be better. And so you know, patients start sniffing around they start looking at where can I find that and then through word of mouth, they they start to hear about a particular provider and then that’s what gets the focus in a particular clinic.

Vaissnavi Shukl
Something you you wrote in one of your research papers was deep and insightful. You heard about how medical tourism may benefit estimation countries but they also may worsen health inequities, both in the destination countries and in the patient’s home countries. What are some of the factors responsible for

Valorie Crooks
this? Yeah, so you know, this, this kind of questioning comes from the thinking that I have around medical tourism, so in the work that I’ve done, I’ve not focused on certainly outcomes, which is the kind of conversation a lot of people would like to have with me. I haven’t focused on the cost of a procedure and destination a versus destination being and doing economic policies. I’ve been doing work asks ethical and equity questions with all kinds of collaborators, including a close collaborator of mine right here at Simon Fraser University. I’m Jeremy Slater, who is a bio ethicist and we’ve asked a lot of ethical questions. And so one of the kinds of questions that I’ve been asking in this work and my colleagues might be asking is who benefits? Okay, necessary at the level or the scale of a single person but also at the scale of a destination? So what are the harms? And what are the benefits both for patients home countries as well as for the destinations? So in relation to destination countries? You know, I was mentioning earlier in our conversation, that’s sort of origin of some medical tourism destinations emerge because they have underutilised or unutilized capacity within their health system and they’re looking to offer that to international patients, but in other cases, you have purpose built precede purpose built facilities. Or clinics, specifically for international patients. And in relation to that latter kind of example. It’s not uncommon that things like tax incentives have been given. There’s oftentimes international investment coming into the country in order to bring foreign dollars in to allow for the creation of a particular hospital or clinic. But how does that actually benefit the health system locally? You know, if you are coming in bringing in international investment monies building a purpose built clinic, you mentioned for example, a heart hospital that’s known in India, that particular model of procedure that’s been exporting it well, there’s a heart hospital and that started in Cayman Islands that, you know, was brought forth. Exactly. So, in that instance, you know, somebody exported a model from India, it landed in Cayman Islands, but the question is, how does came in benefit from that? How does its health system benefit? You know, if you’re given tax incentives, the location of where that clinic was built, there was waiving of environmental protections and environmental assessments. It was one of the last lands where the endangered Luca CO was living. You know, you have a fairly small country that is providing resourcing infrastructure wise, housing wise in order to support the President’s clinic. How does this feed back into benefiting the local economy but also the local health system? How do we ensure that hospitals and clinics that are purpose built to attract international patients are not poaching health workers out of the domestic system in ways that are harmful? How do we make sure there’s enough capacity within that host country in order to make sure that we are not harming its own health system locally? But also, again, what are the spillover benefits, we could imagine medical tourism is being highly privatised and think about it as being its own particular aspect of the health system. But if a health emergency happens, that patient is going to land in the public hospital typically or in a private hospital, in the country that is typically kind of built with the intention of domestic patients using it. And so there’s a lot of kind of spillover and so it raises a lot of really challenging questions in terms of how do we ensure that there are benefits and you know, so medical tourism, it isn’t offshoring kind of sector, right. You’re talking about, well, especially in that medical tourism 2.0 model that I talked about, so, you know, international investor comes along, they helped to build clinic, a clinic here their money any maybe returning internationally, possibly with some staying domestically, international patients coming into set hospital, oftentimes some local workers, but it’s not uncommon for surgeons and trained medical professionals to be also coming internationally. You know, there’s lots of offshoring sectors, but the thing is that in with medical tourism, we’re seeing it’s showing sector and health as a basic human right. And so that’s why I think we need to ask particular kinds of equity driven and ethical questions in a way that maybe we wouldn’t ask the same questions of a telemarketing company that started in the same location that also was brought in by international classmate and may, you know, have its executives and senior level management as being coming in internationally as well. So I just want to sort of frame that so that you understand why it is that I’ve been asking these questions, but then, you know, up to this point, I’ve been telling you about how I think about it and the kinds of questions I asked and destinations but also patient’s home countries. You know, there are ways in which there can be harms, but there can also be benefits. So, you know, I’m talking to you right now from Vancouver and Canada, have a public health system that has no payment at the point of service provision. It’s funded through taxation. And so you might kind of say, well, you know, if somebody chooses to exit the system and go abroad for care, that’s their choice. There’s no harm to the system. It’s just that it’s one less person in what could be a bottleneck when last person on a waitlist for a hip replacement or a knee replacement. But you know, at this sort of smaller scale, it’s not uncommon for patients to be asked to undergo particular kinds of testing so to request blood tests to request other tests to be done before they arrive abroad. So that’s an intersection between someone’s decision to go abroad privately and the public system that is here within Canada. And then also when somebody returns if they were going, I’m just using the hip and knee replacement because that came up in in your example, but when they return, they’re actually going to need to have follow up care. They’re going to need to have the kinds of community referrals but they haven’t actually received the care locally and so they may actually be disrupting the follow up care kind of weightless in our sort of plan for that. So this is, is one example of how we can see sort of local impacts in the home country it also if you have a lot of people exiting a domestic system, whether it’s a public system, like what I was talking about in Canada or something that’s highly privatised if you have people leaving because they’re not able to access a particular type of care domestically, then sure on one side, you’re lessening a bottleneck but on the other side, you’re you’re removing the pressure for change and the pressure for reform. So this is also another sort of potential criticism of medical tourism and how it may not entirely be helpful for patients home countries. But there are other kinds of impacts in sort of the home context as well. So you know, for more invasive care, it’s really common for somebody to travel abroad with a friend or a family member, if not more than one. So then you have those peoples intersection and interaction with the health system. Those people who are taking their time off of work. So you can really what happens is that one individual person’s decision to travel abroad for privately funded health care. That’s intentional in the context of medical tourism, actually impacts a whole network of people and actors, some of whom are there because and receiving those impacts because they’re in an economic sector, this is looking at benefit from the practice. So they’re there to actually be impacted and they’re looking forward to what that impact would be. But there’s others that may be impacted quite negatively. And you know, another example at a kind of thinking about that sort of finer scale. Resolution. You know, I have absolutely heard of and I know firsthand experiences not from my own lived experience, but from conversations I’ve had with patients and physicians, instances of a patient’s choice to pursue medical tourism as resulting ultimately in a fracture between a long standing positive relationship between patients and physicians. Because, you know, it’s not entirely uncommon for patients to be driven to look abroad for health care that they’re not going to be able to access domestically because they’re not a viable candidate. So you know, one example might be bariatric surgery. Where you have to be within a particular weight range. And so in, you know, people’s minds, they might be thinking about people who are very overweight, but actually, you can be underweight you can be an A not an advisable patient for bariatric surgery. Bariatric surgery is not devised for those people that can’t lose that final 10 pounds. But when you’re talking about, you know, the ability to go abroad, to pay for the care that you want, and to use your money to get the outcome that you’re searching for, regardless of what harms might be if you are willing to accept those harms, those potential negative health outcomes you can use your money to talk and to get you what it is that you’re looking for. And so you know, you can see in those instances, there have been many, many complicated documented cases of patients returning from accessing care abroad that they were they should really never have been able to get and then coming back to their home countries and requiring extensive care and treatment that also happens in instances where, you know, someone may be exposed to, you know, a particular kind of negative consequence of the procedure and then they’re back in their home country trying to deal with it. But, you know, I just thought I would mention, you know, that there are one of the things that that people will go abroad for procedures that they are not a candidate for at home. Now, sometimes that could be due to gender identity, it could be due to our religious belief, and so it may not result in a fundamental harm, but sometimes it’s due to you’re not an advisable candidate because you’ve already had four hip replacements in your lifetime, or because you are underweight for bariatric surgery or because if you receive procedure X wires that it will interact negatively with this other ongoing care that you’re receiving. And

