Download Wellness Tourism - University of Delaware

Wellness Tourism:
The effects of the Globalization of the Healthcare
Industry
By
William Lane, F. J. DeMicco, G. Gokul
(DRAFT in Progress)
The University of Delaware
(Contact [email protected])
2007
Introduction
When thinking about tourism and health, most people think of becoming sick
while on a trip. This is a sure way to ruin any vacation. However, for centuries people
have traveled to enhance their health. The Greeks and Romans often traveled for health
and greatly valued baths, in medieval times people traveled for spiritual health, and in the
18th and 19th century the European elite traveled to spas and the sea for health reasons.1
People still travel for religious enlightenment and to spas. A more recent phenomenon is
people traveling to other countries for medical procedures. While common belief is that
elite people from underdeveloped countries travel to first world countries for treatment,
the trend is the opposite. People from first world countries are traveling to less developed
countries for treatment.2 This trend is having effects on both the home and host countries
and both doctors and patients move across borders. The shift towards a globalized
healthcare system not only affects the demand and supply of patients and doctors, but
also the economies and cultures of countries. Patients become tourists in the country they
go to for treatment, and affect the places they visit. This paper explores the factors that
are fueling this trend as well as the effects it is having.
1
2
Mueller, H & Kaufmann, E. (2000). Pg. 1
DeMicco, Frederick J
2
Reasons for Seeking Foreign Care
There are three major reasons that cause people to seek care in a foreign country:
1. They cannot afford the care at home and/or do not have health insurance.
2. Waiting times at home for the surgery are too long.
3. They procedure is not available at home.
Cost
Costs of healthcare have been rising at drastic rates in recent years. In America
they are growing at double digit rates.3 Many people can not afford the cost of such
care. The bulk of Americans are lucky enough to have insurance that will pay the
bulk if not all of the cost. Insurance however does not cover everything. Many people
seek procedures that are considered cosmetic and will not be covered by insurance.4
A facelift for example would cost about $20,0005. Few people could afford this cost,
but if they travel to South Africa the procedure would only cost $1,250.6
It is not only cosmetic surgeries that people cannot afford. There are about 43
million people in the U.S without health insurance and another 120 million without
dental coverage.7 This number is expected to grow as the cost of providing insurance
grows. Someone who is uninsured is unlikely to be able to afford the $100,000 cost of
a life saving bypass surgery. The cost of the surgery in Thailand, $12,000, is much
more affordable.
3
Single-Payer: Good for Business?. Pg. 2
DeMicco, Frederick J
5
DeMicco, Frederick J
6
DeMicco, Frederick J
7
DeMicco, Frederick J
4
3
Long Waiting Lines
In countries with universal health coverage, like the U.K, cost is not an issue.
Instead, people face long waits for procedure. Sometimes it can take years to receive
needed care. “If you wait six months for a heart bypass, you may not need it
anymore”. 8 Instead, for a few thousand dollars, you could fly to a foreign country to
receive care the next day. Another problem in these countries is that people are
passed through the system quickly. In the U.K, you would be discharged from the
hospital 5 hours after a normal delivery.9 In other countries you are encouraged to
stay longer and be sure both the mother and baby are healthy.
Superior Procedures
The third major reason people seek care in foreign countries is a surprising one.
Many procedures are available in foreign countries that are not yet approved in the
US. This is not because they have been found to be unsafe, but rather because
approval by the F.D.A is a slow bureaucratic process. India is especially known for its
high tech procedures. Instead of a hip replacement, patients can have their hips
resurfaced. This procedure is less invasive and allows for better, faster recovery.
People can even play sports after the procedure.10 These procedures yield results
superior to those available in the US so patients would rather have them.
This seems to be one of the newest ways to attract tourists to a foreign country.
The number of tourists is limited, so countries need to create new needs and products
for the tourists.11 By creating new procedures, they create a new need among tourists.
8
DeMicco, Frederick J
Vacation, Adventure And Surgery?.
