MedicalTourism_ACostorBenefittotheNHS_ ComplicationsAfterCosmeticSurgeryTourism. NEWSMEDIAREPORTSOFPATIENTDEATHSFOLLOWINGME THEREALCOSTOFCOSMETICSURGERY
Medical Tourism: A Cost or Benefit to the NHS?
Johanna Hanefeld1*, Daniel Horsfall2, Neil Lunt2, Richard Smith3
1 Department Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,
2 Department of Social Work and Social Policy, University of York, York, United Kingdom, 3 Faculty of Public Health & Policy, London School of Hygiene & Tropical
Medicine, London, United Kingdom
Abstract
‘Medical Tourism’ – the phenomenon of people travelling abroad to access medical treatment – has received increasing
attention in academic and popular media. This paper reports findings from a study examining effect of inbound and
outbound medical tourism on the UK NHS, by estimating volume of medical tourism and associated costs and benefits. A
mixed methods study it includes analysis of the UK International Passenger Survey (IPS); interviews with 77 returning UK
medical tourists, 63 policymakers, NHS managers and medical tourism industry actors policymakers, and a review of
published literature. These informed costing of three types of treatments for which patients commonly travel abroad:
fertility treatment, cosmetic and bariatric surgery. Costing of inbound tourism relied on data obtained through 28 Freedom-
of-Information requests to NHS Foundation Trusts. Findings demonstrate that contrary to some popular media reports, far
from being a net importer of patients, the UK is now a clear net exporter of medical travellers. In 2010, an estimated 63,000
UK residents travelled for treatment, while around 52,000 patients sought treatment in the UK. Inbound medical tourists
treated as private patients within NHS facilities may be especially profitable when compared to UK private patients, yielding
close to a quarter of revenue from only 7% of volume in the data examined. Costs arise where patients travel abroad and
return with complications. Analysis also indicates possible savings especially in future health care and social costs averted.
These are likely to be specific to procedures and conditions treated. UK medical tourism is a growing phenomenon that
presents risks and opportunities to the NHS. To fully
understand its implications and guide policy on issues such as NHS
global activities and patient safety will require investment in further research and monitoring. Results point to likely impact
of medical tourism in other universal public health
systems.
Citation: Hanefeld J, Horsfall D, Lunt N, Smith R (2013) Medical Tourism: A Cost or Benefit to the NHS? PLoS ONE 8(10): e70406. doi:10.1371/journal.pone.0070406
Editor: Pieter H. M. van Baal, Erasmus University Rotterdam, The Netherlands
Received January 31, 2013; Accepted June 19, 2013; Published October 24, 2013
Copyright: � 2013 Hanefeld et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This project was funded by the National Institute for Health Research Health Services and Delivery Research (HS&DR) Programme (project number HSR
09/2001/21). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, National Institute
for Health Research, National Health Service or the Department of Health. The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: Johanna.Hanefeld@lshtm.ac.uk
Introduction
The phenomenon of people travelling abroad to access medical
treatment – commonly termed ‘Medical Tourism’ – has received
increasing attention in academic and popular media [1]. The
confluence of available and affordable air travel, internet-based
marketing by providers, and an increasing requirement for out-of-
pocket expenditure, even in universal public health care systems
such as the UK NHS, suggests that increasing numbers of patients
may consider travelling for treatment. The PIP scandal highlighted
challenges for UK patients in seeking redress from private
providers, especially where these may be based in other
jurisdictions [2,3].
As the new NHS reforms introduce yet greater market elements,
including the removal of the cap on income from private patients
[4], and the EU Directive on crossborder healthcare is
implemented which codifies rights around patient mobility [5], it
is imperative to consider the challenges and opportunities that
medical tourism – inward and outward – may present to the NHS
[6].
Yet, reliable information on even the basic number, character-
istics, motivations and experiences of such patients is scarce, as
patients arrange and pay for such care privately [7]. Indeed, a
recent review of medical tourism literature [8] found that
academic literature relies heavily on opaque data from private
consultancy firms or unverified media reports [9,10]. In the
absence of even the basic level of information in these areas, it is
understandable that rhetoric has filled the vacuum. In this paper
we present evidence from the largest study yet conducted
concerning medical tourism, undertaken from an NHS perspec-
tive, to provide a firmer footing for debate and discussion by
health professionals, NHS managers and those involved in the
wider policy-making context.
Methods
Authors interviewed 77 UK medical tourists and 63 other UK
stakeholders between March 2011 and August 2012. Interviewees
gave written consent to participate in the study. Interviews were
recorded, transcribed and thematically analysed. The study
received ethical clearance from the National NHS Ethics review
process submitted through the Sheffield Research Ethics Com-
mittee approval (11/H1308/3).
Analysis is three-fold: (i) the volume and characteristics of
outbound and inbound UK medical tourists is based upon the
International Passenger Survey (IPS); (ii) assessment of NHS
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income from foreign patients is based upon freedom-of-informa-
tion requests submitted to 28 NHS Foundation Trust hospitals;
and (iii) evaluation of the challenges encountered, costs incurred
and potential savings for the NHS is based on a review of
published and grey literature and interviews with UK nationals,
NHS managers and policy makers. Each of these is described
below.
Analysis of the International Passenger Survey (IPS)
The IPS, conducted by the UK Office of National Statistics
(ONS), collects information from passengers as they enter or leave
the UK. Passengers are randomly selected as they travel through
passport control and a brief survey is administered. One of the
survey questions asks passengers to define their primary purpose
for travel; ‘medical treatment’ is one of the answers recorded, thus
providing insight into the number of passengers who self-declare
that they are travelling for medical treatment.
The IPS dataset from 2000–2010, from the Office of National
Statistics (ONS), was analysed by two authors independently,
triangulating results. Data from the IPS, interviews, literature and
NHS tariffs were used to calculate cost impacts. Authors used the
different data sources accessed to carefully triangulate and better
understand the reliability of the data from the IPS, which is
reflected on in the discussion.
FOI Requests
Submitted to 28 Foundation Trust hospitals on volume and
income from international private patients. Trusts were purposely
selected to be those most likely to be visited by inbound tourists
i.e., large and well-known Trusts, such as Great Ormond Street
Hospital for Sick Children, many of which are based in London.
Data on foreign patients was analysed to understand the potential
of earnings from foreign patients.
Qualitative Analysis
Authors interviewed 77 UK residents who travelled abroad for
treatment and 63 other UK stakeholders between March 2011
and August 2012. Interviews were recorded, transcribed and
thematically analysed. The study received ethical clearance from
the National NHS Ethics review process.
Results
While the level of inward travel of foreign patients to the UK
(although not necessarily the NHS) has been relatively stable over
the last decade, there has been a substantial increase in the
number of UK residents travelling abroad to access medical
treatment, as indicated in Figure 1.
Destination of UK Outbound Medical Travellers
Figure 2 shows UK residents most commonly travel for medical
treatment to North, West, and Southern Europe with France
being the most visited country over the decade.
Examining this in greater detail (Fig 3) suggests that Central and
Eastern Europe are second most popular, and that Poland and
Hungary are increasingly popular.
South Asia, primarily India, also attracts large numbers of UK
patients, making it the most frequently visited non-European
country, with a relatively stable pattern of travel to India, Pakistan,
and in much lower numbers Sri Lanka and Bangladesh, possibly
reflecting a diaspora effect. In contrast, East Asia shows a different
pattern, with virtually no medical travellers recorded by the IPS
prior to 2003, yet by 2010 15% of all UK medical travellers went
to East Asia. This increase of 430% is unlikely to be solely related
to diaspora patients, but does correlate with many South East
Asian countries marketing strategies at this time [11].
Based on the IPS data, and patient interviews, treatment specific
destinations emerge. For example, UK dental patients increasingly
travel to Hungary and Poland, which corresponds to the varied
availability of NHS dental treatment over the last decade [12].
Fertility tourists often travel to countries in Eastern Europe,
Cyprus and Spain possibly owing to more easily accessible
gametes, and less stringent regulation which allows anonymous
donation as well as a greater number of embryos transferred [13].
Inward Medical Travel
As evident in Figure 1, data from the IPS suggests that
international patient inflows to the UK (independent sector and
NHS private services) were in the region of 52,000 in 2010. Data
over the decade also confirms that while growing, the overall
numbers of patients travelling into the UK to access medical
services is rising at a much slower rate than UK residents travelling
out for care. So, contrary to some popular media reports, far from
being a net importer of patients, the UK is now a clear net
exporter of medical travellers.
Major source countries for patients coming into the UK include
Spain, Greece, Cyprus and the Middle East. The number of
Greeks and Cypriots travelling into the UK to access treatment
rose rapidly in 2009 and 2010. These figures may reflect a change
as a result of the economic crisis, which in turn has meant severe
public sector cuts in these countries, including in health [14].
Similarly, while medical tourists from Ireland may choose to travel
to access treatment not available there, including termination of
pregnancies, the rapid increase in patients from Ireland in recent
years may reflect the cuts in the health sector there and greater
numbers of UK citizens resident in Ireland returning to the UK
for treatments (see Figure 4). The ‘dip’ in both inbound and
outbound medical travel evident in Figure 1 in 2008 may be
attributable to the onset of the crisis. Examining the number of
travellers by quarter found a much lower number of inward and
outward medical travellers in Quarter 3 of 2008 during the onset
of the crisis, than the rest of the year, or Quarter 3 in 2009. In the
case of Irish, Spanish (and perhaps French) residents, it is highly
likely that a substantial number will be UK expats and it is unclear
whether these engage in out-of-pocket medical treatment (in the
private sector or NHS) or whether they accept NHS services free
at the point of use for which they may (or may not) be eligible.
A further significant number of patients travel from the Middle
East (specifically from the United Arab Emirates and Kuwait)
although visitor numbers from both countries dropped sharply in
2008 and 2009 respectively. Despite some variation between years,
a stable inward flow of medical travellers from Nigeria is also
evident over the past decade, perhaps reflecting the growing
wealth of some sections of that population.
International activity within hospital trusts. Our Free-
dom-of-Information requests suggest that Trusts could not always
clearly identify international patients within their pool of private
patients because nationality was not recorded when they
underwent treatment and nationality/place of residence may
differ. Looking at the 28 Trusts within our sample, their
international activity ranged from relatively marginal to being
one-third of their total private work.
Where Trust managers were interviewed (at seven sites) they
spoke of international patient flows and activities within the
context of pressure on NHS resources, and pre-existing interna-
tional activities and linkages. Commercial imperatives were
balanced with strong statements regarding the core NHS role,
centred on NHS services and prioritising NHS patient care.
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International patient activity was typically specialist where it was
not possible to treat locally because of relatively small volumes and
the complex nature of treatment required. Relationships, primarily
clinical ones, for example where a clinician from aboard had
trained or worked in a UK hospital were paramount in
maintaining flows of international patients. Established practices
of education, training, consultancy and linkages were reported to
help facilitate referrals. Rather than systematic links these personal
networks appeared paramount in linking UK hospitals to
international patients.
What is the Impact of Medical Tourism on the NHS
‘Bottom-line’?
Using the IPS data, analysis from interviews with medical
tourists, academic literature and published NHS data we
calculated possible costs and savings for the NHS for three types
of medical tourism identified (see annex S1 for calculations).
Fertility tourism. Based on data from the Office of National
Statistics on multiple births in the UK and evidence from a
hospital in London which found over a quarter of multiple births
were in women who had travelled abroad for fertility treatment
[15], we estimated the cost incurred through multiple births as a
result of individuals travelling abroad for fertility treatment.
Figure 1. The number of people who travelled into or out of the UK for medical treatment during the period 2000–2010.
doi:10.1371/journal.pone.0070406.g001
Figure 2. Map depicting total numbers of medical travellers and their destinations from the UK over the period 2000–2010.
doi:10.1371/journal.pone.0070406.g002
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Multiple pregnancies pose risks to mothers and children. We
concentrated on the actual costs of multiple births per se as the
exact needs throughout pregnancy and possible complications are
highly variable between women, and thus our estimates will be
highly conservative. We calculated the additional cost of a twin or
triplet over singleton birth resulting from fertility travel in 2010 to
be £15.5 million.
