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    Anthropology & Medicine
    Vol. 18, No. 1, April 2011, 119–136
    Selling medical travel to US patient-consumers: the cultural
    appeal of website marketing messages
    Elisa J. Sobo * , Elizabeth Herlihy and Mary Bicker
    San Diego State University, San Diego, California, USA
    (Received 1 July 2010; final version received 6 September 2010)
    More US-based patients than ever are travelling abroad for medical or
    dental services. Beyond financial incentives, what cultural factors have
    supported this trend? Because of their interest in selling medical travel,
    medical travel agencies (MTAs) have vested interests in this question.
    To find out how they are answering it, an ethnographic content analysis
    of MTA websites was undertaken. Beyond themes promoting a ‘worry-free
    experience’ of ‘legitimate services’, themes linking healthcare consumerism
    to culturally specific identity ideals and self-creation/representation pro-
    cesses predominated. Themes relating to the demonstration of social
    position, savvy expression of good consumer judgment, and achievement
    of libertarian ideals figured highly. However, various inconsistencies
    (including an appeal to tourism in some but not other situations) suggested
    that medical travel involves, for the US-based consumer, a complex act
    of juggling context-specific self-identity desires and expectations in relation
    to healthcare. The potential impact of prevailing discourses on ‘self-
    construction-in-practice’ was explored. Findings enhance understanding of
    the care seeking process as experienced within the context of globalized,
    mass-mediated healthcare consumerism. They also point to the need for
    finer-grained distinctions than the global gloss ‘medical travel’ offers.
    Keywords: medical tourism; medical travel; healthcare consumerism;
    self-construction; identity; internet marketing; qualitative research; global-
    ization; USA
    Introduction
    Travel for the primary purpose of obtaining medical or dental services is on the rise.
    Some reasons for this are financial and technological – but, as in other realms of
    medicine, cultural features also must play a role in fostering demand. Medical travel
    agencies or MTAs (i.e., their owners and those who manage and staff them) have
    vested interests in sharply perceiving and leveraging these features to corner the
    market. An examination of strategies undertaken by MTAs to do so can broaden
    knowledge regarding the cultural context in which US consumers consider and
    undertake medical travel. To this end, an ‘ethnographic content analysis’ (Altheide,
    1987) of MTA websites targeting the USA was undertaken.
    The study’s findings enhance understanding of care-seeking processes as
    experienced within the context of globalization and in light of the rise of
    *Corresponding author. Email: esobo@mail.sdsu.edu
    ISSN 1364–8470 print/ISSN 1469–2910 online
    ? 2011 Taylor & Francis
    DOI: 10.1080/13648470.2010.525877
    http://www.informaworld.com
    consumerism as a major tenet in US culture. They illuminate themes prevalent in the
    decision to outsource one’s healthcare, and elucidate the self-construction practices
    and aims implicated. By focusing on medical travel facilitators rather than producers
    or consumers, this study highlights a generally overlooked yet potentially crucial part
    of the medical travel marketplace. And by incorporating the internet, the research
    has great relevance for scholars seeking to adequately understand contemporary
    social life and self-construction (cf. Garcia et al. 2009; e.g. Altheide 2000; Holstein
    and Gubrium 2000).
    Background
    The global business of medicine
    In part due to ‘the liberalization of trade in services, the growing cooperation
    between private and public sectors, the easy global spread of information about
    products and services, and, most importantly, the successful splicing of the tourism
    and health sectors’ (Bookman and Bookman 2007, 95), more patients outbound
    from various North American and European nations have joined the medical travel
    consumer population. In the USA, thanks to (among other things) high numbers of
    un- and under-insured individuals; an increasing demand for so-called lifestyle care,
    such as knee replacements and aesthetic or cosmetic surgery; technological
    developments supporting quicker, less invasive surgeries; increased awareness of
    options due to word-of-mouth (including internet discussions); and increased general
    media coverage of the phenomenon, the number of medical travellers is growing year
    by year (Keckley and Underwood 2008, 3).
    Asian nations are among those that have actively pursued medical travellers as
    well as programmatically encouraging necessary infrastructural development
    (Whittaker 2008, 275). 1 Hotelmarketing.com estimates that ‘the industry in
    Malaysia, Thailand, Singapore and India, currently worth around half a billion
    dollars a year in Asia, is projected to generate more than US$4.4 billion by 2012.
    India’s medical tourism business is growing at 30 per cent per year’ (Anonymous
    2006). Similarly rosy prognostications abound.
    While some outbound travellers seek treatments unavailable in the USA, the
    majority of medical travel has been explained by financial logic: a hip replacement
    costs about $37,000 in the USA and $13,000 in India. An $80,000 US heart bypass is
    $16,000 in Thailand (Higgins 2007). Using weighted average procedure prices, one
    report put the average savings from the US perspective at about 85% (Keckley and
    Underwood 2008, 13). Although in many reports financial logic speaks for itself,
    it only can do so in light of pervasive US beliefs that healthcare is a market good
    and that patients are (capable) consumers.
    Beyond its financial logic, care procured at certified non-US facilities is generally
    of equal or better quality than the US standard (Milstein and Smith 2006). This
    appeals in the cultural context of consumer advocacy and provider accountability.
    One source of information on quality is the Joint Commission International (JCI),
    organized by the US-based Joint Commission, which accredits US healthcare
    organizations. Other organizations, such as the International Society for Quality
    in Health care (ISQUA), also have participated in accreditation efforts. Quality is
    assured through a number of processes, including use of evidence-based clinical
    guidelines, provision of care plans to patients for facilitation self-care, electronic
    120 E.J. Sobo et al.
    medical record and clinical information systems, coordination of care with a
    patient’s home-town providers, adverse event action plans, outcomes measurement
    and reporting, etc (Keckley and Underwood 2008, 8–9).