10
DeMicco, Frederick J
11
Guerron-Montero, Carla
9
4
Before these procedures were created no one wanted them since they didn’t exist.
Now that they do exist, people want them and will travel to acquire them. Innovation
is what will allow tourist destinations to set themselves apart from other destinations.
Quality of Care
Many people may think that care in a developing nation would be low quality.
However, the quality is actually high. Many people actually say it is “first class”.12
These hospitals are normally accredited in the US. Some are even branches of well
known hospitals in the US13. Harvard Medical School for instance, will open a center
in Dubai by 2010.14
It is interesting that the quality of care is so high in the developing nations when
they also have “teeming, dusty streets”.15 Some developing nations, like Jamaica
don’t even have proper sewage systems.16 It is hard to imagine that they will be able
to properly deal with hazardous medical waste if they lack a basic sewage system.
The waste will likely be disposed of improperly, leading to health problems among
the local population. While the quality of care for foreigners in the hospital is high, it
will decrease the quality of life and health for locals. More examples of this will be
discussed later in this paper.
What is Wellness Tourism?
To understand what wellness tourism is, we must first define what wellness is.
For the purpose of this paper we will use the definition created by the World Health
12
Vacation, Adventure And Surgery?.
DeMicco, Frederick J
14
DeMicco, Frederick J
15
Vacation, Adventure And Surgery?.
16
Kincaid, Jamaica Pg. 14
13
5
Organization. They define it as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease.”17 This means that Wellness Tourism would
entail a host country providing visitors with facilities and opportunities to improve their
physical, mental and social well being. The major part of the industry, however, is
medical tourism, which focuses primarily on the physical well being of a person. With a
cornerstone of medical tourism, countries branch out to provide a wide array of services
that focus on the other components of wellness tourism.
Effects of the Industry
A trip to a foreign country means much more than simply visiting a hospital.
Countries like India are marketing themselves as a “global health destination”.18 By 2012
they predict the industry will bring $2.1 billion to the country.19 In order to draw patients
to the country they need to offer more than innovative procedures and cheaper prices.
When a patient decides to travel to a foreign country for surgery they receive many
benefits. Hospitals in these countries resemble 5-star hotels. Patients receive private
rooms and are given dedicated nurses.20 Patients are also given vacations to beaches and
resorts close to the hospital after their surgery. Airlines even offer special frequent flyer
mile programs to patients to ease the cost burden associated with returning for follow up
visits.21 While this pampered care costs far less for the patient than it would at home it
still brings a large amount of money to local economies. A detailed look at the different
ways medical tourism affects countries is needed to fully understand the industry.
17
Mueller, H & Kaufmann, E. (2000). Pg. 1
India Fosters Growing Medical Tourism Sector Pg. 1
19
India Fosters Growing Medical Tourism Sector Pg. 2
20
DeMicco, Frederick J
21
DeMicco, Frederick J
18
6
Movement of Health Personnel
The movement of health personnel is increasing as medical tourism becomes more
popular. Currently, the bulk of doctors and nurses move from developing countries to
industrialized ones.22 This is commonly known as brain drain and is a major problem in
developing countries. The most educated people leave the country in search of better
wages and living conditions. While many people in developing countries would like to
migrate, most are not able to. This creates a problem for the developing countries as they
put money into education systems to educate their people in order to improve the country
and then the people simply leave. This happens with medical personnel too. The great
cost to train these people is not offset by the remittances they send back to the country.23
These remittances also go to family members instead of the public which funded the
education. As health professionals leave the country will face a shortage of doctors and
nurses which will lead to decreases in the quality of and access to care in the country.
Some people however feel that remittances are better than having a tourist industry.
As we will see later, most tourist facilities (including hospitals) are owned by foreigners
so most of the profit leaves the country. Remittances however go directly to locals and
into the local economy. According to Marion Bernard Amos, people in Jamaica feel this
is better.24 However, there are other big picture problems that result from people leaving
their home country and simply sending back some money. These are illustrated in the
following sections.