The long-term costs resulting from assisted reproductive
technologies, including multiple pregnancies will not differ
between medical tourists and fertility patients who received care
in the UK. However, our research indicates that patients will
travel in search of reproductive care to countries with regulations
that will allow fertility treatment likely to result in a higher number
of multiple births. Any effort to address the rise in multiple births
in the UK therefore needs to take account of medical travel and
involve specific targeted information to be effective.
Cosmetic tourism. We also calculated the likely cost of
complications resulting from cosmetic tourism based on a recent
study by Miyagi et al. [16], who described a cohort of patients in a
tertiary facility which reported problems arising from cosmetic
surgery undertaken abroad over a period of three years. The
authors calculated the cost of treatment provided within the NHS
for complications and highlighted the reimbursement received by
the hospital from the PCT (which was less than the expenditure of
the hospital). Based on our calculations complications of medical
tourists are at a cost of £8.2 million per annum within the NHS.
Bariatric surgery. Compared to other types of tourism
discussed, bariatric tourism may represent savings rather than
costs for the NHS, as well as wider social savings. With 25% of the
UK population classified as clinically obese, the financial impact of
obesity on the NHS is calculated as £4.3billion by the DoH [17].
Obesity also has wider costs for social services. For example, a
study by the National Office of Accounting estimated that 18
million working days were lost due to obesity with surgery offering
potential savings. Hawkins et al. [18] demonstrated that there was
a 32% increase in bariatric patients in paid work after surgery.
Based on these estimates, the 13 bariatric tourists interviewed
for this research would represent a saving of £112,506 (in cost of
procedure and in future health care and social services savings).
Even as a high estimate, the key point remains that patients
travelling abroad to receive bariatric surgery are likely to represent
a saving to the NHS and social services. Further research on the
longitudinal effects of bariatric surgery is needed and now
underway in the University of Glasgow at the Surgical Obesity
Treatment Study (ScOTS).
Income Generated by Inbound Medical Travellers
Income generated by inbound medical travellers can be divided
into additional tourism revenue, capturing the general expenditure
related to patients visit to the UK, and medical expenditure
(revenue to hospital).
Tourism revenue from all inbound medical
travelers. Tourism revenue by medical travellers to the UK
per annum is based on the most recent IPS data for inbound
medical travellers (2010). As respondents in the IPS survey
specifically state they are visiting for health care, it is assumed they
would not have otherwise have visited the UK, and thus are an
addition to visitor/tourist numbers to the UK. Hence, any
spending would be seen to be a net benefit not otherwise coming
to the UK.
Based on hospital data for patients treated within NHS
hospitals, it can be assumed that 20% of inbound medical
travellers receive treatment as inpatients, the remainder as day-
case procedures. Expenditure was calculated for patients staying in
the UK for a number of different scenarios, ranging from those
who stay for four days to receive outpatient treatment to patients
who receive in-patient treatment for 10 days and stay a further two
weeks for follow-up (see Table 1). Assumptions were based on
Figure 3. Pie Chart showing total outward medical travel by UK residents by destination region over the time-period 2000–2010.
doi:10.1371/journal.pone.0070406.g003
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interview data collected and on an average hospital stay of
inpatients (not just medical tourists) in 2010 to 2011 from the NHS
Hospital Episode Statistics. These assumptions were that: patients
likely arrive some days before treatment and remain additional
days to fully recuperate or even take the opportunity for additional
tourism activities; people travel with one companion, and
travellers from the Middle East travel with two, and that these
are not captured by the IPS (based on interview data and
corroborated by a 2008 national survey conducted by Which?).
This seems reasonable given the higher foreign patient number
captured from the FOI letters and interview data from patients
who often reported reluctance to be identified as medical tourists
possibly due to the negative public image of medical tourism,
making it unlikely that accompanying persons will identify as
medical tourists. Cost of accommodation was calculated at £80
per night and £100 per day as spending for patients when they
were not in hospital and for their travel companions.
Figure 4. Nine most common countries of origin for those who travelled to the UK for medical (2000–2010).
doi:10.1371/journal.pone.0070406.g004
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Calculations are summarized in Table 1 and further explained
in Annex S1 suggest that, even without taking the cost of the actual
medical treatment into account, medical tourists to the UK
contribute around £219 million in additional ‘tourism spending’
to the UK economy per year.
Healthcare revenue from all inbound medical
tourists. To estimate the spend on medical procedure by
inbound medical tourists in NHS facilities as accurately as
possible, we submitted Freedom-of-Information requests for data
on income from private patients in NHS hospitals, including UK
and non-UK patients, to 28 NHS Foundation hospitals. Of 28
hospitals 19 were able to provide data on the percentage of income
that resulted from non-UK resident patients and number of non
UK residents treated as private patients. Authors excluded
Moorfields Eye Hospital, as a review of the data across different
hospitals indicated this as an outlier. Given the focus on eye
medicine, it has a very large number of patients visiting for
outpatient procedures at a lower per cost treatments compared to
other elective procedures. The remaining 18 reported a combined
income from private patients of £195 million over a period of 12
months between 2010–2011.
Those who were able to provide differentiated data indicated
that £42 million of their total income was from non-UK resident
patients; looking across these 18 hospitals, this meant close to 25%
of their private income was from incoming medical tourists. While
our sample of hospitals was weighted towards large London-based
facilities which do experience a higher number of international
patients, income ranged vastly between hospitals surveyed: from
over £20million to just £2,466 with a mean of £2.5million.
Those hospitals that were able to report numbers of patients
reported a total of 6,722 patients from abroad out of a total of
88,775 private patients counted, i.e. seven percent of private
patients were inbound medical tourists. It might therefore appear
that medical tourists may be especially profitable, yielding close to
a quarter of revenue from only 7% of volume. For a detailed listing
of patients and income per hospital, see Annex S2.
Discussion
Results confirm that a small but increasing number of UK
patients are travelling abroad to receive medical treatment.
Medical travel is complex and not a uniform phenomenon. The
majority of UK patients travel within Europe, but an increasing
number are seeking treatment further afield. Patients are traveling
specifically to Poland and Hungary, and increasingly to India and
East Asia. Diaspora, country-specific marketing campaigns, and
specific specialism’s seem to determine patterns of flows of UK
patients seeking care abroad. Patients returning from treatment
abroad experience complications.
The analysis demonstrates both the possibility of costs and
savings to the NHS as a result of patients travelling abroad, which
need to be considered. Unsurprisingly, the largest numbers of
inbound medical tourists were in the large hospitals which are
internationally known for their specialism; foremost amongst these
Great Ormond Street Hospital for Sick Children which reported
income of over £20million from 656 patients. Data received and
summarised in Appendix 2 also highlights the variation in the
percentage of income that international revenue represents for
hospitals; to some, especially the large hospitals in London, it
marks a significant proportion of private patient income while for
others it contributes a very small percentage of funding.
Table 1. Calculation of additional spend by incoming medical tourists and their travel companions.
Inbound medical travellers No Nights in hotel Cost hotel Expenditure Total expenditure
52000
Inpatients* 10400
Hospital for ten days 75% (75% from ME) 7800 14 8,736,000 10,920,000 19,656,000
Hospital for five days 25% (5% from ME) 2600 7 1,456,000 1,820,000 3,276,000
Subtotal inpatients 10,192,000 12,740,000 22,932,000
Accompanying persons inpatients
Hospital for ten days 75% (75% from ME) 13650 24 26,208,000 32,760,000 58,968,000
Hospital for five days 25% (5% from ME) 2730 12 2,620,800 3,276,000 5,896,800
Subtotal accompanying persons 28,828,800 36,036,000 64,864,800
Total inpatient and accompanying 39,020,800 48,776,000 87,796,800
Outpatients 41600
4 day stay (25%) 10400 4 3,328,000 4,160,000 7,488,000
7 day stay (40) (2.75% ME) 16640 7 9,318,400 11,648,000 20,966,400
14 day stay (35%) (2%ME) 14560 14 16,307,200 20,384,000 36,691,200
Subtotal outpatients 28,953,600 36,192,000 65,145,600
Accompanying persons outpatients 41600
4 day stay (25%) 10400 4 3,328,000 4,160,000 7,488,000
7 day stay (40) (2.75% ME) 17098 7 9,574,880 11,968,600 21,543,480
14 day stay (35%) (2%ME) 14809 14 16,586,080 20,732,600 37,318,680
Subtotal accompanying persons OP 42307 29,488,960 36,861,200 66,350,160
Total outpatient and accompanying 131,495,760
Total 219,292,560
doi:10.1371/journal.pone.0070406.t001
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Our analysis of data suggests that the UK is now a net exporter
of medical tourists. While incoming medical tourists may be less
likely to declare treatment as primary purpose for their visit to the
UK than outbound tourists, data over time clearly shows a greater
acceleration in outbound over inbound medical tourists. Despite
the variations in numbers of patients visiting different hospitals and
in the income per patient, the number of medical tourists was
comparatively smaller than the percentage of income generated by
them (7% of patients generating close to 25% of private income).
These figures suggest that non-UK residents travelling to the UK
for medical treatment seek high-end specialist expensive proce-
dures, and may generate substantial revenue. Additional numbers
of patients for specialist procedures may also help NHS doctors
with surgical learning curves.
The changing destinations of UK travellers and the differing
origins of those travelling to the UK show that medical travel is a
dynamic phenomenon, which can rapidly increase and change.
This highlights the importance of continuous routine monitoring
to understand medical tourism and to enable researchers,
professionals and policymakers to better consider the costs and
benefits of medical tourism to the UK.
UK residents who had travelled abroad reported experiencing
complications following their return, which echoed case reports in
the literature. While we calculated potential costs of these to the
NHS, complications experienced also pose an ethical question.
There is currently no guidance or regulation on risk or safety for
UK residents who consider travelling abroad for treatment.
Potential savings as a result of medical travel, especially evident
from bariatric patients here, are noteworthy especially at a time of
constrained public resources.
Our findings from NHS Trusts indicates that for those wishing
to increase their private income as a result of the income cap being
raised foreign private patients may be more attractive than
domestic private patients.
While this particular research focused on the impact of medical
tourism on the UK NHS, the findings give an indication of
possible impact of medical tourism in other countries. They are
likely to have particular resonance for other universal public health
systems.
Strengths and Weaknesses of the Study
While the study used the most robust data set available to
measure volume of medical tourism to the UK, the International
Passenger Survey, it has several weaknesses. The IPS only surveys
0.2% of travellers entering and leaving the UK. In addition,
inbound figures on medical tourists do not provide information on
whether these are accessing treatment in the public or the private
sector. Interviews with medical tourists also suggested that not all
may identify themselves as travelling for medical purposes.
Moreover, costs calculated are based on published literature often
drawing on small samples.
Thus, although data and analysis presented here represent the
most comprehensive analysis of inbound and outbound medical
tourism to date, they clearly identify the significant gap in
understanding of this increasingly important phenomenon. The
particular strength of the findings here lies in the mixed–methods
approach. Authors undertook the first comprehensive analysis of
the IPS from a medical tourism perspective. Findings were
triangulated by drawing on published literature, and by analysis of
interviews with 77 UK medical tourists. Similarly, the cost
estimates were developed based on results from interviews, costs
reported in the published literature, the IPS data set and freedom
of information requests to 28 hospital foundation trusts. Hence,
each finding has carefully been considered and based on more
than one data source.
Directions for Future Research
The impact of medical tourism warrants better monitoring.
Findings demonstrate impact in terms of possible costs and
benefits and the highly dynamic nature of the phenomenon means
that the absolute numbers presented here could grow rapidly.
Only continuous monitoring will allow better understanding and
informed policy-making to ensure patient safety.
Estimates of cost presented here mark a first step based on the
limited data available. To better understand costs and potential
savings of medical tourism requires not only better data on volume
of travel but also on the differences in long-term health outcomes
between patients who travelled and those having received
treatment at home. Further research of comparative outcomes is
needed.
This research does not explore the ethical dimensions that are
involved in many of the considerations relating to medical tourism,
including why patients opt to receive care outside of the UK.
While data here represents the economic costs of complications
experienced by patients these obviously will have to be considered
alongside considerations of patient safety.