    Consequently, some US insurance companies (such as BlueCross BlueShield
    of South Carolina) and government payers (such as the state of West Virginia) have
    considered sending patients overseas for certain types of care, or offering them
    cash rebates for doing so (Bramstedt and Xu 2007; Carrol 2007). In California,
    several insurance companies now offer bi-national (US-Mexico) coverage.
    Anthropological views
    Beyond attending to its various political-economic dimensions for critical purposes
    (e.g., Scheper-Hughes 2002), existing anthropological literature on medical travel has
    generally focused on the medical travel consumer. Most scholars have been
    interested in how consumers use (or strive to use) medical travel to meet particular
    cultural expectations.
    For example, Beth Kangas, a pioneer in the area, has studied travel from Yemen
    undertaken (when possible) for cancer and other care unavailable there. Kangas has
    shown that Yemenite families send relatives abroad for care as a public demonstra-
    tion of affection or ‘to prove that they did everything they could for their loved ones’
    (Kangas 2002, p. 66) as well as to avoid criticism for not doing so, and to deflect
    attributions of culpability for a relative’s demise onto the medical system (see also
    Kangas 2007). In addition to its physical benefits, then, medical travel is crucial
    in how people create and maintain their identities as ‘good’ relatives (e.g., parents,
    spouses, children).
    While Kangas has focused on people with problems such as cancer, other work to
    date has been concerned with travel for reproductive procedures. (e.g., Inhorn and
    Patrizio 2009; Speier 2008; and see Inhorn and see Speier, this issue). Identity and
    social role fulfilment issues remain a prominent theoretical focus. Particular
    questions relate to the relationship between gendered reproductive ideals and
    cultural and socio-political citizenship, status, and authority. The antagonism
    between the kind of corporeal partibility supported by market logic and the ideal of
    bodily integrity, the rise of consumer-oriented medicine in general, and the critique
    of US biomedicine implicit in much outbound medical travel also has been of
    concern.
    Cosmetic or aesthetically-motivated medical travel also has garnered a share of
    research attention; here, self-production displaces reproduction but otherwise similar
    concerns surface. Sara Ackerman, for example, conducted ethnographic interviews
    of cosmetic surgery seekers in Costa Rica (Ackerman n.d.). While her main focus
    was the social divisions manifest in and reinforced by the plastic surgery trade, most
    consumers to whom she spoke were quite self-concerned. Further, most cast the
    decision for alteration as part of a holistically restorative process. Cosmetic surgery
    was seen as a form of mind-body realignment or repair, in which an inner ‘self’ that
    had become disjointed from a person’s (often younger, or ideal) body was reunited
    with the body that it deserved or to which it was already once connected. Cosmetic
    surgery, from this perspective, is the opposite of frivolous. It provides for ‘full social
    participation, or citizenship’ (Ackerman n.d.).
    Anthropology & Medicine 121
    Questions raised
    While there is much to be learned directly from consumers, it also makes sense to
    query the various organizational or institutional contexts for their actions. Doing so
    can reveal both the structural and discursive constraints delimiting their actions,
    and the desires and understandings they bring to the endeavour, at least inasmuch as
    the contexts reflect them. In this regard, scrutiny of medical travel facilitation
    organizations is ideal.
    Whether for profit or service motives, medical travel agencies or MTAs (i.e., their
    owners and those who manage and staff them) have vested interests in attaining
    a keen understanding of consumer concerns and desires: they want to leverage
    this understanding to meet consumer needs and/or sell their goods. Assuming
    they have got an at least fairly accurate reading of their market (it is in their
    best interests to do so), an examination of the themes articulated on their sites,
    and the ways these themes are deployed in the quest to produce actual customers,
    can broaden knowledge regarding the cultural context in which US consumers
    consider and undertake medical travel. So too can information regarding whether
    and how internal differentiation of the US medical travel market (for instance
    for oncology vs. procreative vs. aesthetic services, etc) is reflected in MTA website
    discourse.
    There is another reason for querying MTA websites. Existing research on medical
    travel highlights issues related to self-construction, self-perception, and self-
    presentation that consumers find salient. Further scrutiny may help advance
    understanding in this area. 2
    For example, the ‘self’ referenced by Ackerman’s participants seems to be what
    Victor de Munck elsewhere has shown as a culturally constructed ‘self symbol’ – one
    that not only reflects cultural ideals but also provides an ‘illusion of a unified,
    coherent self’ (de Munck 1992, 167). This illusion veils a multiplicity of identities and
    associated ‘subselves,’ each including particular ‘behavioural, cognitive, and affective
    complexes’ (de Munck 1992, 171). Participants in Ackerman’s work would have
    subjectively experienced regeneration through reintegration both because of their
    culturally constructed expectations for ‘self’ (including self-coherence) and in spite of
    the incoherence that the ‘self’ serves to mask.
    The ‘self’ may a symbol be but, as Holstein and Gubrium (2000, 12) note, it is
    ‘widely produced’ in keeping with the contemporary cultural (including institutional)
    demand for it: it is ‘something persons must continually manifest as a basis
    for making sense of their conduct and relationships’. For Holstein and Gubrium,
    self-construction is an ongoing, practical, every-day, contingent, context-based
    ‘interpretive practice’ (Holstein and Gubrium 2000, 94) and a lot of work goes into
    this. People are not each on their own, however. People participate in myriad
    institutions or ‘going concerns’ (Holstein and Gubrium 2000, 13, citing Hughes
    1984). Furthermore, ‘Selves are themselves institutional projects in the sense that
    institutional discourses provide the conditions of possibility and institutionalized
    discursive practice supplies the model of production for putting into effect our
    identities as part of accomplishing matters of ongoing local interest’ (Holstein and
    Gubrium 2000, 95).
    In light of this, and in light of the increasing numbers of medical travellers, in
    addition to seeking to catalogue MTAs’ understanding of consumer concerns and
    desires, research might also ask what ‘model of production’ or self template medical
    122 E.J. Sobo et al.
    travel agency (MTA) websites are providing. As these questions involve cultural
    meanings, an ethnographically informed approach will work best.