22
World Health Organization. Pg. 4
World Health Organization. Pg. 4
24
Bernard-Amos, Marion
23
7
Brain Drain
Many programs have been introduced to try to curb brain drain. These include
migration taxes, mandatory periods of service and income tax incentives.25 These
programs have seen results, and now medical tourism offers additional incentive for
health professionals to stay in or return to their home countries. Despite the fact that
doctors in India make 1/10th to 1/20th of their US counterparts, many are returning to
India from the US.26 One reason for this is they will be much more prestigious in India.
While there are 2,000 pediatric cardiologists in the US there are only 4 in India.27 Doctors
will be well known and be held in high regard by society. While they are making a lot
less money, the cost of living in India is also lower so they will still be well off. These
doctors also see the growth of the medical tourism industry and see the money it is
bringing with it. They can see that this industry will continue to grow and bring in more
money for doctors. Another factor is that malpractice is less expensive in India.28 In
America doctors are constantly fearful of being sued and losing a large sum of money.
They spend thousands of dollars each year for malpractice insurance. In India this cost is
much smaller so doctors can keep more of the money they make. Expatriate doctors also
realize that their skills are needed at home.29 They feel that they should help the country
that trained and raise them. This decision is becoming easier now that doctors can make
more money be seeing foreign patients at home. They can also access high tech
equipment that was previously unavailable at home.
25
World Health Organization. Pg. 9
Vacation, Adventure And Surgery?.
27
Vacation, Adventure And Surgery?.
28
Vacation, Adventure And Surgery?.
29
Vacation, Adventure And Surgery?.
26
8
It is questionable if these new opportunities in the medical field are really open to
everyone. In the articles reviewed for this paper, only male doctors were quoted. This
may be a sign that the medical profession is a gendered one as it once was in the US. If
women are kept out of the profession then only men will directly benefit.
Commercial Facilities
It may sound like by developing facilities and personnel for medical tourism, the
quality of and access to care in the host countries will improve. This could not be
farther from the truth. “Alongside the familiar images of [India] (teeming, dusty
streets and poverty) you can add gleaming new, private hospitals.”30 These facilities
stand in stark contrast to the rest of society. As with many tourist facilities, hospitals
that cater to foreigners are usually built by foreign companies. The bulk of money
brought in by these hospitals ends up flowing back to the foreign country.31 This
illustrates the repatriation of profits effect that is often associated with tourism in a
country. Due to majority ownership of facilities by foreign investors, most money
ends up flowing back to foreign countries.
Creation of a Two-Tiered Healthcare System
Another problem is that these facilities end up creating a two-tiered healthcare
system.32 The hospitals created by foreign investors are private and patients have to
pay to use them. Other hospitals in the country are often government run. The
problem is that by having a two tiered system a stark difference is created between
30
Vacation, Adventure And Surgery?.
World Health Organization. Pg. 6
32
World Health Organization. Pg. 6
31
9
the two systems. The quality of care in the public hospitals is much lower.33 The
lower quality is a direct result of the private hospitals. Doctors would rather work at
the private hospitals since they pay better.34 This leads to an internal brain drain. It
also causes an effect known as “cream skimming”.35 This effect means that the people
who need the care the least are served the best and the poor who need it the most are
not served. This is a unique example of the reverse multiplier effect36. Due to catering
to tourists, the cost of care is rising. Locals can no longer access quality care and are
left with poor access to low quality care in the public hospitals.37
It is clear that the management plans of these countries leave a lot to be desired.
For a tourism industry to be successful, a management plan is required that involves
all stakeholders.38 As is common with the tourist industry, India has focused on
tourists. They are allowing the tourist needs to dictate the plan. Instead there should
be a dialogue between the needs of locals and wants of tourists. This would involve
the locals who are the stakeholders being overlooked. Below are steps that these
countries can take to make sure the medical tourism industry benefits tourists and
locals.