Conclusions
UK medical tourism is a growing phenomenon. To fully
understand its implications and guide policy on issues such as NHS
global activities and patient safety will require investment in
further research and monitoring. Despite existing data limitations
it is evident that UK medical tourism is dynamic and changing.
Findings indicate costs arise where patients travel abroad and
return with complications. Analysis also indicates possible savings
in the case of specific procedures especially in future health care
and social costs averted. Inbound medical tourists offer potentially
high income to NHS hospitals. Results of this research may also be
indicative of the impact of medical tourism in other public health
systems.
Disclaimer
The views and opinions expressed therein are those of the
authors and do not necessarily reflect those of the HS&DR
Programme, NIHR, NHS or the Department of Health.
Supporting Information
Annex S1 Cost calculations.
(DOCX)
Annex S2 Responses to FOI requests to 28 Foundation
Trust Hospitals.
(DOCX)
Author Contributions
Conceived and designed the experiments: JH DH NL RS. Analyzed the
data: JH DH RS. Wrote the paper: JH DH NL RS. PI on overall research
project: NL. Investigator: RS.
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15. McKelvey A, David AL, Shenfield F, Jauniaux ER (2009) The impact of cross-
border reproductive care or ‘fertility tourism’ on NHS maternity services. BJOG:
An International Journal of Obstetrics and Gynaecology 116: 1520–1523.
16. Miyagi K, Auberson D, Patel AJ, Malata CM (2012) The unwritten price of
cosmetic tourism: An observational study and cost analysis. Journal of Plastic,
Reconstructive & Aesthetic Surgery 65: 22–28.
17. O’Neil P (2010) Shedding the Pounds: Obesity Management, NICE Guidance
and Bariatric Surgery in England. London: Office of Health Economics.
18. Hawkins S, Osborne A, Finlay I, Alagaratnam S, Edmond J, et al. (2007) Paid
Work Increases and State Benefit Claims Decrease after Bariatric Surgery.
Obesity Surgery 17: 434–437.
UK Medical Tourism
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Research
Aesthetic Surgery Journal
2017, Vol 37(4) 474–482
© 2016 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjw198
www.aestheticsurgeryjournal.com
Complications After Cosmetic Surgery Tourism
Holger J. Klein, MD; Dario Simic; Nina Fuchs, MD;
Riccardo Schweizer, MD; Tarun Mehra, MD;
Pietro Giovanoli, MD; and Jan A. Plock, MD
Abstract
Background: Cosmetic surgery tourism characterizes a phenomenon of people traveling abroad for aesthetic surgery treatment. Problems arise
when patients return with complications or need of follow-up care.
Objectives: To investigate the complications of cosmetic surgery tourism treated at our hospital as well as to analyze arising costs for the health
system.
Methods: Between 2010 and 2014, we retrospectively included all patients presenting with complications arising from cosmetic surgery abroad. We
reviewed medical records for patients’ characteristics including performed operations, complications, and treatment. Associated cost expenditure and
Diagnose Related Groups (DRG)-related reimbursement were analyzed.
Results: In total 109 patients were identified. All patients were female with a mean age of 38.5 ± 11.3 years. Most procedures were performed in South
America (43%) and Southeast (29.4%) or central Europe (24.8%), respectively. Favored procedures were breast augmentation (39.4%), abdominoplasty
(11%), and breast reduction (7.3%). Median time between the initial procedure abroad and presentation was 15 days (interquartile range [IQR], 9) for
early, 81.5 days (IQR, 69.5) for midterm, and 4.9 years (IQR, 9.4) for late complications. Main complications were infections (25.7%), wound breakdown
(19.3%), and pain/discomfort (14.7%). The majority of patients (63.3%) were treated conservatively; 34.8% became inpatients with a mean hospital stay
of 5.2 ± 3.8 days. Overall DRG-related reimbursement premiums approximately covered the total costs.
Conclusions: Despite warnings regarding associated risks, cosmetic surgery tourism has become increasingly popular. Efficient patients’ referral
to secondary/tertiary care centers with standardized evaluation and treatment can limit arising costs without imposing a too large burden on the social
healthcare system.
Level of Evidence: 4
Editorial Decision date: September 30, 2016; online publish-ahead-of-print November 14, 2016.
Medical tourism in general characterizes a phenomenon of
people traveling abroad to access health treatment – reach-
ing from dental procedures, assisted reproductive tech-
nology, ophthalmologic and psychological care via cancer
treatment, orthopedic and cardiac surgery, to organ and
cellular transplantation and not least cosmetic surgery pro-
cedures.1,2 While some countries in South America have
developed strong reputations for aesthetic surgery and
dental care, countries from Far East have become famous
for general surgery procedures with medical services at
particularly affordable prices being as low as 10% com-
pared to those in the United States.3,4 Above that, even
industrialized countries such as Switzerland, Belgium,
Germany, or Canada attract well-off patients from abroad
offering sophisticated care with modern technologies focus-
ing on patients’ preferences and satisfaction.1 It is not sur-
prising, that this rapidly growing trend captures attention
From the University Hospital Zurich, Zurich, Switzerland.
Corresponding Author:
Dr Jan A. Plock, University Hospital Zurich, Division of Plastic
Surgery and Hand Surgery, Raemistrasse 100, 8091 Zurich,
Switzerland.
E-mail: jan.plock@usz.ch
mailto:jan.plock@usz.ch?subject=
Klein et al 475
in academic and popular media, which is underlined by a
Google internet search for the term “medical tourism” result-
ing in more than 30 million hits (performed in December
2015). Although precise records of people seeking medi-
cal treatment abroad are lacking with an estimated high
number of unknown cases, rough calculations account for
about 6 million US Americans that claimed medical care
overseas in 2010 – with the tendency to triple in 2017.5
Amongst the different types of medical tourism, cos-
metic surgery procedures hold a special position and have
proven to be particularly popular for different reasons.
First, the phenomenon of cosmetic surgery tourism is
largely price-driven as most of the requested procedures
have to be paid out the patient’s own pocket – both in their
home countries and abroad. Such cost-conscious patients
mainly originating from highly industrialized countries are
willing to accept certain inconveniences and insecurities
in order to undergo aesthetic procedures at an attractively
low price in less developed states.5-7 Travel agencies that
specialize in whole package arrangements offering aes-
thetic procedures performed by well-trained physicians in
an often-luxurious ambience mollify the patient’s doubts
and qualms. First world service at third world cost is the
calculus in the scope of increasing healthcare expenditure
in rich world countries.6 Cosmetic surgery tourism is addi-
tionally fueled by the preservation of patients’ anonymity,
shorter waiting lists, accessible online information, and the
relative affordability of international airfares along with
favorable economic exchange rates.8 Another factor con-
tributing to this growing popularity of seeking procedures
abroad is an increasing strive for consumerism where the
patient can dictate requested surgical procedures.
Nonetheless, it remains to be questioned if travel agen-
cies or private clinics abroad specializing in cosmetic sur-
gery tourism can keep their glamorous promises. Whereas
on-site complications might be directly handled by the
surgeon/anesthesiologist in charge, problems arise when
complications occur after the patient’s return in their
home country. Even deaths of individuals traveling abroad
for cosmetic and bariatric surgery have been reported in
this context.9 In case of surgical failure or hospital negli-
gence, it is often difficult for patients to receive adequate
compensation for malpractice in many countries.10 As to
that, initial savings might blur patients’ farsightedness.11
Consequently, sufficient follow up care is one of the most
challenging hurdles that cosmetic surgery tourism is fac-
ing today. Regularly reported complications are infec-
tions, wound dehiscence, pain/discomfort and aesthetic
dissatisfaction.5,6,12,13
Although cosmetic surgery tourism as a niche has
become a stand-alone industry, little is known about clin-
ical outcomes, complication rates, opportunity costs, and
responsibility regarding treatment of complications and
cost coverage. Any direct numbers regarding quality-control
or patient satisfaction are lacking for self-explanatory
reasons. However, as the trend for cosmetic procedures
abroad continues to grow, so does the need for an effi-
cient management of resulting complications. Increasing
numbers of individuals have presented to our department
requesting treatment during the last 5 years. In this retro-
spective study, we set out to investigate these complica-
tions of cosmetic surgery tourism as well as to analyze cost
effectiveness of treatment for complications at our center.
METHODS
Approval was obtained from the Ethics Committee of the
University of Zurich (KEK-ZH-Nr. 2014-0585). We retro-
spectively included all patients presenting as emergency
cases or as outpatients at our department between 2010
and 2014 with complications arising from cosmetic sur-
gery abroad. Concerned medical records were reviewed
for patients’ characteristics including performed oper-
ations, follow-up period, geographical area and surgical
complications. Chart review was conducted in July 2015.
Performed procedures abroad were grouped according
to their type of surgery: breast surgery (augmentation,
reduction, mastopexy, change of implants), body con-
touring (abdominoplasty, liposuction, thigh lift, brachio-
plasty), facial surgery (facelift, otoplasty, blepharoplasty,
rhinoplasty), injections (botulinum toxin, fillers), and
others (eg, hair transplantation, genital rejuvenation sur-
gery). Follow-up period between the initial procedure
abroad and presentation at our department was subdivid-
ed into early (≤30 days), midterm (30-180 days) and late
(>180 days) occurrence of complications.
Costs were defined as total direct costs of inpatient
care, allocated to each case under the REKOLE (Bern,
Switzerland) full cost accounting method.14 REKOLE is
the Swiss national cost accounting system for hospitals.
National legislation demanded comparability and trans-
parency in hospital cost accounting, which is why REKOLE
was introduced. It is a full cost accounting method with
the hospital case being the cost unit, which means that
all costs including overheads are allocated to the treated
patients. Revenue was defined as the total earnings per
case, taking into account the change of the reimbursement
system from a largely per-diem based system to a Diagnose
Related Groups (DRG)-based prospective payment system
for discharges after January 2012. The case earnings were
calculated by subtracting the case costs from the calcu-
lated case revenue. The accuracy of revenue-determining
coding as well as cost data in Switzerland is continuously
subject to external and independent audits.
Data were analysed using Statistical Package for Social
Sciences (SPSS, Version 20 for Macintosh; Chicago, IL).
Discrete values are expressed as counts (percentages) and
continuous variables as means (standard deviation [SD])
476 Aesthetic Surgery Journal 37(4)
or medians (interquartile range [IQR]) according to their
distribution.
RESULTS
A total of 109 patients presenting with complications sec-
ondary to cosmetic procedures abroad were identified in the
period between 2010 and 2014 (Figure 1). All patients were
female with a mean age of 35.1 years (SD, 10.5) (range, 18-
62 years) at procedure abroad, while mean age at presenta-
tion was 38.2 years (SD, 11.3) (range, 20-73 years). Over-
all median follow-up time between the initial procedure
abroad and presentation at our department was 84 days
(IQR, 616 days). Forty patients presented with early compli-
cations (≤30 days) with a median follow-up time of 15 days
(IQR, 9 days) (Table 1). Ten of these “early complication”
patients (25%) needed immediate revision surgery due to
acute infection, implant exposure, wound breakdown, or
hematoma. The remaining 30 patients (75%) were treat-
ed conservatively with antibiotics and/or regular wound
care; eventually 4 of these patients (10%) had to under-
go revision surgery subsequently as conservative treatment
failed. Twenty-eight patients suffering from midterm com-
plications (31-180 days) presented after 81.5 days (IQR,
69.5 days) (Table 1). This “midterm complication” group
comprised 28 patients (26%) with 10 patients presenting
with wound breakdown, 7 patients with pain/discomfort,
5 patients with delayed infection, and 2 patients who com-
plained about the aesthetic result. The rate for immediate
reoperation was as low as 7% (2 patients) in this group.
Conservative treatment was predominant (71%), 6 patients
had to be operated subsequently when conservative man-
agement failed. Late complications (>180 days) were found
in 41 patients with a median follow-up period of 2.96 years
(IQR, 9.4 days) (Table 1). This “late complication” group
with 41 patients (38%) included unsatisfying results in 5
patients, prolonged pain/discomfort in 8, implant rupture in
8, capsular contracture in 7, and infection mostly due to late
seroma in another 4 patients. None of these patients had to
be operated immediately. Elective surgical intervention was
required in 18 patients.