    Methods
    To address the issues at hand, an ‘ethnographic 3 content analysis’ (Altheide 1987)
    was undertaken of MTA websites: cultural artefacts created by the medical travel
    industry. This approach entails a reflexive, iterative engagement with documents;
    the ‘constant comparison’ technique (Glaser and Strauss 1967) is dominant. The
    investigator plays a central role, moving back and forth reflexively between, as per
    Altheide’s list, ‘concept development, sampling, data collection, data coding, data
    analysis, and interpretation’ (Altheide 1987, 68). Recall that consumers’ imagined
    presence and real feedback provided by them to MTAs play a huge role in shaping
    the artefacts under analysis – just as the ‘going concern’ of the MTA provides an
    institutional context for shaping consumer selves. Ethnographic content analysis
    findings therefore can reveal much more than just what the media ‘contain’.
    Sampling strategy
    ‘MTA website’ was defined as a website intended to sell comprehensive medical
    travel services, which are not only clinical services but also transportation,
    accommodation, and pre- and post-procedural assistance. To limit focus, further
    eligibility was limited to MTAs with offices in the USA and websites in English.
    To ensure a broad sampling universe, searchenginewatch.com was consulted for
    the latest search engine rankings released by comScore (Gunasekera, Ernst, and Ezra
    2008). The research used the top three which, together, accounted for 91% of all
    internet searches (Burns 2008). The search term ‘medical tourism’ was selected as it
    produced the highest number of eligible MTA ‘hits’ in feasibility tests (regarding
    scholarly objections to this label, see Sobo 2009; see also Inhorn and Patrizio 2009;
    Kangas, 2010).
    To amass a sample that would provide ample data for valid and reliable findings,
    for each search engine, each of the first 150 hits that met the eligibility criteria
    described was collected, leading to 49 eligible websites. Twenty-seven were unique.
    Because ‘the World Wide Web is a fast-moving medium’ (van Esch, Cornel, and
    Snoek, 2006, 1235), each website’s pages were printed for static storage and data
    stability, with colour and animation information noted as relevant.
    Building the codebook and coding website content
    The websites were randomized and divided for inductive code development. Coding
    focused not only on prevalent ideas or ‘themes’ (content) but also, following Norris
    et al. (2006), the structural characteristics (form; e.g. colour palate, organizational
    features) of the various websites. The research’s main goal was to build a conceptual
    map or model of MTA ideas about potential customers directly from, or grounded in
    and traceable to, the texts under study (Glaser and Strauss 1967; Strauss and Corbin
    1998). As ethnographic content analysis is a reflexive process (Altheide 1987), the
    final model was also influenced by what the researchers saw during preliminary
    sampling trials as well as by literature regarding the US healthcare consumer
    Anthropology & Medicine 123
    movement and, in regard to structural codes, by their knowledge of basic website
    architecture.
    The search for themes began with ‘open coding’ (Glaser and Strauss 1967), in
    which all three authors (the research team members) closely reviewed the websites
    through iterative, recursive reading with the aim of identifying and labelling
    variables. Team members independently reviewed their allocated websites to the
    point of saturation (i.e., when the texts became redundant). Each took careful notes
    on all discrete ideas about medical travel mentioned, bearing in mind the situation-
    specific contexts in which they were brought up. Each attended to repetitions,
    metaphors and analogies, key words, transitions and syntactic connectors, indige-
    nous categories or typologies (e.g., ideas expressed colloquially), depiction of causal
    chains, evaluation claims, shifts from past to present tense, and digressions
    (Hill 2005; Quinn 2005; Ryan and Bernard 2003). Each compared like examples
    across websites and looked for disconfirming cases.
    Each team member produced a preliminary set of data-grounded open codes.
    To best reflect the MTA point of view, code names were drawn directly from, or
    paraphrases of, language used in the websites.
    The team met to compare code sets and then hone and merge them. The team
    then generated a codebook with, as is standard, one row for each code and four
    columns: one each for the code, its definition, an example, and any special rules.
    MB and EH then reviewed website print-outs to extract data regarding structural
    features. They did this together as a quality assurance measure.
    MB and EH began thematic coding also as a pair. Pair coding promotes
    reliability because it demands explicit vocalization of assumptions and regular cross-
    checks of the same as well as calling on paired investigators to regularly challenge
    each other’s distinctions (Salinger, Plonka, and Prechelt 2008, 18). When agreement
    was secure, MB and EH split and individually coded the remaining websites. They
    met regularly with each other and ES to compare notes and ideas; troubleshoot any
    difficult passages, and reconfirm or realign code agreements. The codebook was
    refined by consensus, as needed. By the time the 15th website was coded, redundancy
    had clearly been realized and the codebook had long been stable. The formal analysis
    phase then began.
    Thematic analysis
    With the data at hand, each team member individually sorted the codes into groups
    representing the organizing principles implicated in MTA rhetoric. The team then
    came together to compare, discuss, reorder as deemed appropriate, and name the
    higher-order categories and relationships that emerged when the individual sorts
    were combined. Reference was made, as needed, to open-coding notes, and to the
    websites themselves (when questions related to context of use). Disconfirming cases
    and rival hypotheses regarding code categorization were sought out and explored.
    A preliminary figure depicting the categories in relation to one another was
    mapped and then refined. MB and EH prepared summaries of every category and its
    subsumed themes, including for reference pertinent website passages.
    As a final double-check, both MB and EH coded three more websites each,
    bringing the total number of coded websites to 21. No new codes or insights were
    124 E.J. Sobo et al.
    noted, and no ideas generated on the basis of the initial 15 websites were
    disconfirmed.
    In addition, to help assure validity, the team also sought periodic feedback from
    an MTA owner with whom the first author had previously worked. A second MTA
    worker recruited by the first corroborated the final summary of findings.