Solutions for a Two-Tiered System
There are some ways that the difference between private and public hospitals can
be lessened. The first method is to tax private hospitals and use the money collected
33
World Health Organization. Pg. 6
World Health Organization. Pg. 6
35
World Health Organization. Pg. 6
36
Guerron-Montero, Carla
37
World Health Organization. Pg. 10
38
Guerron-Montero, Carla
34
10
to fund public hospitals.39 This, however, may discourage foreigners from investing
in hospitals as they will not make a large profit. It is common for countries to offer
tax incentives to foreign investors to encourage them to invest. Unfortunately, this
significantly decreases the amount of money the investment would bring to the
country. Another method is to form relationships between public and private
hospitals. These linkages could include shared facilities, joint research projects, or
professional exchanges.40 These linkages would ease some of the burdens on public
hospitals and lead to improved quality of and access to care.
Another solution that is often mentioned is telemedicine. Through telemedicine,
doctors can provide care to patients from a remote location through special
technologies.41 This can allow doctors located in urban areas to also serve people
located in rural areas. These people are often not able to access the care they need.
The problem with telemedicine is that solid power and communication infrastructures
are required.42 Developing countries often do not yet have the infrastructure required
and it would take a large investment to create it. The cost may be so great that it
would be more efficient to invest in more basic care facilities in the country.43 This is
an example of an opportunity cost, a dilemma often faced in the tourism industry.
Developing nations have a limited amount of resources, and must decide how to
spend them. If they choose one option then they forgo many others. Not only will
developing infrastructure for telemedicine forgo the opportunity to create more basic
care facilities; it will also forgo the opportunity to spend these recourses on education
39
World Health Organization. Pg. 10
World Health Organization. Pg. 10
41
World Health Organization. Pg. 10
42
World Health Organization. Pg. 10
43
World Health Organization. Pg. 5
40
11
or other public services. Developing nations must choose what to spend their
recourses on carefully, as each decision will result in benefits and costs to the society.
Combining Surgery and Paradise
Many people will agree that hospitals are depressing places and not good for a
persons mental or social well being. Foreign countries have realized this and start by
making hospitals not feel like hospitals. Instead they are built to resemble four star hotels.
Once people are well enough that are sent to better locations for their recovery. These
places resemble typical tourist locations, but care for recovering patients is also available.
These destinations include beaches and spas.
Many of these locations are located next to the sea. This is because tourists seek
locations that “benefit the soul by making them feel small, yet part of an infinite and
universal cycle.”44 By feeling in touch with the universe, people will feel better mentally,
increasing their mental wellness. This process is also helped by the fact that these people
can escape to stresses of the modern world and simply relax. Resorts often offer yoga and
other forms of relaxation and meditation techniques.45 Spas offer similar amenities as
beachfront resorts; they simply try to recreate the benefits of the ocean away from the
ocean. Ocean water also has beneficial health affects and may aid recovery. Resorts
compound these benefits by offering traditional medicines and therapies to the tourists.46
At these facilities people’s social wellness is also improved. People on vacation
are often more relaxed, friendly and outgoing than at home. This leads to an abundance
of positive social interactions. Resorts encourage this behavior by organizing activities
that promote socialization and interaction between guests. By having positive social
44
Mueller, H & Kaufmann, E. (2000). Pg. 2
Mueller, H & Kaufmann, E. (2000). Pg. 2
46
Mueller, H & Kaufmann, E. (2000). Pg. 2
45
12
interactions at a location that increases ones mental wellness, one will leave in a much
healthier happier state than they came.
This fits well with Graburn’s theory that tourist experiences are sacred.47
According to Graburn, tourists experience a high when on a trip.48 Since tourists are
happy during their “high”, they will be mentally well. Graburn also states that
“the normal social structures of life, work and family roles,
age and gender differences, and so on tends to become looser or
disappear.”49
This would certainly create a positive social environment where people will interact with
each other. This explains why people can easily improve their social wellness while
traveling.