Breast surgery was the most frequent procedure with
68 cases (62.4%), while 17 patients (15.6%) underwent
body contouring procedures; facial surgery was performed
in 5 patients (4.6%), while 14 patients (12.8%) underwent
injections with botulinum toxin or fillers (Table 1, Figure 2).
Main complications were infections (25.7%) followed by
wound breakdown (19.3%), pain/discomfort (14.7%),
implant rupture (8.3%), capsular contracture (6.4%), dis-
satisfaction with the aesthetic result (6.4%), and hematoma
(5.5%) (Table 1, Figure 3). Most procedures were performed
in South America (30.3%) and Southeast (29.4%) or Middle
Europe (24.8%), respectively (Tables 2-4).
The majority of patients presented via our emergency
department (n = 68, 62.4%), none of them in instable
condition. All other patients referred themselves to our
outpatient clinic (n = 41, 47.6%). Thirty-eight patients
(34.8%) became inpatients with a mean hospital stay of
5.2 days (SD, 3.9 days). None of them required medical
intensive care. Almost two-third of these patients (n = 69,
63.3%) were treated conservatively with administration
of antibiotics (n = 17). Forty patients (36.7%) needed
revision surgery, most of them due to infection (n = 19).
Table 5 shows the numbers of patients according to the
type of consultation (outpatient vs inpatient) and the type
of treatment (conservative vs surgery).
Total cost expenditure reached SFr 530,000 (~US
$534,000, ~EUR 486,000) while (DRG-related) reimburse-
ment was SFr 550,000 (~US $554,000, ~EUR 505,000),
resulting in a slight overall financial gain of SFr 20,000
(~US $20,000, ~EUR 19,000) for the population of 109
patients. Inpatients caused significantly higher costs (SFr
10,000, US $10,100, EUR 9200 per patient) than outpatients
(SFr 3800, US $3830, EUR 3490 per patient). Inpatients were
profitable with mean gains of SFr 1287 (~US $1300, ~EUR
1180) per patient, while outpatients (including partial inpa-
tients) caused an average loss of SFr −415 (US $418, EUR
381) per patient in our tertiary hospital setting (exchange
rate per July 26, 2016: 1 SFr = 0.92 EUR = 1.01 USD).
DISCUSSION
According to an ISAPS-based (International Society of
Aesthetic Plastic Surgery) article from 2011, highest per-
centages of cosmetic procedures worldwide are performed
Figure 1. Number of patients with complications related to
cosmetic surgery tourism per year.
Klein et al 477
in Switzerland with 59 operations per 10,000 citizens. For
comparison, highest total numbers of cosmetic procedures
are reported for the United States, however accounting
for only 35 cosmetic procedures per 10,000 citizens.15
Independently of these striking numbers, skyrocketing
healthcare costs make people of industrialized countries
gradually claim medical treatment abroad. Consequently,
the willingness to undergo surgery abroad has gained an
entirely new dimension making cosmetic surgery tourism
a thriving industry. As complications are unavoidable,
healthcare systems of patients’ home countries have to
face the consequences in return. Although absolute num-
bers of people traveling abroad for cosmetic surgery are
lacking, we were able to observe this rapidly growing trend
for Switzerland, too (Figure 1): An increasing number of
patients presented to our department with complications
secondary to cosmetic surgery abroad between 2010 and
2014. Allowing for the fact that quality and safety of these
procedures might have ameliorated during the last decade,
the almost exponentially rising number of complications
gives a rough idea of the extent of this phenomenon. This
increase might even be underestimated as cosmetic sur-
gery tourism is absolutely trending in Europe and even
more so in Switzerland with the high price level. There is
no official data available. Financial reasons are current-
ly driving this trend and being a tertiary public hospital
we are supposed to help for any medical issue within the
Swiss healthcare system. The Division of Plastic Surgery
Figure 2. Percentage of performed procedures abroad. Figure 3. Percentage of complications related to cosmetic
surgery tourism.
Table 1. Procedures Performed and Complications According to their Temporal Occurrence
Early (≤30 days) Midterm (31-180 days) Late (>180 days) Total
Procedure
Breast surgery 25 19 24 68 (62.4%)
Body contouring 9 5 3 17 (15.6%)
Injections 2 2 10 14 (12.8%)
Facial surgery 3 1 1 5 (4.6%)
Others 1 1 3 5 (4.6%)
Complication
Infection 19 5 4 28 (25.7%)
Wound breakdown 8 10 3 21 (19.3%)
Pain/discomfort 1 7 8 16 (14.7%)
Implant rupture 1 8 9 (8.3%)
Dissatisfaction 2 5 7 (6.4%)
Capsular contracture 7 7 (6.4%)
Hematoma 5 1 6 (5.5%)
Others 6 3 6 15 (13.8%)
478 Aesthetic Surgery Journal 37(4)
and Hand Surgery at the University Hospital Zurich pro-
vides up to 30 beds for inpatients and serves the popula-
tion of Zurich with about 380,000 citizens and its cantonal
area with a total population of 1.4 million citizens. How-
ever, further hospitals of Zurich and its adjacent area con-
tribute to patients’ healthcare. The annual report of 2015
revealed nearly 6000 consultations and 1650 procedures
for plastic surgery reasons (including aesthetic surgery)
at our division.16 Numbers on purely aesthetic operations
make up for approximately 10%.
We found breast surgery (62%) along with body con-
touring (15%) and injections (13%) as the most frequently
performed procedures, which is in line with previous
studies conducted in Europe.6,12,13,17 Miyagi et al investi-
gated the same issue for the United Kingdom (UK) pre-
senting complications secondary to breast surgery in 74%
and body contouring in 21%.6 Of note, the mean age in
Miyagi et al’s study (43.5 years; range, 30-60 years; survey
period, 2007-2009) was remarkably higher in contrast to
our finding (35.1 years; range, 18-62 years; survey period,
2010-2014). This might largely be related to the growing
desire of younger patients for cosmetic surgery. We found
wound infection (26%) as predominant complication after
cosmetic surgery abroad, followed by wound breakdown
(19%) and pain/discomfort (15%). This basically con-
firms the results of earlier studies, which were conducted
in Great Britain and the United States.5,6,13 Interestingly,
a recent study from the United States presented a series
of patients with mycobacterial infections after cosmetic
surgery in developing countries.18 The authors stated that
the endemic nature of these bacteria combined with a low
domestic (in the United States) incidence of related infec-
tions might delay diagnosis and adequate treatment. In our
study, two of our 28 infectious complications were related
to mycobacteria and correct microbiological results were
delayed by approximately four weeks in both cases. Thus
consulting physicians should have a low threshold to con-
sider atypical etiologies in such scenarios.
Notwithstanding, Miyagi et al as well as Jeevan et al
reported complications due to poor cosmetic results in
37% and 26% respectively, which remarkably differs from
our finding (6%).6,17 A possible reason for this difference
might be the fact that Miyagi et al conducted their study
in a tertiary referral Plastic Surgery practice and Jeevan
et al received their data from a questionnaire, which was
answered by 203 UK consultant plastic surgeons mainly
belonging to the private sector. There may be a significant
bias of complicated cases presenting in public hospitals
with emergency units and plastic surgery private practices
– the latter ones probably seeing more late complications
and aesthetic dissatisfaction. Of note, pertinent literature
does not provide data on complications resulting from local
injections such as botulinum toxin or fillers. However, this
type of complication was observed in 13% of our patients
reflecting the growing sector of “minimal invasive rejuve-
nation.” These quite affordable and quick procedures are
meanwhile regularly offered as “to-go” interventions along
the road or at exclusive hotels.
Overall median follow-up time between the initial pro-
cedure abroad and presentation at our department was
84 days (IQR 616 days). The large IQR of the overall fol-
low up period was related to patients presenting several
Table 2. Procedures Performed According to their Originating Subcontinent
Breast surgery Body contouring Facial surgery Injections
Others Total
America
South America 21 4 0 6 2 33 (30.3%)
North America 1 0 0 0 0 1 (0.9%)
Europe
Middle Europe 21 3 2 1 0 27 (24.8%)
South Europe 3 0 0 0 0 3 (2.8%)
West Europe 1 0 0 1 1 3 (2.8%)
Asia
Far East 2 0 0 1 1 4 (3.7%)
Middle East 0 1 0 1 0 2 (1.8%)
Africa
North Africa 2 1 0 1 0 4 (3.7%)
Total 68 (62.4%) 17 (15.6%) 5 (4.6%) 14 (12.8%) 5 (4.6%)
Klein et al 479
months/years after the initial operation abroad (eg, in case
of capsular contracture). These “outliers” diminish the
meaningfulness of the overall median follow-up period in
terms of a significant skewedness. Accordingly, we subdi-
vided our cohort into three groups corresponding to their
time-dependent occurrence of complications (early/acute,
midterm, late complications) with more informative and
statistically more reliable follow up medians. Early com-
plications occurring within the first 30 days after opera-
tion include acute, possibly life-threatening complications
such as infections, hematoma/bleeding or dehiscence
potentially necessitating urgent surgical revision. With the
end of this “early” period, regular wound healing should
allegedly be completed and severe consequences become
rather unlikely. The “midterm” group comprises compli-
cations that are directly related to the operation abroad,
but do mostly not require urgent intervention. During this
period scar formation is peaking and possibly leading to
pain/discomfort, and delayed wound-healing disorders are
to be expected. Additionally, patients usually start judging
the cosmetic result after wound healing has terminated and
swellings have vanished accounting for complaints due to
poor aesthetic result. Patients also start doing sports and
participate more in social activities, which may influence
judgments and discomfort during this period. Eventually,
the “late group” includes unsatisfying results, chronic prob-
lems like prolonged pain/discomfort, implant rupture, or
capsular contracture. None of the “late group” patients
had to be operated immediately. If conservative treatment
fails or is impossible (eg, capsular contracture), elec-
tive surgery may be an option. Each group of the present
study accounted for more or less one-third of the patients.
Notwithstanding this fact, almost two-third of the patients
presented via our emergency room, notably none of them
in unstable condition. Initial consultation in the emergency
room is associated with higher costs for the national health-
care system and prolonged waiting time for the patients.
Additionally, pressure on already overstretched emergency
units should be avoided. Consequently, the provided cat-
egorization might help primary and secondary care ser-
vices to refer patients either directly to the emergency
room (early category) or re-schedule for an appointment
in the outpatient clinic (midterm, late category). As to that,
Supplementary Figure 1 provides a complementary outline
aiming at cost and resource effective triage and treatment
limitations of patients with complications secondary to
cosmetic surgery abroad. Note, that boundaries between
the categories might partly be fluent. Under these circum-
stances taking care of “early” complication cases after sur-
gery abroad may financially be more attractive for public
hospitals and teaching units than in the private setting of
aesthetic plastic surgeons. Emergency availability, immedi-
ate diagnostic tools, bed and operating room capacity, as
well as personnel resources may advocate for treatment of
Table 3. Country-Related Numbers of Performed Operations
America
South America 33 (30.3%)
Brazil 16
Colombia 5
Dominican Republic 4
Venezuela 4
Ecuador 3
Peru 1
United States 1 (0.9%)
Europe
Southeast Europe 32 (29.4%)
Turkey 14
Serbia 8
Bulgaria 2
Croatia 2
Macedonia 2
Romania 2
Slovenia 2
Middle Europe 27 (24.8%)
Germany 10
Czech Republic 9
Austria 3
Poland 3
Belgium 1
Hungary 1
South Europe 3 (2.8%)
Italy 2
Portugal 1
West Europe 3 (2.8%)
United Kingdom 2
France 1
Asia
Far East 4 (3.7%)
Thailand 3
India 1
Middle East 2 (1.8%)
Emirates 1
Lebanon 1
Africa
North Africa 4 (3.7%)
Morocco 2
Tunisia 2
480 Aesthetic Surgery Journal 37(4)
acute complications in secondary and tertiary care centers,
while the mid- and long-term complications may be served
equally well in the private sector or in specialized hospital
outpatient clinics predominantly on patients own cost.