    Findings
    Key structural features of the 27 websites are shown in Table 1. Business names
    were fairly similar in the sample, referring generically to healthcare, global travel,
    and sometimes affordability.
    Themes (codes, code categories) prominent on the websites fit into several higher-
    order groups that, as shown in Figure 1, supported a ‘worry free experience’,
    the MTAs’ key good. This experience would be, first and foremost – as per the
    ‘MTA promise’ – ‘world class’, ‘high quality’, and ‘affordable’. Themes illustrating
    with more detail how these overarching goals were to be achieved comprise three
    lower-order, goal-supporting category groups: ‘self-production via consumption’,
    ‘all-inclusive patient care’, and ‘legitimate services’. The legend provides details
    regarding the figure’s arrangement.
    Table 1. Sample characteristics (N¼27).
    Structural feature Websites where present
    Site map 16 (59%)
    Dominant colour: Blue 21 (78%)*
    Agency logo 27 (100%)
    ‘Our Process’ page 17 (63%)
    Procedure information list 27 (100%)
    Procedure information list with external links 05 (19%)
    Cost comparison table 12 (44%)
    FAQs 22 (81%)
    Registration page: for individuals 11 (41%)
    Registration page: for providers 03 (11%)
    Page/area for payers (insurers) 10 (37%)
    Page/area for providers 11 (41%)
    ‘Contact us’ dialogue page 27 (100%)
    Terms and conditions information 18 (67%)
    Links to media: Agency coverage 10 (37%)
    Links to media: Medical travel (e.g., popularity of) 19 (70%)**
    MTA update blog 07 (26%)
    Patient testimonials – Written 19 (70%)
    Patient testimonials – Video 09 (33%)
    Marketing questionnaire 08 (30%)
    Rotating photographs 15 (56%)
    Photo emphasis on tourism vs. medicine 6 (22%)***
    *Of these (n¼21), nine paired blue with white; four paired it with green; three with yellow; one
    with grey; and one with tan.
    **52% of this was video coverage.
    ***The majority of frozen, sampled versions of the 27 websites (20; 74%) contained pictures
    emphasizing the medical aspect of medical travel (one had no emphasis).
    Anthropology & Medicine 125
    MTA promise
    The most commonly mentioned themes on the MTA websites related to each MTA’s
    driving intention to connect consumers with top-notch care at affordable prices.
    Websites made liberal use of catch-phrases indicating such (for example, ‘Our
    primary aims to facilitate the highest standard of quality medical treatment and
    patient care at a cost which is affordable’ [4.1; i.e. Website 4, page 1]). However,
    these phrases were under-defined. Themes in the supporting categories (see Figure 1’s
    lower three rows) filled in the picture.
    Worry free experience
    M T A Promise
    World class High quality  Affordable
    Self-production via
    consumption
    Social consumer
    Socially accepted
    Trendy practice
    Elite practice
    Luxurious facilities
    Group outings
    Tourism opportunities
    Savvy consumer
    Consumer-driven Care Plans
    Comparatively Cheap
    - The Savvy Consumer considers
    all other themes as well-
    Libertarian consumer
    Privacy Respected
    No Waiting
    Elective Options
    Less Red Tape
    Unavailable in the USA
    At Home (Here)
    Packages available
    Tailoring provided
    Program/case managers
    Standing by 24/7
    Physician consult by phone
    Clinical services
    Organizations' Western Affiliation/s
    Clinicians' Western Affiliation/s
    Clinicians' Western Training
    Clinicians’ Thorough Training
    State of the Art Facilities/Equipment
    Complication/Success Rates
    Facilitative Services
    Partner Verification Process
    Long-term Industry Relationships
    Extensive Industry Experience
    Credentialed
    Profit Model
    Non-exploitive
    No Kickbacks
    Abroad (There)
    Local Personal Assistant
    Quality Clinical Time Given
    English Communication
    Access to Western Amenities
    Recuperate in Comfort
    Private Services
    ←Connectivity/Facilitation→
    All-inclusive
    Patient care
    Legitimate services
    Figure 1. Visual depiction of themes and their overall organization in medical travel agency
    or MTA websites. Boxes contain coded themes, organized into categories (underlined). The
    spatial location of a given box or row of boxes reflects its position in website discourse on
    MTA services. Meta-themes are represented in the top two rows, with row two’s general
    ‘MTA promise’ themes supporting the even more general promise of a ‘worry free experience’
    (row one). The lower three rows (rows three-five) depict the categories whose themes reference
    details regarding how overarching promises will be achieved. Labels for these rows (groups
    of categories) are shown in column one, in boldface. ‘Self-production via consumption’
    (row three) is central because it, and particularly its central category (‘savvy consumer’),
    figured centrally in the analysis. The ‘savvy consumer’ is in fact produced with reference to or
    the support of all other themes and categories infusing the MTA websites. The arrows linking
    row (category group) labels, and the lower placement of rows four and five, map the ‘savvy
    consumer’ group’s contingent or dependent relationship. The central, themeless category in
    row four (‘connectivity/facilitation’) links the two main aspects of ‘all-inclusive care’ together
    as well as being a key MTA industry product; and the bottom row depicts themes of legitimacy
    that are foundational to the whole enterprise. While themes denoted in the figure directly
    correspond to or paraphrase MTA messages, category (box) and category group (row) labels
    reflect underlying organizing principles, which generally remained implicit in the texts.
    126 E.J. Sobo et al.
    Legitimate services
    Key to the MTA enterprise is the assertion that the services sold are legitimate.
    Through themes categorized under ‘Clinical Services’, MTAs represented offshore
    clinical care as the same if not better than the US standard. For example, one MTA
    offered ‘hospitals which are JCI accredited and are affiliated with a branch of the
    prestigious Johns Hopkins University’ [13.4]. This MTA further asserted that ‘most
    of their physicians are educated in UK or US and are board certified’ [13.8].