Vaissnavi Shukl
so that counselling is not aligning with what the team needs and so against the advice of a local team or a local doctor one goes to another country where such questions are probably not as regulated or as asked it’s still go through with it kind of putting their own bodies in danger. Right.

Valorie Crooks
That’s right. And this is not I wouldn’t say that this is the most common driver for medical tourism. Yeah, this is something that can happen. You know, you can enter a different regulatory environment where something that you were, you couldn’t access at home because it was unproven and untested because it was unavailable, or because you were not a candidate. So it’s available, but you are not a candidate for that in your domestic context. You can go on the global market and say, hey, where can I get this done? And, you know, that that kind of driver around medical tourism, you know, it’s gonna have a whole spectrum of outcomes for some people, it’s life saving, you know, they were being denied fundamental care in their home country because of, you know, it could be a religious practice because of gender identity because of some other aspects. And so the ability to go abroad is life saving, saving and life changing. But then in the other instance, as I was giving you some examples, you can have people going, because they’re not a viable candidate domestically, you know, because also medical tourism can prey very much on people’s hopes. And then see you can also have, you know, people who are experiencing incredibly life limiting contexts, people who are willing to take a chance on anything, people who are willing to go for whatever the extreme is to see what kind of outcome they can get in order to potentially have less limiting context. And so that’s sort of another and that, that can take you really into the untested and unproven areas where you know, you’ll have some stem cell clinics and stem cell procedures that are being offered that are really preying on the hopes of people who are in incredibly challenging circumstances that are life limiting. And, you know, hopefully, by the by it from the clinic’s perspective, they’re hoping that that these patients will be willing to pay literally whatever it takes in order to see an improved outcome, even though the evidence base may not be there because again, you can shift regulatory contexts in the practice of medical tourism and so the protections that you have that might prevent you from interacting with such a clinic in your home jurisdiction may not be there in the international,

Vaissnavi Shukl
just out of curiosity, do people travel to receive attention for mental health? Or is that something that hasn’t yet received as much attention when it comes to medical tourism?