Of note, all patients of our study were female, which
significantly differs from data provided by the American
Society for Aesthetic Plastic Surgery with 10.3% of sur-
gical and 9.4% of nonsurgical procedures are performed
on males.19 This might be related to the fact that aesthetic
surgery in males in Europe is not as common as in the
United States. To the best of our knowledge there is no
data available on gender related cosmetic surgery tourism.
Healthcare in Switzerland is universal and is reg-
ulated by the Swiss Federal Law on Health Insurance.
There are no free state-provided health services, but
health insurance is compulsory for all persons resid-
ing in Switzerland. Health insurance covers the costs
of medical treatment and hospitalization of the insured.
Table 4. Subcontinent-Related Numbers of Complications
Infection Hematoma Wound
breakdown
Pain/discomfort Implant rupture Dissatisfaction Capsular
contracture
Others Total
South America 9 1 7 2 4 1 2 7 33
South East
Europe
6 3 8 4 1 4 0 6 32
Middle Europe 8 1 4 7 3 2 2 0 27
Far East 1 0 0 0 0 0 2 1 4
North Africa 2 0 1 1 0 0 0 0 4
South Europe 0 1 1 0 1 0 0 0 3
West Europe 1 0 0 1 0 0 1 0 3
Middle East 1 0 0 0 0 0 0 1 2
North America 0 0 0 1 0 0 0 0 1
Table 5. Number of Patients According to the Type of Consultation (Outpatient vs Inpatient) and the Type of Treatment (Conservative vs Surgery)
Type of consultation Type of treatment
Outpatient (65%) Inpatient (35%) Conservative (63%) Operation (37%)
Procedure
Breast surgery 44 (64.7%) 24 (35.3%) 44 (64.7%) 24 (35.3%)
Body contouring 12 (70.6%) 5 (29.4%) 11 (64.7%) 6 (35.3%)
Injections 7 (50%) 7 (50%) 7 (50%) 7 (50%)
Facial surgery 5 (100%) – 4 (80%) 1 (20%)
Others 3 (60%) 2 (40%) 3 (60%) 2 (40%)
Complication
Infection 7 (25%) 21 (75%) 9 (32.1%) 19 (77.9%)
Wound breakdown 19 (90.5%) 2 (9.8%) 19 (90.5%) 2 (9.53%)
Pain/discomfort 15 (93.8%) 1 (6.2%) 14 (87.5%) 2 (12.5%)
Implant rupture 4 (44.4%) 5 (56.6%) 4 (44.4%) 5 (55.6%)
Dissatisfaction 7 (100%) – 6 (85.7%) 1 (14.3%)
Capsular contracture 3 (42.9%) 4 (57.1%) 3 (42.9%) 4 (57.1%)
Hematoma 5 (83.3%) 1 (16.7%) 5 (83.3%) 1 (16.7%)
Others 11 (73.3%) 4 (26.7%) 9 (60.0%) 6 (40%)
Klein et al 481
However, the insured person pays part of the treatment
costs by means of an annual deductible (called “fran-
chise”, ranging US $184-1534) and by a charge of 10% of
the costs. As to that, the Swiss national healthcare sys-
tem takes care for complications resulting from surgical
interventions regardless of whether the primary surgery
was performed domestically or abroad. Excluded from
this lawful obligation are purely aesthetic complaints.
Though, even in these cases, an insurance inquiry can
be made on an individual basis.
Switzerland has a propitious geographic location in the
center of Europe enabling people to seek aesthetic surgery
abroad within few hours – guaranteeing remarkably lower
prices, shorter waiting lists, excellent care, and quality in a
luxurious ambience and the possibility to combine holidays
with cosmetic procedures. Our data reflect this assumption
as almost 60% of the patients underwent beauty surgery in
neighboring European countries. Within Europe, favored
countries are Turkey, Germany, Czech Republic, and Serbia –
probably offering the best combination of low prices, well-
trained physicians, high standard care, informative and
trustworthy internet presence, and none/reduced language
barriers. Three earlier studies, conducted in the UK, con-
sistently found the neighboring European countries (espe-
cially the Southeast of Europe) as primary destination for
cosmetic surgery tourists.5,6,17 Outside Europe, despite
long travel distances, South America (30%) has proven its
popularity for cosmetic surgery tourism with Brazil (15%)
as market leader. Attractive airfares and a not irrelevant
percentage of South American (45,000, 0.5%), Spanish
(85,000, 1%), and Portuguese (275,000, 3%) immigrants
might explain this trend20 for Switzerland.
In the age of DRG revenue management, analysis of
cost effectiveness plays an increasingly important role.
Our results indicate that the treatment of complications
resulting from cosmetic surgery tourism can be handled
cost-effectively. Considerable potential for savings lies in
the referral of non-emergency cases to the outpatient clinic
instead of the emergency room. Adequate comparable
data are lacking in pertinent literature; merely Miyagi et al
reported that remuneration provided by the Primary Care
Trust (UK) to the hospital was less than 70% of the actual
expenditure. To be mentioned, international comparisons
of costs and reimbursement need to be adjusted to the rel-
atively high cost and reimbursement level for medical care
in Switzerland.21
Several international collaborative initiatives have faced
the problems of cosmetic surgery tourism by establish-
ing recognized contracts including measures for ensur-
ing accountability if complications arise, appropriate
hygiene standards and post-procedural care. In addition,
the International Society of Aesthetic and Plastic Surgery
(ISAPS) and the American Society of Aesthetic and Plastic
Surgeons (ASAPS) have issued guidance for patients on
the risks of cosmetic tourism and information they should
seek prior to any procedure abroad.22 The latter includes
the ISAPS Patient Safety Diamond, which emphasizes four
facets that the patient should establish. These include
details of the operation (including indications, likelihood
of success, and associated risks), qualifications and track
record of the surgeon, quality and resources of the health-
care facility, and the appropriateness for the individual
patient to undergo the specified procedure.
Although this is the first survey addressing cosmetic
surgery complications in Switzerland, our study is limited
by the fact that a national database on absolute numbers of
Swiss people seeking cosmetic procedures abroad is lack-
ing. Consequently, relative numbers serving as “quality
feature” for cosmetic procedures abroad cannot be calcu-
lated. Likewise, numbers from neighboring hospitals treat-
ing complications secondary to cosmetic surgery tourism
have not been included in our study for ethical reasons
(inter-cantonal ethical approval and individual informed
consent from all patients is required). Moreover, patient
numbers seeking cosmetic procedures abroad might be
lower for other countries so that the results presented here
may not be directly transferred to other health systems and
societies. As the price level in Switzerland is relatively high
in comparison to adjacent countries in Europe and the size
of the country is limited, patients are motivated to seek
cosmetic procedures at lower cost within reasonable travel
time. Future studies should also include data on patients’
ethnicity and descent.
CONCLUSIONS
Cosmetic surgery tourism has become a stand-alone in-
dustry with ongoing trend to expand. Overall complica-
tion rates as markers for the quality of surgery performed
abroad remain unknown, as data on the total number of
these procedures is lacking. Following efficient patients’
referral with subsequent professional evaluation and treat-
ment in qualified plastic surgery units, immediate as well
as later occurring complications secondary to cosmetic
surgery abroad can be treated effectively at reasonable
costs without imposing a too high burden on the social
healthcare system. The majority of complications can be
treated conservatively and in an ambulatory setting.
Supplementary Material
This article contains supplementary material located on-
line at www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
http://www.aestheticsurgeryjournal.com
482 Aesthetic Surgery Journal 37(4)
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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NEWS MEDIA REPORTS OF PATIENT DEATHS FOLLOWING ‘MEDICAL
TOURISM’ FOR COSMETIC SURGERY AND BARIATRIC SURGERYdewb_320 21..34
LEIGH TURNER
Keywords
bioethics,
empirical ethics,
medical ethics,
Mexico,
patient protection,
health care
ABSTRACT
Contemporary scholarship examining clinical outcomes in medical travel for
cosmetic surgery identifies cases in which patients traveled abroad for
medical procedures and subsequently returned home with infections and
other surgical complications. Though there are peer-reviewed articles iden-
tifying patient deaths in cases where patients traveled abroad for commer-
cial kidney transplantation or stem cell injections, no scholarly publications
document deaths of patients who traveled abroad for cosmetic surgery or
bariatric surgery. Drawing upon news media reports extending from 1993 to
2011, this article identifies and describes twenty-six reported cases of
deaths of individuals who traveled abroad for cosmetic surgery or bariatric
surgery. Over half of the reported deaths occurred in two countries. Analy-
sis of these news reports cannot be used to make causal claims about why
the patients died. In addition, cases identified in news media accounts do
not provide a basis for establishing the relative risk of traveling abroad for
care instead of seeking elective cosmetic surgery at domestic health care
facilities. Acknowledging these limitations, the case reports suggest the
possibility that contemporary peer-reviewed scholarship is underreporting
patient mortality in medical travel. The paper makes a strong case for
promoting normative analyses and empirical studies of medical travel. In
particular, the paper argues that empirically informed ethical analysis of
‘medical tourism’ will benefit from rigorous studies tracking global flows of
medical travelers and the clinical outcomes they experience. The paper
contains practical recommendations intended to promote debate concern-
ing how to promote patient safety and quality of care in medical travel.
INTRODUCTION
Four years ago, while searching the internet for articles
about medical tourism and globalization of health care, I
discovered a news report describing the death of a woman
from New Jersey who traveled to the Dominican Repub-
lic for what the reporter described as a tummy tuck pro-
cedure and liposuction.1 The article indicated that the
woman experienced respiratory problems following her
operation and died six days later. I later found an article
that described the deaths of three Americans who trav-
eled to Mexico for cosmetic surgery, experienced compli-
cations during or following their operations, and died
after being transported to medical centers in California.2
I found these articles thought-provoking and troubling.
The journalists provided disturbing accounts of the
1 V. Corderi. 2005. Plastic surgery tourism? Dangers of going under the
knife on the cheap. Dateline MSNBC 18 March 2005. Available at:
http://www.msnbc.msn.com/id/7222253/ns/dateline_nbc/. [Accessed 1
February 2011].
2 C. Clark & S. Dibble. 1996. When cosmetic surgery in Baja goes bad;
Deaths raise questions about risks at clinics. The San Diego Union-
Tribune 14 July: A1.
Address for correspondence: Leigh Turner, PhD, University of Minnesota Center for Bioethics, N504 Boynton 410 Church St SE, Minneapolis, MN
55455, USA. Email: turne462@umn.edu.
Conflict of interest statement: No conflicts declared
Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) doi:10.1111/j.1471-8847.2012.00320.x
Volume 12 Number 1 2012 pp 21–34
bioethics
developing world
© 2012 Blackwell Publishing Ltd.
, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
quality of care these women received at the international
clinics they visited.
After reading these two news media accounts, I decided
to see whether I could locate additional news reports of
deaths of individuals who had traveled abroad for cos-
metic surgery or bariatric surgery. To focus my search I
placed four constraints upon the process of finding and
analyzing news reports.
First, hoping to obtain basic demographic data, I decided
to eliminate from my analysis news reports that mentioned
deaths of medical travelers but provided little information
about such details as individuals’ ages, their gender, the
countries from which patients departed, the nations to
which they traveled for surgery, and when patients died.
Second, I restricted my searches to several English-
language databases. Though in one case I was able to
supplement an English-language report with several news
reports written in Spanish and published by media
sources in Mexico, four English-language databases were
my primary resource for conducting searches.
Third, I excluded from my analysis reports of individu-
als who experienced post-operative complications but did
not die after traveling abroad and undergoing cosmetic
surgery or bariatric surgery. There are several reasons why
I focused upon mortality rather than morbidity. Reports
of complications following travel for cosmetic surgery and
bariatric surgery have already appeared in peer-reviewed
medical journals.3 In contrast, to date scholarship does not
appear to have identified cases of mortality related to
international travel for cosmetic surgery and bariatric
surgery. In addition, while complications following travel
for cosmetic surgery and bariatric surgery have potentially
significant implications for patients and public health
systems, in many instances physicians are able to address,
at least to some extent, the post-operative complications
described in these case reports. Reports in peer-reviewed
medical journals describe post-operative care in which
infections are treated and in some instances reconstructive
surgery is performed in an effort to treat injuries and
scarring resulting from surgery and post-operative com-
plications. In contrast, patients who die during surgery or
in the post-operative period following cosmetic surgery or
bariatric surgery suffer the ultimate loss. Furthermore,
they die after undergoing elective procedures that did not
have to be performed. I should note that while I searched
for reports of mortality in medical travel for cosmetic
surgery and bariatric surgery I found many news reports
that described patients with post-operative complications
after traveling abroad for cosmetic surgery or bariatric
surgery. Had my analysis of news media sources included
reports of both mortality and morbidity the list of cases
would have increased in dramatic fashion.