Wellness and Tourism in General
After examining Wellness Tourism, one begins to see that all tourism is actually
related to wellness in some manner. According to Dean MacCannell, tourists are in
search of authenticity.50 The have lost a sense of identity in the modern world, and search
for meaning in the primitive51, or as other anthropologists have stated in nature. If people
have lost a sense of identity and place within society they are not well mentally or
socially. They seek out places that will allow them to become well again. They travel to a
beach or visit primitive peoples to once again understand their place in the universe or
interact socially. After these interactions, they will be well again and ready to once again
face the modern world. Many people also travel to escape the stresses of work and other
47
Graburn, Nelson H Pg. 27
Graburn, Nelson H Pg 27
49
Graburn, Nelson H Pg. 29
50
MacCannell, Dean Pg 57
51
MacCannell, Dean Pg 57
48
13
obligations in their lives. When traveling people can relax and be relived of stress which
increases their mental wellness. In these ways we can see that many kinds of tourism are
related to a person wanted to increase their wellness.
Reproductive Tourism
One interesting subgroup within medical tourism is reproductive tourism.
Reproductive or infertility tourism is when people seek medical assistance in
reproduction in a place other than their home country.52 People take part in this type of
tourism for many reasons. The most common are because the procedures are prohibited at
home, the person is considered unfit for parenthood at home, waiting lists at home are too
long or the cost at home is too high. Many of these reasons are similar to the general
reasons that medical tourism take places, but some are unique to reproductive tourism.
These reasons often center around ethics and laws which are typically a declaration of the
country’s agreement on ethical issues.53
Ethical debates occur when people do not agree on issues. In the postmodern
world, people generally shared a common world view.54 Many people are striving to
return to this uniform view, but in modern society beliefs vary too much for this to
happen easily. In Europe, legislators want to agree on laws to regulate medically assisted
reproduction throughout the European Union. Views between countries vary greatly
however. Italy, for example, has banned all research on and preservation of embryos.55
This is because the law is the belief of the many Catholics in the country.56 Not everyone
52
Pennings, Guido
Pennings, Guido
54
Pennings, Guido
55
Pennings, Guido
56
Pennings, Guido
53
14
in the country however agree with this belief. Problems like this often happen in
democracies where the majority makes the decisions. For this reason people travel to
other countries to seek the medical procedures they desire. Not only will they travel to
other European countries that allow the procedures to be conducted; they also travel to
countries like India.
This brings its own problems to host countries. While the majority of people in
the country may not feel that these procedures are ethical, the money brought in by
conducting them on foreigners may lead to their protests falling on deaf ears. Politicians
may even be bribed by foreign companies to not make legislation against such
procedures. Other problems revolve around the donors. Donors are often paid large
amount of money for donating eggs.57 This can cause problems in developing nations as
people will jump at the opportunity to make money. They may not take the time to
consider the risks that can occur from the procedure of donating. Often times people may
not even be properly informed of the risks as companies want to obtain large numbers of
donors.58 In developing nations with less strict laws these problems can be even worse.
Many countries have attempted to stop people from traveling to undergo
reproductive procedures. In the 1990s German border guards would examine women
returning to the country. If they were found to have undergone a procedure they would be
prosecuted since it was illegal in Germany.59 Positive local sanctions are an important
prerequisite for travel, so methods such as this would greatly decrease the number of
people traveling for reproductive reasons. With new articles to the European Community
57
Pennings, Guido
Pennings, Guido
59
Pennings, Guido
58
15
treaty, such practices are now condemned in Europe.60 This is an example of how a more
commonly held belief, that services should be allowed to move freely between countries,
outweighs another belief that is only held locally.
This is similar to people taking part in sex tourism. People taking part in sex
tourism can engage in activities that are illegal at home, just as people who seek
reproductive procedures in foreign countries do. Both behaviors result from a difference
in laws in different countries. Just as the poor are often targeted for donations, the poor
are also targeted by the sex tourism industry. It seems that when laws differ it is the poor
that are taken advantage of.