    Several websites bolstered claims of affiliation and equivalence by directly
    referencing the international heritage of the current Western clinical workforce. For
    example, one asserted, ‘In the USA, 1 out of 20 practicing doctors are Indians....
    Indian doctors are found in almost all parts of the world.... Indians make up
    roughly 20 percent of the ‘International Medical Graduates’ – or foreign-trained
    doctors – operating in the US’ [17.29].
    In addition to highlighting Western affiliations and training, the thoroughness
    of clinician training and the state of the art facilities and technologies on offer were
    promoted. For instance, one hospital was advertised as ‘equipped with cutting edge
    technology, digital flat panel cath labs, state of the art operating theatres’ etc [5.23].
    Also relevant were references to complication and success rates; for example, ‘The
    death rate among patients during surgery is only 0.8 percent. This is less than half the
    equivalent rate in most major hospitals in the United States’ [11.32].
    In website discourse, MTA ‘Facilitative Services’ were represented as of the
    highest professional calibre. Many listed their credentials as members of the Better
    Business Bureau and Medical Tourism Association. Processes for verifying the
    legitimacy of providers/partners were explained (e.g. ‘[Our MTA] investigates every
    facet of a surgeon’s credentials...Our process for choosing doctors takes an average
    of three months and generally only one surgeon out of thirty meet our strict
    requirements’ [16.44]). Many claimed to have longstanding professional relationships
    within the industry, as well as extensive experience in the MTA field (e.g. ‘We have
    over 20 years of experience running healthcare service companies and working with
    medical centers overseas 75 years’ [5.5]), although quantitative data regarding
    how long a given agency had been in business was rarely provided.
    The integrity of the MTA business itself was defended through reference to a
    ‘Profit Model’ that explicitly denied the exploitation of foreign workers or receipt
    of kickbacks. Prices were justified with reference to ‘the lower cost of living
    [overseas], a strong dollar, and lower physician fees’ [5.46], although some MTAs
    also noted that malpractice insurance costs, too, are lower outside of the USA
    (e.g. 3.1).
    All-inclusive care
    On top of legitimacy rhetoric, another layer of thematic content focused on
    positioning MTAs as able to offer ‘all inclusive’ service. This included travel
    packages or tailor-made itineraries.
    The ‘all inclusive’ ‘worry free experience’ began ‘At Home (Here)’. A program or
    case manager would ‘work with you, making notes of your preferences, and with
    your cooperation and input, we will arrange a complete and comprehensive medical
    and travel package which includes all our customized services’ [11.3]. In addition,
    ‘Your US Case Manager will help you with your travel from home country to
    Anthropology & Medicine 127
    destination country in detail. They will provide you with valuable advice about rules
    and regulations, culture and what to expect’ [9.5].
    Both before and during medical travel, ‘program managers are available 24/7 to
    serve you. They sleep with their cell phones so that they are in constant contact with
    you. You will never have to worry’ [11.10]. Foreign physicians also are available by
    phone (sometimes with video): ‘We can arrange for a ‘‘consultation conference call’’.
    The intention here is that you get to know the medical team and they understand
    more about your physical condition, required treatment and any personal history’
    [12.4]. There was no question that a personal relationship would be forged – one that
    extended beyond hospital and even national walls.
    Round the clock care was not just clinical: Once overseas (‘Abroad [There]’),
    ‘You will be assigned a personal assistant who will meet you on arrival. This person
    will be your ‘friend away from home’ and is at your disposal during your stay.
    That person will accompany you to all medical appointments and will be with you
    pre- and post-operatively in the hospital’ [16.45]. Some MTAs spoke, for instance,
    of ‘transportation, translation, concierge service and more,’ to be provided by this
    advocate [10.18].
    Overseas clinicians are portrayed in the websites as able to spend significant
    quality clinical time with each patient, constantly checking in and making themselves
    available. In addition, clinicians simply are more numerous: ‘The level of service
    in terms of nursing care is second to none with nurse-to-patient ratios approaching
    one-to-one’ [5.3]. Further, communication will be in ‘fluent English’ [10.2] or, if not,
    via fluent interpreters. Access to Western amenities (e.g., television channels, coffee
    makers, in-room safes, familiar foods) is assured.
    Also assured is privacy as well as comfort during recuperation. For example,
    in one facility, ‘All rooms are newly renovated suites with an ocean view. This area is
    ideal for your recovery’ [16.35]. In another, one may ‘relax and recuperate in idyllic
    surroundings’ [11.31]. This type of setting, sold as fostering healing, is opposed in
    website discourse to settings in which recovery is rushed, surroundings unpleasant,
    roommates unavoidable, iatrogenic infections expectable, and access to nurses and
    other clinicians delayed or difficult.
    Self-production via consumption
    Throughout the medical travel process, in addition to the body work surgery
    and other procedures involve, consumers can work on bolstering a specific type of
    self-image. For instance, consumers engage in practices that reinforce a ‘social’ self-
    image. Medical travel is sold as a socially acceptable option: ‘hundreds of thousands
    of people annually are exploring the advantages of medical tourism’ [16.10]. Many
    MTAs referred to validating media coverage as (e.g. ‘But as FOX 26’s Melissa
    Wilson reports’ [1.11]). Medical travel was sold as part of a new, ‘trendy’ movement,
    with today’s medical traveller on the leading edge of a popular ‘rush’ [11.23].