Fourth, though I could have expanded my search to
include reports of morbidity and mortality in all types of
medical travel, I chose to restrict my search to accounts of
deaths of individuals undergoing cosmetic surgery or bari-
atric surgery. This decision meant that I did not seek
articles describing morbidity and mortality in medical
travelers undergoing such procedures as stem cell injec-
tions, treatments for cancer, ‘Liberation therapy’ for Mul-
tiple Sclerosis, and organ transplantation. Both news
media reports and academic journals report cases of indi-
viduals who have traveled to such countries as China,
Egypt, India, Pakistan, and the Philippines, participated
in commercial organ transplantation, and suffered mor-
bidity or mortality following organ transplantation.4
News reports and articles published in peer-reviewed jour-
nals also describe cases involving morbidity and mortality
in patients who traveled abroad for stem cell injections.5
More recently, academic journals and popular news media
have reported morbidity and mortality in individuals who
after being diagnosed with multiple sclerosis engage in
medical travel to obtain access to the procedure com-
monly known as ‘Liberation therapy’.6 Rather than
pursue the intimidating task of trying to identify reports of
mortality associated with all types of medical travel, I
3 Nontuberculous mycobacterial infections after cosmetic surgery –
Santo Domingo, Dominican Republic, 2003–2004. MMWR Morb
Mortal Wkly Rep 2004; 53: 509; M. Newman, A. Camberos & J.
Ascherman. Mycobacteria abscessus outbreak in US patients linked to
offshore surgicenter. Ann of Plast Surg 2005; 55: 107–110; M. Newman
et al. Outbreak of atypical mycobacteria infections in U.S. Patients
traveling abroad for cosmetic surgery. Plast Reconstr Surg 2005; 115:
964–965; J. Birch, R. Caulfield & V. Ramakrishnan. The complications
of ‘cosmetic tourism’ – an avoidable burden on the NHS. J Plast Recon-
str Surg 2007; 60: 1075–1077; A. Handschin, A. Banic & M. Constan-
tinescu. Pulmonary embolism after plastic surgery tourism. Clin Appl
Thromb Hemost 2007; 13: 340; D. Birch et al. Medical tourism in
bariatric surgery. Am J Surg 2010; 199: 604–608; J. Snyder & V.A.
Crooks. Medical tourism and bariatric surgery: more moral challenges.
Am J Bioeth 2010; 10: 28–30; E. Furuya et al. Outbreak of Mycobac-
terium abscessus wound infections among ‘lipotourists’ from the United
States who underwent abdominoplasty in the Dominican Republic.
Clin Infect Dis 2008; 46: 1181–1188.
4 S. Kennedy et al. Outcomes of overseas commercial kidney transplan-
tation: an Australian perspective. Med J. Aust 2005; 182: 224–227; M.
Canales, B. Kasiske, M. Rosenberg. Transplant tourism: Outcomes of
United States residents who undergo kidney transplantation overseas.
Transplantation 2006; 82: 1658–1661; G. Prasad et al. Outcomes of
commercial renal transplantation: a Canadian experience. Transplan-
tation 2006; 82: 1130–1135.
5 B. Dobkin, A. Curt & J. Guest. Cellular transplants in China: obser-
vational study from the largest human experiment in chronic spinal
cord injury. Neurorehabil Neural Repair 2006; 20: 5–13; N. Amariglio
et al. Donor-derived brain tumor following neural stem cell transplan-
tation in an ataxia telangiectasia patient. PLoS Med 2009; 6: 221–231;
C. Cohen & P. Cohen. International stem cell tourism and the need for
effective regulation. Part I: stem cell tourism in Russia and India: clini-
cal research, innovative treatment, or unproven hype? Kennedy Inst
Ethics J 2010; 20: 27–49.
6 J. Burton et al. Complications in MS Patients after CCSVI Proce-
dures Abroad (Calgary, AB). Can J. Neurol Sci 2011; 38: 741–746; C.
Alphonso. Death of MS patient fuels debate over new treatment. The
Globe and Mail 2010; 19 Nov.
22 Leigh Turner
© 2012 Blackwell Publishing Ltd.
decided to limit my search to reports of mortality in
patients traveling abroad for cosmetic surgery or bariatric
surgery. Though for practical reasons I have limited the
scope of my study, the research methods identified in this
article could be used to investigate news media reportage
of both mortality and morbidity in all types of interna-
tional medical travel.
DATABASES AND SEARCH TERMS
I conducted searches using ProQuest Newsstand, Google
News, Google News Archive, and Google. In addition, I
used Google Alerts to send to my email account updates
related to deaths of patients who had traveled abroad for
cosmetic surgery or bariatric surgery. Search terms com-
bined the general concepts of ‘medical tourist’, ‘cosmetic
surgery tourist’, and ‘bariatric surgery tourist’ with
‘death’. Specific search terms entered into databases
included: death medical tourism, death medical tourist,
medical tourist dead, medical tourist died, medical tourist
investigation, medical tourist death investigation,
medical tourist charges, medical tourist police, death cos-
metic surgery tourism, death cosmetic surgery tourist,
death lipotourism, death lipotourist, death lipo tourist,
death lipo tourism, dead facelift medical tourist, died
facelift medical tourist, died medical tourist pectoral
implants, dead medical tourist pectoral implants, dead
medical tourist breast implants, died medical tourist
breast implants, dead medical tourist breast augmenta-
tion, died medical tourist breast augmentation, death
medical tourist lap band, death medical tourist bariatric
surgery, and death medical tourist gastric bypass.
Despite my effort to identify appropriate search terms,
searches generated many articles describing deaths of
tourists by car and motorcycle crashes, electrocution,
fires and explosions, drowning, falls, and other accidents.
I discarded these articles and selected for analysis only
those publications describing deaths of individuals who
were reported to have died during or shortly after under-
going cosmetic surgery or bariatric surgery. Searches pro-
ceeded in an iterative manner. Once I identified an article
that provided an account of someone who had traveled
abroad for cosmetic surgery or bariatric surgery and died
during or after his or her operation I then used that
person’s name as a search phrase. In some instances that
step generated additional articles for review.
NEWS MEDIA ACCOUNTS OF
DEATHS OF MEDICAL TRAVELERS
UNDERGOING COSMETIC SURGERY
OR BARIATRIC SURGERY
To summarize information obtained from news media
reports I provide brief descriptions of twenty-six reported
cases of mortality in individuals who traveled abroad and
underwent cosmetic surgery or bariatric surgery at inter-
national medical facilities. Standard practice in peer-
reviewed academic journals is to conceal identities of
patients. Although the names of individuals are disclosed
in news media reports and therefore in the public domain,
I have replaced the names of individuals with patient
numbers. Cases are reported in chronological order and
extend from 1993 to 2011.
Patient 1 traveled from California, USA to Tijuana,
Mexico and underwent plastic surgery in 1993.7 She
went into cardiac arrest in the recovery room following
surgery and subsequently was transported to a medical
center in San Diego. Life support was discontinued two
weeks after she was hospitalized in San Diego. Two
weeks following discontinuation of life support the
patient died.
Patient 2 traveled from California, USA to a clinic in
Tijuana, Mexico in March 1996.8 There, she underwent a
‘tummy tuck’ procedure. The patient experienced compli-
cations from surgery and was transported to a medical
facility in San Diego. Life support was discontinued a few
days after her arrival and she died within a week of
having surgery.
Patient 3 traveled from California, USA to Tijuana,
Mexico in April 1996.9 She underwent liposuction and
vaginal reconstruction at the same clinic Patient 1 visited.
Following surgery, clinic staff members found the patient
was unconscious and not breathing. The patient was
transported to the same medical center to which Patient 2
was sent, declared comatose, and admitted to ICU. Ven-
tilator support was discontinued eight days after her
operation and the patient died three days later.
Patient 4 twice traveled from California, USA and
underwent breast implantation procedures at a small
clinic in Tijuana, Mexico.10 The patient’s incisions
became infected following her first surgical procedure;
her implants were then removed. The patient returned to
the clinic for a second breast implant procedure in
October 1996. The patient experienced a complication
and died a short time following the operation. Family
members contacted Baja California State Prosecutors. I
was unable to locate reports documenting the outcome of
this investigation.
Patient 5 traveled from New York, USA to the
Dominican Republic and underwent liposuction at a
7 C. Clark & S. Dibble. 1996. When cosmetic surgery in Baja goes bad;
Deaths raise questions about risks at clinics. The San Diego Union-
Tribune 14 July: A1.
8 Ibid: A1.
9 Ibid: A1.
10 S. Dibble. 1996. Death after operation stirs probe; Tijuana plastic
surgeon’s credentials questioned. The San Diego Union-Tribune 20
October: B1.
Reports of Patient Deaths Following ‘Medical Tourism’ 23
© 2012 Blackwell Publishing Ltd.
medical clinic in June 1998.11 Fat extracted during the
liposuction procedure was injected into the patient’s but-
tocks. The patient died at the clinic. The surgeon was
charged with involuntary manslaughter. I was unable to
determine how this case was resolved.
Patient 6 traveled from Puerto Rico to the Dominican
Republic and underwent liposuction at a medical clinic in
August 1998.12 Fat removed during the liposuction pro-
cedure was injected into her calves. The patient experi-
enced complications following surgery and was flown
back to Puerto Rico and admitted to intensive care.
Below-the-knee amputations were performed in an
attempt to treat her life-threatening condition. The
patient died approximately two weeks following admis-
sion to intensive care. The surgeon was arrested for two
days and then released. It appears that no further legal
action was taken.
Patient 7 traveled from Puerto Rico to the Dominican
Republic and had a breast reduction operation in Sep-
tember 1998.13 The patient had to be hospitalized for an
infection following the procedure. Two weeks after the
operation the patient died. An investigation was initiated
in Puerto Rico. There are no publicly accessible reports
documenting how the investigation was resolved.
Patient 8 traveled from Illinois, USA to Guadalajara,
Mexico for liposuction in 2001.14 Surgery was performed
at a private clinic. The patient died after experiencing an
adverse reaction following administration of an anaes-
thetic agent.
Patient 9 traveled from California, USA to Tijuana,
Mexico for liposuction and a ‘tummy tuck’ operation in
2002.15 The patient returned home following the proce-
dure but began feeling ill. She returned to Tijuana and
sought treatment for an infection. She died – reportedly
of a pulmonary embolism and cardiac arrest–while
undergoing a second surgical procedure.
Patient 10 traveled from New Jersey, USA to the
Dominican Republic in November 2004.16 There, she
underwent liposuction and a ‘tummy tuck’ procedure at a
clinic. One week after surgery the patient died. She is
reported to have died of a blood clot in her lungs.
The Santo Domingo Attorney General initiated an
investigation. There is no record of the outcome of the
investigation.
Patient 11 traveled from Austria and underwent lipo-
suction surgery in western Hungary in January 2005.17
The patient died a day after surgery. An investigation was
initiated in Hungary; there is no account of how it
concluded.
Patient 12 traveled from Ireland to New York, USA in
March 2005.18 At a Manhattan clinic she had cosmetic
surgery on her face, nose, neck, eyelids and lips. The
morning following surgery the patient collapsed in the
recovery room and went into cardiac arrest. Attempts to
resuscitate her were unsuccessful and she was transported
by ambulance to a nearby hospital. She was removed
from life support and died three days after the operation.
At the time of the patient’s death the treating surgeon had
settled 33 malpractice lawsuits. Following the investiga-
tion of this patient’s death, the surgeon surrendered his
medical license and can no longer practice medicine in
New York. In 2010 the surgeon paid $2.1 million to settle
the malpractice suit resulting from the death of this
patient.