Organ Trafficking
Closely related to medical tourism is organ trafficking. Modern medical
technologies allow doctors to save lives by transplanting organs. However, the need for
organs is many times greater than the supply. People end up waiting long periods of time
for organs, and many die before receiving them. Since organs can save lives people are
willing to pay a premium for them. This leads to many practices that are considered
unethical. In many developing countries organs are obtained in ways that many feel are
unethical or that should be illegal. These include obtaining them from executed prisoners,
obtaining them forcefully from a person, and killing people for organs (including
children). Many of these practices still occur even if they are made illegal. This occurs
because of the high price that “organ brokers” will pay for organs.61 Many people in
developing nations will also willingly donate organs. People in poor areas of these
countries jump at the money offered for organs that they can live without, such as part of
60
61
Pennings, Guido
Scheper-Hughes, Nancy Pg. 221
16
their liver or a kidney. The problems with this are similar to the ones that arise from
people donating eggs for reproductive tourists. They are often poorly informed of the
complications and risks from the surgery.62 In many parts of India “Organ Bazaars” exist
where poor people will come to donate organs for money and the ill rich will come to
purchase them.63 The people who work in these bazaars do not feel they are doing
anything wrong. They say they are helping match donors and ill patients which saves
lives.64 Both people can benefit from this transaction. While such bazaars are illegal, they
still exist.65
Just like with reproductive and sex tourism we see the poor being taken advantage
of. As Jamiacia Kincaid has illustrated, people from first world countries often do not
take the time to fully understand the place they visit66. They may not know where the
organs they are receiving come from and how dangerous it is for the donors. Even if they
know it may not matter. If they see people from these countries as primitive and not as
beneficial to society, then they may feel that them sacrificing their life for a first world
patient is appropriate.
In China, organs are harvested from executed prisoners. People in China believe
that this practice is good because it helps the greater good, and is a way for the prisoner’s
family to regain their honor.67 A family’s honor is very important in Chinese culture. This
belief leads to ethical views that would not be accepted in many other countries. When
two Chinese men were found to be selling these organs in New York City they were
62
Scheper-Hughes, Nancy Pg. 195
Scheper-Hughes, Nancy Pg. 195
64
Scheper-Hughes, Nancy Pg. 195
65
Scheper-Hughes, Nancy Pg. 195
66
Kincaid, Jamaica Pg. 4
67
Scheper-Hughes, Nancy Pg. 196
63
17
arrested by the FBI. What they were doing was legal in their country but because of
different ethical views in America it was illegal in New York.
This illustrates the point made by Jamacia Kincaid that tourism is a form of
imperialism.68 Tourists bring with them views of what is right and wrong and will try to
force these views on the locals. As more people travel in search of organs, they will
hopefully question where the organs come from. As it is publicized that the source of
organs in china is one that many tourists will view as unethical, people will stop seeking
organs in china and go elsewhere. If the Chinese change their traditions to fit those that
the tourists feel are acceptable, then the tourists will have forced their cultural views on
the locals of China.
Ethics in Medical Tourism
As society becomes more globalized we will see more ethical problems emerge.
People come from diverse cultures, and have their own beliefs. They want to be able to
maintain their own identity within society and will not easily give in to others beliefs.
While Christian missionaries tried to spread their beliefs to others and make the world
uniform, people have worked to regain their original cultural beliefs. We are a far way
from being able to agree on every ethical issue worldwide. Industrialized nations may see
their ethics as superior to those of less developed countries and try to force them to
follow them, but people hold their beliefs strongly and will not easily give in.
Conclusion
68
Kincaid, Jamaica Pg. 30
18
Globalization is changing the world’s societies, leading to new opportunities as well
as problems. According to economic theory, countries that are more efficient in an
industry will dominate that industry if there are no barriers to trade. While people have
traveled to increase their wellness for centuries, it is only recently that we have seen them
travel for medical procedures. As nations develop barriers to trade are lifted and they can
compete with industrialized nations. We can see that India is attracting patients because
they can offer less expensive better procedures. It is good for a developing nation to be
able to compete with industrialized nations for customers. However this industry is
mostly owned by foreigners. This causes most of the profits to leave the country and not
benefit locals. The industry is also causing a two-tiered system with low quality public
hospitals.