    Of course, as MTAs note, ‘the global elite have been travelling [for care] for
    years’ [12.8]’. Today, MTAs can connect everyone with clinics ‘where the rich
    and famous have been going’ [12.58]. When people ‘realize they can afford VIP
    treatment...they’re packing their bags’ to partake in ‘‘‘lifestyles of the rich and
    famous’’ treatment’ [16.10]. Thus, through medical travel, common consumers join
    the ranks of ‘high profile corporate clients’ [12.14], a ‘well-known Dallas socialite’
    [16.10], and so on. They, too, are accommodated in luxury, for instance ‘at a 4 or
    128 E.J. Sobo et al.
    5 star hotel’ [4.7]. Customers have access to ‘premier packages with extensive
    customized luxuries’ [11.3]. Promoting customers’ alignment with people of value,
    the MTAs ‘take an active role in bringing you the healthcare you need and
    deserve’ [7.2].
    Luxuries to be deservingly indulged include not only the facilities but also local
    sights. One website promised ‘an exotic tourist destination with plenty of beaches,
    mountains, rivers and greenery to enjoy’ [13.23]. Another noted, ‘Some medical
    tourists spend a few days sightseeing before their procedures while others enjoy the
    same while recuperating’ [1.24]. Some mentioned the option of making medical travel
    a sociable group event: ‘Are you considering travelling with more than two people
    to same destination for medical treatment? Our group discount package is designed
    to accommodate your needs’ [10.51].
    Another marketing angle is an appeal to healthcare consumerism in which self-
    empowered customers make savvy choices, actively self-managing their care. For
    instance, one Website ‘empowers you to take charge of your health’ [10.1]; another’s
    ‘intention is to provide you with all possible information on the hospitals and
    surgeons for you to make an informed decision’ [7.43]. Not the doctor’s order but the
    consumer’s choice drives a medical travel booking.
    Customers are encouraged to discuss options with their local providers; however,
    when given, this directive generally has a rote, legalistic feeling, as if a mandated
    disclaimer. Statements reinforcing consumer agency and emphasizing the MTA’s
    role in assisting and enabling consumers to make their own choices dominate.
    Websites assert that consumers will ‘gather as much information as possible’ [11.31]
    in their quest for the best possible care; they contain statements indicating that, given
    access to information (including but not limited to price comparisons), consumers
    are quite able to judge healthcare offerings properly. In light of the information
    MTAs provide (including information referred to in all category boxes in Figure 1),
    and information that the websites say will be collected by savvy consumers from
    other sources, consumers (the websites say) demonstrate good judgment by selecting
    offshore care.
    Finally, MTA websites mobilize libertarian ideas in making their sales pitch for
    MTA consumption. For example, in medical travel, one’s privacy is respected. This
    is not only because of legal regulations, adherence to which demonstrates legitimacy,
    but also, and moreover, because customers have the liberty to seek care without
    others knowing. One website acknowledged, conspiratorially, ‘It is extremely
    advantageous for certain individuals to go ‘‘on vacation’’ and return home looking
    refreshed and younger without anyone knowing they received plastic surgery’ [16.9].
    Elective options can be sought via MTAs without fear of judgement. In addition,
    there is ‘no waiting’ and ‘less red tape’ involved in care procured abroad, such as
    bariatric surgery (which at home can depend upon proving to gatekeeping
    authorities that one is a ‘good’ candidate). ‘Elective options’ and even procedures
    ‘unavailable in the USA’ can be had through offshore sources. A libertarian vision of
    individual freedom and respect for self-determination is endorsed.
    Over- and non-conforming websites
    During analysis, a number of websites stood out as different. Two subverted the
    overarching offer of a ‘worry free experience’ by focusing on the figure’s MTA
    Anthropology & Medicine 129
    Promise strip’s categorical themes without actually providing supportive details. One
    over-emphasized its ability to secure the ‘LOWEST cost possible worldwide’ [19.1;
    emphasis in original]. Another, in a bid to present itself as better than the rest,
    claimed that ‘prostitution, child sex trades and underage sex runs rampant in most
    of the countries that many of these other medical vacation companies send people to’
    [21.4], drawing excess attention to the issue. Although such amplifications aroused
    coder suspicion regarding the legitimacy of these MTAs, their over-conformity did
    substantiate the conceptual model.
    Three other websites were categorically different, first in their overall visual
    emphasis (failing to conform to the blue and white biomedical norm, focusing on
    touristic vs. medical photos). Second, although qualified for inclusion as
    comprehensive travel agencies, these MTAs’ websites provided little actual
    information about travel bookings and accommodations. Third, in comparison
    with the majority of websites, they de-emphasized patient agency.
    Further inspection revealed that these MTAs sold mostly wellness and
    place-based treatments. That is, they sold mostly complementary and alternative
    medicine – not mostly biomedical travel. For those that sold both, patient-consumers
    were welcomed generically, rather than differentiated by procedure (specifics were
    related via drop-down menus in which cardiac surgery might be followed by
    liposuction). Consumers were thus given the option to align their healthcare needs or
    desires (many of which would be termed by the dominant biomedical system as
    ‘elective’) with biomedicalized, ‘legitimate’ services.
    Discussion
    The findings reflect publicly expressed MTA discourse, and the sample was small.
    Even if representative, because they were frozen in August 2008, the content of these
    MTA websites may differ from that which might be encountered on live MTA
    websites today.
    Nonetheless, the themes identified fit well with what has been seen in the broader
    literature on healthcare consumerism and in the emerging ethnographic literature
    on medical travel. In addition, because of our realistic search strategy, it is likely that
    the websites ‘hit’ also would have been among the first MTA websites that patient-
    consumer searches produced. This plus the fact that two MTA industry members
    validated our results creates confidence in the research’s relevance.
    Key findings
    Key findings reveal MTA assumptions that potential consumers want ‘world class’
    care (and luxury) for minimal money. Further, they want to be made to feel in
    control of their health as well as that it is being taken care of by someone else for
    them, as it would for a VIP.
    Conflicting sub-discourses still coherent
    The consumer portrayed was not wholly consistent. Some themes coexisted with
    conflicting ones although, for the potential consumer, conflicts would not be salient
    130 E.J. Sobo et al.
    because (in addition to being unified in the master tenet of consumerism) each was
    highlighted in distinct situational contexts, often in separate parts of the websites.