Patient 13 traveled from Nigeria to Marbella, Spain
and underwent liposuction at a clinic in October 2005.19
Following significant blood loss during surgery the
patient was transported from the clinic to a nearby hos-
pital. The patient was declared dead upon arrival at the
hospital. According to the verdict delivered by Spanish
Court, the patient died as a result of the liposuction
canella puncturing the liver and colon. The physician was
sentenced to one year imprisonment for manslaughter,
fined 120,000 Euros, and had his medical license sus-
pended for three years.
Patient 14 traveled from England to Cyprus in Novem-
ber 2005.20 She had a facelift at a private medical clinic.
Following surgery the patient experienced complications
as well as symptoms of dizziness and breathlessness. She
was transferred to a nearby hospital and died there two
11 K. Ross. 1998. Quest for Physical Perfection Becomes Sad, Caution-
ary Tale. The Washington Post 12 September: A03.
12 Ibid.
13 Wire services. 1998. Plastic Surgery Deaths Raise Serious Questions.
Orlando Sentinel 18 September: 4.
14 2001. Woman Dies During Liposuction Surgery. Guadalajara
Reporter 16 March.
15 B. Hitt. Surgery South of the Border. CBS13. 3 November 2008.
Available at: http://sacramento.cbslocal.com/investigations/tijuana.
surgeries.south.2.855666.html [Accessed 10 Jan 2012].
16 M. Sherman & Y. Betances. 2003. The price of perfection. The
Eagle-Tribune. Available at: http://lopeztallaj.com/enlosmedios/
publicaciones/paginasexternas/eagletribune/eagletribune.htm,
[Accessed 10 Jan 2012]; V. Corderi. Plastic surgery tourism? Dateline
MSNBC 18 March 2005. Available at: http://www.msnbc.msn.com/id/
7222253/ns/dateline_nbc/ [Accessed 10 Jan 2012].
17 Associated Press. 2005. Hungarian police probe death of Austrian
patient who died after liposuction. 1 February.
18 S. O’Driscoll. 2005. Cosmetic surgery was ‘significant’ in NY death.
Irish Times 26 May: 10; W. St. John. 2005. The Irish Patient and Dr.
Lawsuit. The New York Times 24 April: 9.1; J. Eligon & C. Moynihan.
2010. Verdict After Fatal Surgery Surprises a Victim’s Family. The New
York Times 1 May: A15.
19 E. Davies & G. Keeley. 2005. Nigerian President’s wife dies after
plastic surgery operation in Spain. The Independent. 25 October; G.
Tremlett. 2005. Spanish look into death of Nigerian first lady after
cosmetic surgery. 25 October: 18; J. Clayton & E. Owen. President’s
wife died in coma after surgery ‘for slimming’. The Times. 25 October:
38.
20 Bristol woman died after facelift. Bristol Evening Post. 14 November
2008: 9; Western Daily Press. Woman died after facelift in Cyprus. 14
November 2008: 21.
24 Leigh Turner
© 2012 Blackwell Publishing Ltd.
days later. After four years, police in England ended their
investigation due to their inability to obtain medical
documents from Cyprus.
Patient 15 travelled from Rhode Island, USA to
Mumbai, India in May 2006.21 The patient underwent a
breast reduction and ‘tummy tuck’ procedure. She died
four days after the operation. A family member claimed
that the patient’s physicians attributed her death to a
blood clot that reached her lungs and caused a pulmo-
nary embolism.
Patient 16 traveled from Oregon, USA to Curitiba,
Brazil in July 2006.22 There, the patient underwent gastric
reduction duodenal switch surgery. Three days following
surgery the patient died. In news media coverage a family
member attributed the cause of death to a pulmonary
embolism.
Patient 17 traveled from Florida, USA to Ensenada,
Mexico for gastric bypass surgery in June 2007.23 The
patient returned to Florida five days after surgery. Less
than twenty-four hours following her return home the
patient’s fiancée found her struggling to breath. The
patient died a short time later. The Palm Beach County
Medical Examiner’s Office concluded that the patient
died of peritonitis.
Patient 18 travelled from Wellington, New Zealand to
Kuala Lumpur, Malaysia for lap band surgery in June
2007.24 Two weeks after surgery, while recovering at a
Malaysian resort, the patient is reported to have col-
lapsed and died. Family members requested an investiga-
tion by the local coroner; lack of access to medical
records hampered the investigation.
Patient 19 travelled from Ireland to Bogota, Colombia
for liposuction and cosmetic surgery on his face in 2007.25
The patient is reported to have died on the operating
table after experiencing heart failure. The patient’s
spouse noted the possibility that the patient had con-
sumed cocaine and alcohol the day before surgery. The
Irish state pathologist indicated that the death should be
classified as ‘per operative’ and the County Coroner in
Ireland concluded that the death was ‘caused by cardiac
failure related to prolonged surgery’. These decisions had
no practical effect because the treating physician was
based in Colombia and outside the legal jurisdiction of
the Dublin County Coroner’s office.
Patient 20 travelled from the US to Guadalajara,
Mexico for breast reduction surgery in July 2007.26 The
treating surgeon reportedly performed a full mastectomy
and then inserted breast implants. The patient’s incisions
opened and became infected after surgery and she spent
over a month in hospital. She is reported to have died of
a heart attack in October 2007. According to news
reports, the physician was arrested and charged with
fraud, medical irresponsibility, severe damages, and pro-
fessional usurpation. At the time of his arrest 43 patients
had filed complaints against him. The doctor was jailed
for one year.
Patient 21 traveled from California, USA to Tijuana,
Mexico for liposuction and a breast lift in July 2008.27
Her operation was performed at a clinic located within a
hotel complex. The patient experienced heart failure
during surgery and died at the clinic. Family members
filed a complaint with the Attorney General. It is unclear
how the investigation concluded.
Patient 22 traveled from Texas, USA to Panama for
liposuction in June 2009.28 The patient traveled there with
a group of other U.S. patients. Surgery was performed at
a private clinic. The patient reportedly had surgery, was
transferred to a recovery room, and then died after suf-
fering respiratory failure. Family members requested a
medical forensic investigation. There is no record of how
the investigation concluded.
Patient 23 traveled from Mattersburg, Austria to
Hungary for liposuction in January 2009.29 The patient
experienced severe pain following the operation and died
later that month. The Austrian Municipal Prosecutor’s
Office ordered an investigation of the case. The outcome
of the investigation is unknown.
Patient 24 traveled from Belarus and underwent a
breast enlargement procedure at a private clinic in Dubai,
21 T. Mooney. 2006. Cosmetic surgery overseas ends in death for R.I.
woman. The Providence Journal 19 May 2006: A01; J. Wolff. 2007.
Passport to Cheaper Health Care? Good Housekeeping 1 September.
22 J. Wolff. 2007. Passport to Cheaper Health Care? Good Housekeep-
ing 1 September.
23 A. Ceron & J. Schwartz. 2007. Infection Killed Woman Who Got
Gastric Bypass in Mexico. Palm Beach Post. 30 August; B1.
24 K. Meade. 2007. Death raises warning on overseas surgery. The
Australian: 29 October: 2; Woman dies after trip for stomach op. 2007.
Sunday Star Times. 27 October.
25 S. Carroll. 2008. Coroner warns on dangers of cosmetic surgery. The
Irish Times 2 July: 6; Anonymous. 2008. Family granted leave to seek to
quash inquest verdict on son’s death. The Irish Times 28 August: 6; T.
Healy. 2010. A Fresh Inquest has been ordered into the death of a
Dublin man who died while undergoing cosmetic surgery in Colombia.
Irish Independent 21 May: 21.
26 Associated Press. 2007. Mexican doctor charged with posing as
plastic surgeon, botching dozens of operations. International Herald
Tribune 28 December; J. Bernstein-Wax. 2008. Scam artists taint
medical care in Mexico. Los Angeles Times 6 January: A6.
27 Death and Funeral Notices. 2008. The San Diego-Union Tribune. 20
July; Dies woman during plastic surgery in Tijuana. 2008. Que Pasa
Baja 11 July. Available at: http://quepasabaja.com/?p=552 [Accessed 10
Jan 2012]; R. Morales. 2008. Investigan muerte de una dama.
El-Mexicano 09 July; Fallecio en una cirugia estetica. 2008. 10 July.
28 Jose Vasquez. 2009. American ‘Medical Tourist’ Women Dies in
David After Undergoing Liposuction. The Boquete Times Newspaper
22 June.
29 Hungary Around the Clock. 2009. Austrian dies after liposuction in
Hungary. Hungarian Portal. 30 January. Available at: http://
www.caboodle.hu/nc/news/news_archive/single_page/article/11/
austrian_die/?cHash=7f191cec8d [Accessed 10 Jan 2012].
Reports of Patient Deaths Following ‘Medical Tourism’ 25
© 2012 Blackwell Publishing Ltd.
UAE in 2010.30 Two days after undergoing the procedure
the patient experienced complications, was hospitalized,
and then died. The private clinic was ordered closed by
the Dubai Misdemeanors Court and the treating physi-
cian was convicted for unlawfully operating on the
patient and being responsible for her death. The sentence
was a fine and one year jail sentence. Sentencing occurred
after the accused physician had already left the country.
Patient 25 traveled from California, USA to Tijuana,
Mexico and underwent liposuction in May 2010.31
Shortly after the operation concluded the patient experi-
enced heart failure; efforts to revive her were unsuccess-
ful. The Baja California Attorney General’s Office
opened an investigation into the case and in July 2011 the
surgeon was charged with manslaughter, arrested, and
taken to a state penitentiary in Mexico. At present there
is no record of a trial verdict.
Patient 26 traveled from California, USA to Tijuana,
Mexico for lap band surgery in May 2011.32 Following
surgery, the patient reportedly suffered a cardiac arrest
and died. Significant blood loss is reported to have
occurred before the patient’s cardiac arrest. The family
filed a compliant with the Baja California Attorney Gen-
eral’s Office and the Attorney General’s Office has initi-
ated an investigation. At present the investigation
appears to remain in progress.
Table 1 provides a summary of information extracted
from news media accounts of deaths of twenty-six indi-
viduals who left their local communities and traveled
abroad for cosmetic surgery procedures. Columns iden-
tify reported age of individuals at time of death, gender,
identified surgical procedures, departure nation (country
from which individual left for medical care), destination
nation (country in which surgery was performed), and
year of death.
OVERVIEW OF REPORTED DEATHS
Of the twenty-six reported deaths, twenty-five of the indi-
viduals were women. The youngest person reported to
30 B. Za’za. 2010. Woman dies of organ failure after breast enlargement
operation. Gulf News. 2 March; B. Za’za. 2010. Doctor, cosmetician
held liable for woman’s death from botched surgery in Dubai. Gulf
News 29 March.
31 K. Darce & S. Dibble. 2010. Officials in Baja close clinic where U.S.
woman died. The San-Diego Union-Tribune 29 May: B1; Doctor
Claims He Was Not At Fault in Woman’s Liposuction Death. 2010; 25
May. Available at: http://www.10news.com/news/23677779/detail.html
[Accessed 10 Jan 2012]; Doctor’s Credentials Questioned After
Woman’s Liposuction Death. 2010; 25 May. Available at: http://
www.10news.com/news/23676557/detail.html [Accessed 10 Jan 2012].
32 S. Dibble. 2011. Family seeks answers after woman’s Lap-Band
death. The San Diego Union-Tribune 9 June. Available at: http://
www.signonsandiego.com/news/2011/jun/09/family-seeks-answers-
after-womans-lap-band-death/ [Accessed 10 Jan 2012].