The globalization of the industry has also caused many ethical dilemmas. As
different cultures interact their views on issues will vary. What may be perfectly
acceptable in one country may be illegal in another. This can cause problems as countries
feel that their view is the right one and try to force people to follow it.
With medical tourism, people are able to do what they feel is right. If something
is illegal in their home country, but they believe it should be allowed, they can travel to a
place where it is not illegal. However, the money brought by tourists can often encourage
illegal and/or unethical practices in the host country. Money can greatly motivate a poor
person, even to the extent that they will do something illegal or dangerous. This is often a
problem with tourism as the money brought by tourists can greatly disrupt a society.
Developing countries try to curb these actions but it is often hard to do without harming
the tourism industry.
19
As society becomes more globalized it is important for one society to not push its
views on another. Every culture is unique and people should be allowed to maintain their
own identity within the greater society. Host countries should not simply give in to tourist
demands, but work to find a balance between local beliefs and tourist demands. With
proper regulation, both tourists and locals can benefit from globalization.
20
Bibliography
Bernard-Amos, Marion (2006 October) Jamaica Presentation for anthropology of tourism
Class
DeMicco, Frederick J. Club Medic. FIU Research Journal (In Press)
Graburn, Nelson H.. Secular Ritual: A general theory of tourism In S.B. Gmelch (Ed).,
Tourists and Tourism (pp.23-33). Illinois: Waveland Press.
Guerron-Montero, Carla (2006) Anthropology of Tourism class
India Fosters Growing Medical Tourism Sector (2003, July 2). Yale Global Online,
Retrieved October 29, 2006, from
http://yaleglobal.yale.edu/display.article?id=2016
Kincaid, Jamaica. (1988). A small place. New York: Farrar, Straus and Giroux.
MacCannell, Dean.. Sightseeing and Social Structure: The moral integration of
modernity In S.B. Gmelch (Ed)., Tourists and Tourism (pp.55-70). Illinois:
Waveland Press.
Mueller, H & Kaufmann, E. (2000). Wellness Tourism: Market analysis of a special
health tourism segment and implications for the hotel industry. Journal of
Vacation Marketing, 7, 5-16.
Pennings, Guido. (May 2005)Legal harmonization and reproductive tourism in
Europe.(ANALYSIS). In Reproductive Health
Matters, 13, p120(9). Retrieved October 29, 2006, from
Expanded Academic ASAP via Thomson Gale:
http://proxy.nss.udel.edu:2104/itx/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T002&prodId=EAIM&docId=A134313000&s
ource=gale&userGroupName=udel_main&version=1.0
Scheper-Hughes, Nancy. (April 2000)The Global Traffic in Human Organs. In Current
Anthropology, 4 pg 191-224.
Single-Payer: Good for Business?. (2004, Nov. 15). The Nation, Retrieved
October 29, 2006, from
http://www.thenation.com/doc/20041115/mintz
Smith, K & Kelly, C. (2006). Wellness Tourism. Tourism Recreation Research, 31, 1-4
Vacation, Adventure And Surgery? (2005, Sept. 4). CBS News, Retrieved
21
October 29, 2006, from
http://www.cbsnews.com/stories/2005/04/21/60minutes/main689998.shtml
Wojcik, Joanne. (July 17, 2006)Vendors target self-insured.(News)(Brief article).
In Business Insurance, 40, p64. Retrieved October 29, 2006, from
Expanded Academic ASAP via Thomson Gale:
http://proxy.nss.udel.edu:2104/itx/infomark.do?&contentSet=IACDocuments&type=retrieve&tabID=T003&prodId=EAIM&docId=A148375672&s
ource=gale&userGroupName=udel_main&version=1.0
World Health Organization. (2002). Bulletin v.80 n.2 Switzerland: Author. Retrieved
October 29, 2006, from
http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S004296862002000200012&lng=pt&nrm=iso&tlng=en
22