    For instance, savvy distrust of medicine at home contrasted with faith in
    medicine abroad – faith justified by the argument that it is equivalent to medicine at
    home (e.g., in terms of clinician training, accreditation standards, and so on).
    Similarly, the ideal of empowered, agentic medical consumerism at home stood in
    opposition to the hope for facilitated, worry-free, MTA-managed (vs. self-managed)
    care overseas. Other oppositions included consumer justification of procedures or
    the medical travel process as ‘socially acceptable’ and even ‘trendy’ while seeking to
    maintain privacy about care procured; the practice of frugality in the face of an
    expectation for world-class services and VIP treatment; travel to foreign lands
    without forfeiting access to US-style amenities and US-style medicine; identification
    with the disenfranchised at home (those denied access to care) but self-construction
    as members of the global elite through medical travel consumption; the desire for
    and sense of entitlement to luxury but easy acceptance of low wages and living
    standards for offshore healthcare workers; and one’s serious need for care but
    concurrent anticipation of an easy recovery allowing for sight-seeing.
    MTA marketing appeals to the cultural expectations and ideals for the various
    subjectivities and self-representations mobilized in its potential customers, each of
    whom differs depending on (among other things) where he or she is at in the
    decision-making and travel-undertaking process. The contrapuntal messages
    following from this within-audience diversity suggests that medical travel involves,
    for the US-based consumer, a complex, context-dependent act of expressing and
    forgetting situationally-specific (at home vs. abroad, disenfranchised vs. elite, ill vs.
    well) self-identities. This process of situational self-reconfiguration and self-
    representation is cross-culturally common and constant (see de Munck, 1992,
    2000; Ewing, 1990). Self-concept shifts, adjusting to the particular as need be
    (see Holstein and Gubrim 2000). Contradictions inherent in disparate MTA themes
    are thus non-problematic.
    Medical traveller or medical tourist?
    MTA website discourse suggests that one situationally preferable identity for
    potential medical travellers may be that of ‘tourist’, particularly in order to come to
    grips with the anticipated experience of recovery. As Sara Ackerman (n.d.) has noted
    in regard to aesthetic surgery, the post-operative period is often elided by a
    persuasive and pervasive ‘before and after’ narrative. This research team observed
    the same narrative in the website discourse, for aesthetic and non-aesthetic
    procedures alike. The ‘before and after’ script reinforces, in its very omission of
    ‘in between’, the ideal or the ‘speedy recovery’. This is not to say that websites never
    mentioned a recovery phase – but when they did, the ways in which it is better
    overseas, not its duration and the debilitation it might entail, were highlighted.
    Accordingly, although medical ‘travel’ more accurately and objectively describes
    the general process under study (see Sobo 2009; see also Inhorn and Patrizio 2009;
    Kangas 2010), references to medical ‘tourism’ may represent a purposive strategy
    to minimize consumer fears regarding post-surgical debilitation. Thinking of an
    operation, for instance, as something to be followed (quickly and comfortably) with
    a trip to the Taj Mahal may in fact feed patient-customer optimism in regard to
    Anthropology & Medicine 131
    procedures that always, everywhere, entail risks and recovery costs such as pain,
    nausea, and exhaustion.
    Related to this, the websites’ main texts said nothing of the actual risks of
    particular treatments or procedures. To sell ‘worry free’ medical travel, this is
    understandable. Indeed, where risk was addressed it was mostly in terms of how risks
    were lower and success rates higher offshore, or how the careful vetting done by the
    MTA mitigated the possibilities (e.g., ‘Like any procedures performed locally,
    procedures done aboard [sic] also carry certain risks. However, by selecting the
    best accredited hospitals...we minimize this risk substantially’ [13.19]). Risk was
    sometimes mentioned in ‘terms and conditions’ sections (which two-thirds of the
    websites had; see Table 1), or in procedure details, but in legalistic language whereby
    risk was cast as part of the inevitable ‘small print’ and nothing for the non-paranoid,
    careful patient-consumer to worry about.
    Consumer savvy and patient agency
    The US-based MTA market is part of a world where medical consumerism is
    practised and encouraged (Baer, 2001; Keckley and Eselius, 2009; Lupton, 1997;
    Sobo, 2001; Williams, 1994). This includes by the government, which offers (among
    other consumer resources) ‘Your guide to choosing quality health care’. This
    document instructs people to ‘make quality health care choices’, ominously adding,
    ‘Your good health, and your family’s, depends on it’. (Agency for Healthcare
    Research and Quality 2001, 2). Ensuring access to safe, high-quality care is the
    consumer’s responsibility. The consumer is imagined as having enough agency and
    self-efficacy – as well as information – to act successfully on this charge.
    This simplistic conceptualization of individual responsibility for health deflects
    attention from structural impediments to such. It also encourages individuals to
    conceive of the body as a socially significant and self-constructed project – one
    attained through well-executed healthcare consumerism (cf. Shilling 1993). In a
    society where consumer rights are celebrated, and getting a ‘good deal’ or added
    value is something to be proud of, the patient’s (or potential patient’s) self-esteem
    and the (real or imagined) esteem in which others hold him or her can be enhanced
    through actively and wisely self-managing care – as through smartly booking medical
    travel.
    For this reason, most MTA websites highlight savvy consumerism and patient
    agency. They celebrate the client who takes charge of his or her care through medical
    travel. The wise medical consumer or ‘Wisdom’ narrative, described in regard to
    elective surgery seekers and seen in discourse on indicated surgeries by proxy
    decision-makers (Sobo 2001, 2005), is replicated in MTA website content – albeit
    in a co-conspiratorial way that emphasizes not only wisdom but also know-how
    and confidence (‘savvy’).