Valorie Crooks
Yeah, that’s a great question. As I said earlier on, it’s very difficult to get any trend information with regard to medical tourism. You know, I wouldn’t rule out people travelling or not travelling for any type of procedure. I’ve talked to people who have travelled for all types of procedures and also, you know, I’ve there are people that travel abroad for certain kinds of therapeutic engagements or people who are travelling abroad for residential treatments as well. And so that can certainly fall within that window.

Vaissnavi Shukl
He also had because the wellness industry is quite big and you know, a lot of times people equate mental health to wellness and so that that boundary between the two can get quite blurred where somebody might have an actual mental health condition, but you might not be able to map it as in detail as say, going to a wellness resort or you know, going to a detox centre or something. Last question, Valerie in 2020. We saw both the aspects of medical tourism come to the forefront where of course this pandemic the health infrastructures of countries was put to test and you rightly mentioned that this can be broken down into one the public health system and the private health system and tourism came to an absolute full stop what happens to the medical tourism industry in cases where pandemics or geopolitical crises really make the movement of people very, very limited?

Valorie Crooks
You know, one of the things that medical tourism requires is ease of movement and so you know, earlier on in our conversation, you were asking if I could sort of see if we could kind of have a mental map of where people are leaving from and where people are going to and I explained the reasons why it’s actually really challenging to do that. But there are some things that we could say about where those arrows would be. So you know, countries that are very difficult to leave because of domestic like because of violence within the country because of instability because almost anywhere you would want to go from that country, you would require a visa and it’s very hard to access that visa. Then similarly countries that you would ultimately want to go to you need to be able to get in them and typically as low barriers as possible if you’re talking about accessing medical care abroad. So again, countries where most people entering will require visas countries where it’s challenging to get the visa countries where there are disputes that challenge your ability to actually even enter where you see flights being cancelled and things like that, you know, these are all things as well as you know, and we see this happening annually in relation to health emergencies as a result of climate change that actually shift your access to whether it’s something like an airport or even your ability to travel. These are all things that poses barriers to that ease of movement. For medical tourism to exist, you must be able to move with relative ease between countries. The higher the barrier is to move between countries, the less likely that someone is going to sort of overcome that barrier in order to access care, because what will happen is a market will open up somewhere else that is lower barrier. And so you know the pandemic certainly provides us with a very recent lived experience of what happens when that barrier it becomes incredibly high for most people. But there are other things as I just gave you some examples of various kinds of geopolitical circumstances, you know, whether paced circumstances and others that can sort of result in impacts in in that ease of movement, you know, the medical tourism industry. itself, it was, I’m sure very much on pause during the pandemic, as we’re most other travel based sectors. You know, people’s need for care would never have left if it was, you know, in relation to a surgical procedure, or whatever it might be. But people’s ability to travel abroad in order to address that need changed dramatically. And so I’m sure that you know, the medical tourism sector in many destinations has worked really hard on marketing has worked really hard on encouraging people to come and then, you know, one of the other things that’s happened as well is that our lives have very much turned to a greater ease of access to virtual things such as even right now your conversation with me via zoom. I know one space that I’ve heard about the medical tourism sector as really kind of having a robust emergence or re emergence following the pandemic is the fact that many of us were sitting on Zoom screens watching our own faces for months or years at a time growing with displeasure because it’s almost like staring at yourself in the mirror. And so you know, some destinations have really tried to take advantage of that by coming back with competitive pricing and competitive packaging for dental procedures and for cosmetic procedures in order to sort of use that as a way to sort of rebound and get things going back for back for rebuilding the sector or following the pandemic, reasonable kind of shutdown period. final final question,

Vaissnavi Shukl
what I’m working on right now in this area and what’s next? So

Valorie Crooks
it’s funny because I would have said the same answer. So like for the last many, many months, I have a final that I need to write for a book that I’m working on about my research on the medical tourism sector in the Caribbean region. I’m looking at what are some of the sort of key lessons that I’ve learned across the travels and across the countries and destinations that I’ve been in? And so also my work on medical tourism has exposed me to other transnational health mobilities that I have also started to pick up on in my research. So you know, I have through my work on medical tourism, interacted with many international retirement migrants so people who travel abroad seasonally, so in Canada, we often call them snowbirds. Seniors who leave for the winter and return back in many destinations. They are medical tourists, but there are a lot of health care complexities with regard to their journeys that I’ve been looking at as well as within the Caribbean region and as well, a companion or parallel mobility that’s really been emerging or offer medical schools is an offering sector as is medical tourism for international patients. And so there are a lot of parallels in terms of the kinds of equity and ethical questions that I asked about. This research even though training to be a physician is very different than practising as a physician on international patients. There are parallels between these mobilities and why both of them are, you know, being planned and being scoped out and in the Caribbean region. So these are some of the projects that I’m working on. Well,

Vaissnavi Shukl
thank you so much for your time. It was lovely speaking to you. I was really looking forward to this to this conversation.

Valorie Crooks
Yes, you’re welcome. It was a pleasure. I’m always happy to chat with people about medical tourism.

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.