    Variation
    The emphasis on patient agency within the ‘savvy consumer’ category did differ
    between websites that sold biomedicine mainly and those that sold mainly
    complementary and alternative medicine (CAM), such as Ayurvedic or spa
    treatment. Biomedically-oriented sites highlighted agency while CAM websites
    132 E.J. Sobo et al.
    did not – perhaps because increased patient agency already exists among those
    opting for CAM.
    We interpret the overt emphasis on patient agency in biomedically-oriented sites
    as reflecting biomedical patient-consumer demand for it (see also Cohen 2008, 226).
    The emphasis may also be related to class re-identification strategies promoted.
    Medical travellers seeking biomedical treatment overseas may be disproportionately
    representative of the working poor, who have limited access to affordable care
    at home. The idea of personal agency may tie in for them with the ‘American Dream’
    of claiming a place at the top of the social structure. It also may be a way to claim
    more control in a political economy that, despite all-American libertarian rhetoric,
    puts full self-determination beyond many people’s reach.
    World-class care for the global elite
    In many ways the websites provide a critique of the US healthcare delivery model – a
    critique that, if heeded by US-based healthcare organizations, might prove
    constructive. But it cannot offset the fact that a new ‘world class’ of clinical care
    has emerged, and although it is ‘Western’ and ‘cutting edge’, it is not synonymous
    with ‘American’. New processes and procedures increasingly have transnational
    origins (Economist 2008b; Inhorn and Birenbaum-Carmeli 2008, 180). Physical
    healthcare spaces dedicated to medical travel have been observed not as ‘little
    Americas’ but rather generic transnational spaces, like international airport hotels
    (Whittaker 2008, 284).
    The eclipse of ‘American’ by ‘world-class’ medical care reflects globalizations’
    prioritization of transnational connections over national boundaries (Hannerz 1996).
    It is supported by MTA website discourse overshadowing nationalism by
    highlighting as needed the existence of a global elite partaking ‘world class’ services
    – a group that MTA customers would be a part of.
    Conclusion
    Holstein and Gubrium (2000, 95) follow Foucault and Hughes to argue that
    particular self-constructions are ‘incited’ by the institutional or organizational sites
    that individuals engage with. Accordingly, while MTA website messages must have
    cultural appeal or resonate with pre-existing cultural desires and self-concepts if they
    are to turn a profit, they also make cultural appeals in the discursive resources
    they offer, providing ‘the conditions of possibility’ and supplying ‘the mode of
    production for putting into effect our identities as part of accomplishing matters of
    ongoing [immediate] interest’ (Holstein and Gubrium 2000, 95). In this way, MTAs
    may not only catalogue but also help create or reinforce particular consumer self-
    constructions. As such, they may play an important catalysing role in healthcare
    consumerism’s evolution and therefore in the ongoing evolution of healthcare per se.
    Prominent MTA website themes suggest – and may help ensure through their
    discursive influence – that the US medical travel consumer wants ‘world-class’ care at
    a low financial cost. He or she also wants to be a particular type of person – a person
    ahead of the trends – a person of high station who has a right to luxury, and
    to control what happens, while depending on others to carry out directions on his
    or her behalf. Cultural expectations and ideals representing ‘American’ aspirations
    Anthropology & Medicine 133
    underwrite the appeal of particular self-perceptions that can be situationally
    actualized or incited for US patient-consumers considering medical travel.
    Acknowledgements
    A portion of this work was funded by a ‘faculty fellowship’ grant from the Ethics Center in
    Science and Technology. Ethics approval was unnecessary due to the public nature of the data.
    No conflicts of interest existed. Diane Boyd, President of the medical travel agency Affordable
    World Care, provided expert feedback over the course of the study. Erik Cohen and Beth
    Kangas kindly provided early guidance and reading suggestions, as did later anonymous
    reviewers, and Kent Sandstrom, to whom the authors owe great thanks. The article’s focus
    on self-contradictions was driven in part by self-contradicting (and self-revealing) responses
    to preliminary findings presented in the University of California Berkeley/University of
    California San Francisco Medical Anthropology and History of Health Sciences Colloquium
    series (22 April 2009). The authors alone remain responsible for the article’s content.
    Notes
    1. In addition to helping patients, offshore providers can positively affect the communities
    where they are situated. In some host countries, medical travel income may be reinvested
    in the national health infrastructure (Siegel 2007). Hospitals catering to medical travellers
    employ local residents. Job creation fuelled by the medical travel boom may even lead
    more supply-zone residents to seek medical training, adding to local knowledge and
    perhaps increasing the sustainability of programmes serving the local poor as well.
    Moreover, as medical travel fuels healthcare’s growth in home countries, nurses, doctors,
    and other healthcare specialists who previously emigrated to places like the USA or UK
    may return home – or stay home to start. Trinidad and India, for example, have seen
    doctors return (Economist, 2008b). Costs, too, may be entailed. For instance, the
    globalized demand for gestational surrogates may exploit poor women, putting them at
    risk for complications during impregnation, gestation, and childbirth (e.g., when
    caesarean sections are undertaken to make the birth convenient for the intended legal
    parents) (Kumar 2008). Communities can suffer as healthcare resources are diverted to
    serve rich foreign nationals. However, as The Economist has noted, ‘state-run health
    bureaucracies in developing countries...neglected the poor long before medical tourists
    arrived’ (Economist 2008a). Indeed, rather than simply creating new inequities, medical
    travel may more commonly serve to recreate existing class, gender, and race/nationality-
    based inequities.
    2. This was not a starting point for the project but rather a point of arrival for us.
    3. Many disciplines other than anthropology use ethnographic methods and many have
    understood them differently from how anthropologists might. The label here is not
    reflective of a traditional anthropological understanding of the meaning of ethnography
    per se. Rather, it reveals an appreciation of the iterative approach that anthropologists
    generally take toward ethnographic data, which it would apply to media sources. The
    method is thereby useful for examining mediated practices and processes that local- or
    geographically-defined boundaries fail to ring-fence.
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