Table 1. Chronological Summary of Cases
Patient Age Gender Procedure Departure Nation Destination Nation Year of Death
Patient 1 65 F plastic surgery California, USA Tijuana, Mexico 1993
Patient 2 38 F tummy tuck California, USA Tijuana, Mexico 1996
Patient 3 57 F Liposuction, vaginal reconstruction California, USA Tijuana, Mexico 1996
Patient 4 23 F Breast implants California, USA Tijuana, Mexico 1996
Patient 5 36 F Liposuction, fat injected into buttocks New York, USA Dominican Republic 1998
Patient 6 26 F Liposuction, fat injected into calves Puerto Rico Dominican Republic 1998
Patient 7 26 F Breast reduction surgery Puerto Rico Dominican Republic 1998
Patient 8 37 F Liposuction Illinois, USA Guadalajara, Mexico 2001
Patient 9 X F ‘tummy tuck’, liposuction California, USA Tijuana, Mexico 2002
Patient 10 43 F ‘tummy tuck’, liposuction Newark, New Jersey Dominican Republic 2004
Patient 11 31 F Liposuction Austria Hungary 2005
Patient 12 42 F Facelift, surgery on nose, eyelids, chin, lips Ireland Manhattan, New York 2005
Patient 13 59 F Liposuction Nigeria Marbella, Spain 2005
Patient 14 62 F Facelift England Lanarca, Cyprus 2005
Patient 15 35 F tummy tuck, breast reduction Rhode Island, USA Mumbai, India 2006
Patient 16 44 F gastric reduction duodenal switch surgery Roseberg, Oregon Curitiba, Brazil 2006
Patient 17 21 F Gastric bypass surgery Palm Beach, Florida Ensenada, Mexico 2007
Patient 18 42 F Lap band surgery Wellington, New Zealand Kuala, Lumpur, Malaysia 2007
Patient 19 33 M liposuction, facial surgery Dublin, Ireland Bogota, Colombia 2007
Patient 20 39 F breast reduction USA Guadalajara, Mexico 2007
Patient 21 55 F Liposuction, breast lift California, USA Tijuana, Mexico 2008
Patient 22 30 F Liposuction Houston, USA David, Panama 2009
Patient 23 57 F Liposuction Austria Hungary 2009
Patient 24 24 F breast implants Belarus Dubai 2010
Patient 25 48 F Liposuction California, USA Tijuana, Mexico 2010
Patient 26 33 F Lap band surgery California, USA Tijuana, Mexico 2011
26 Leigh Turner
© 2012 Blackwell Publishing Ltd.
have died was 21 and the eldest was 65. Eleven individu-
als died after receiving health care in Mexico. Eight of
these deaths occurred in Tijuana. Of the remaining
patients, four died after receiving care in the Dominican
Republic, two died after undergoing surgery in Hungary,
and single deaths were reported to have occurred in
Brazil, Colombia, Cyprus, India, Malaysia, Panama,
Spain, the United Arab Emirates (Dubai), and the United
States. Identified surgical interventions included thirteen
liposuction procedures, four tummy tucks, three breast
implants/breast lifts, three breast reductions, two
facelifts, two injections of fat into buttocks or calves, two
lap bands, one gastric bypass, one gastric reduction
duodenal switch, one vaginal surgery with the specific
type of procedure unspecified, one facial surgery with the
specific type of surgery unstated, one plastic surgery with
the specific procedure unspecified, and one patient
reported as having surgery to her nose, chin, lips, and
eyelids. There were more surgical procedures than there
were individuals because nine patients underwent more
than one surgical procedure. Law enforcement officials
including state pathologists, state Attorney Generals,
local public prosecutors, and local police were reportedly
contacted in fourteen of twenty-six cases. In most
instances there was no additional information describing
outcomes of investigations by law enforcement authori-
ties. In three cases physicians settled lawsuits, spent time
in jail, surrendered their license to practice medicine,
and/or paid fines. In one court decision the treating phy-
sician was sentenced to jail and fined but left the country
prior to sentencing. One investigation is presently under-
way and the physician is charged with manslaughter and
in a state penitentiary awaiting trial.
MIDDLE INCOME AND HIGH INCOME
MEDICAL TRAVEL DESTINATIONS
The World Bank sorts national economies into the four
broad categories of low income, lower middle income,
upper middle income, and high income nations.33 Classi-
fying countries according to 2010 gross national income
(GNI) per capita, GNI in low income countries is $1005
or less, lower middle income is $1006–3975, upper middle
income is $3976–12275, and high income is $12276 or
more. Whatever the limits of this mode of distinguishing
among countries, it provides one metric for broadly cat-
egorizing national economies. Using this scheme, The
World Bank classifies India as a lower middle income
nation; Mexico, Dominican Republic, Brazil, Colombia,
Malaysia, and Panama as upper middle income nations;
Cyprus and United Arab Emirates as high income, non
OECD nations; and Hungary, Spain, and the United
States as high income OECD nations. Of the twenty six
deaths of medical travelers that are noted in this article,
one death occurred in a low middle income nation, nine-
teen deaths occurred in upper middle income nations,
two deaths occurred in high income, non OECD coun-
tries, and four deaths occurred in high income OECD
nations.
There might be a temptation to assume that risks to
medical travelers increase as patients move from ‘high
income’ to ‘low income’ nations, ‘developing’ to ‘devel-
oped’ countries, or ‘developed’ economies to ‘emerging’
economies. The news media reports that I located
suggest the possibility of a somewhat more complicated
scenario. Approximately 73% (19/26) of reported deaths
occurred in upper middle income nations, approxi-
mately 23% (6/26) of deaths occurred in high income
nations, and 4% (1/26) occurred in low middle income
nations. If risks to patients are assumed to be lower in
high income countries and greater in low middle income
nations, then searches of news media databases might
have found more reports of deaths of medical travelers
at health care facilities based in low middle income
nations and fewer news reports describing deaths of
medical travelers who sought cosmetic surgery or bari-
atric surgery at health care facilities located in high
income nations. Study of news media reports does not
reveal true incidence of mortality in medical travel des-
tinations. Nonetheless, the reports of deaths of medical
travelers raise the possibility that there is no straightfor-
ward risk gradient in which medical travelers are at low
risk of mortality when receiving care in high income
nations, higher risk of mortality when being treated at
facilities in upper middle income nations, and even
greater risk of mortality when undergoing procedures in
low middle income nations. Perhaps many factors such
as how health care professionals are regulated, how
effectively medical facilities are inspected and accred-
ited, and how competent regulatory bodies are at
removing from practice clinicians with histories of being
disciplines for offering substandard care, are involved
and it is important to examine the complex interplay of
all relevant factors when considering risks to medical
travelers at particular international health care facilities.
While risks to medical travelers might increase when
they visit specific health care facilities located in select
upper middle income nations, it is important to avoid
developing an overly simplistic model of medical travel
in which medical procedures in middle income countries
are assumed to be ‘risky’ and procedures obtained in
high income settings are presumed to be ‘safe’. Instead,
it seems plausible that more fine-grained analyses are
needed.
33 The World Bank Country and Lending Groups. Available at: http://
data.worldbank.org/about/country-classifications/country-and-
lending-groups [Accessed 10 Jan 2012].
Reports of Patient Deaths Following ‘Medical Tourism’ 27
© 2012 Blackwell Publishing Ltd.
PROTECTING MEDICAL TRAVELERS
FROM RISK OF HARM
The twenty-six case reports that I have identified suggest
numerous points to consider when exploring how to
protect medical travelers from risk of harm or death while
undergoing cosmetic surgery or bariatric surgery. These
practical considerations are proposed as recommenda-
tions based upon my review of news accounts of deaths of
medical travelers as well as contemporary scholarship
examining deaths and post-operative complications in
individuals having cosmetic surgery or bariatric surgery
at domestic facilities. These accounts of medical travel
ending in deaths of patients deserve serious consider-
ation. In particular, they should direct attention to what
steps might be taken to minimize risks to medical travel-
ers and also ensure that they are aware of both risks and
benefits when considering whether to travel abroad for
care.
First, it is important to note that twenty-five of the
twenty-six deaths of individuals traveling abroad for cos-
metic surgery or bariatric surgery were women. This
finding corresponds with contemporary surveys tracking
cosmetic surgery procedures within the United States.
According to the American Society for Aesthetic Plastic
Surgery, in 2009 over 90% of cosmetic surgery procedures
in the U.S. were performed on women.34 If state and
federal health agencies, patients’ rights associations, and
other organizations are interested in promoting public
awareness of risks of undergoing cosmetic surgery both
domestically and at international health care facilities, it
is important to ensure that such messages are directed at
women. Many of the news media reports that I reviewed
indicate that cost savings were a key reason why women
traveled to Mexico, the Dominican Republic, and else-
where for comparatively low cost surgery. One report for
example, describes young woman using cash, twelve post-
dated cheques, and three credit cards to purchase her
weight loss surgery in Mexico.35 Though additional
sources of evidence are needed to buttress the case for this
claim, if public health officials in various countries are
concerned about the quality of care offered by some
international medical facilities it might be prudent to
place particular emphasis upon targeting public safety
messages about risks of cosmetic surgery procedures to
low and middle income women.
Second, many of the deaths described in news media
reports appear to have occurred outside hospital settings.
Several studies of cosmetic surgery procedures in the
United States report that there is an estimated 10-fold
increase in adverse incidents and deaths when cosmetic
surgery procedures are performed in office settings rather
than in ambulatory surgery centers.36 Both domestic and
international deaths associated with undergoing cosmetic
surgery and bariatric surgery might be reduced by man-
dating that most cosmetic surgery procedures and all
bariatric surgery procedures must be performed in hos-
pitals and ambulatory medical centers rather than in
small clinics and offices of physicians. Eight deaths are
reported to have occurred at clinics in Tijuana. Addi-
tional studies are needed to see whether particular fea-
tures of cosmetic surgery clinics there might put patients
at risk of morbidity and mortality. The four deaths in the
Dominican Republic, combined with reports of an out-
break of infections in U.S. patients who underwent cos-
metic surgery in the Dominican Republic, also suggests
the importance of examining practice environments and
regulation of health professionals in this setting.37
Third, in many countries physicians who are not
trained as board-certified plastic surgeons routinely
perform cosmetic surgery procedures. The news media
reports describing deaths of cosmetic surgery tourists do
not reveal whether the physicians involved in these cases
were board-certified in plastic surgery or had equivalent
professional credentials. Nonetheless, domestic and
international cases of deaths occurring during or shortly
after cosmetic surgery suggest the importance of ensuring
that cosmetic surgery is performed according to demand-
ing standards of practice.38 The same exacting standards
must be applied to performance of bariatric surgery.
Perhaps morbidity and mortality rates in cosmetic
surgery and bariatric surgery at both domestic and inter-
national health care facilities might be reduced by limit-
ing the types of physicians permitted to perform most
cosmetic surgery and bariatric surgery procedures.
Next, of the twenty-six reported deaths, four fatalities
occurred in the Dominican Republic. Two of these deaths
34 The American Society for Aesthetic Plastic Surgery. 2009. Cosmetic
Surgery National Data Bank Statistics. Available at: http://
www.surgery.org/sites/default/files/2009stats [Accessed 10 Jan
2012].
35 A Ceron & J. Schwartz. 2007. 8 Days After Surgery in Mexico,
Bride’s Dreams Die With Her. Palm Beach Post 15 July: 1A; A. Ceron
& J. Schwartz. 2007. Infection Killed Woman Who Got Gastric Bypass
in Mexico. Palm Beach Post 30 August: B1.
36 M. Quattrone. Is the physician office the wild, wild west of health
care? J Ambul Care Manage 2000; 23: 64–73; H. Vila et al. Comparative
outcomes analysis of procedures performed in physician offices and
ambulatory surgery centers. Arch. Surg 2003; 138: 991–995; J. Horton
et al. Patient safety in the office-based setting. Plast Reconstr Surg 2006;
117: 61e–80e.
37 E. Furuya et al. Outbreak of Mycobacterium abscessus wound infec-
tions among ‘lipotourists’ from the United States who underwent
abdominoplasty in the Dominican Republic. Clin Infect Dis; 46: 1181–
1188.
38 A. Goodwin, I. Martin, H. Shotton et al. On the Face of It: A review
of the organizational structures surrounding the practice of cosmetic
surgery. National Confidential Enquiry into Patient Outcome and
Death 2010. Available at: http://www.ncepod.org.uk/2010cs.htm
[Accessed 10 Jan 2012].
28 Leigh Turner
© 2012 Blackwell Publishing Ltd.
involved individuals traveling from the United States and
two deaths involved persons from Puerto Rico. Accord-
ing to the U.S. State Department website, ‘The U.S.
Embassy in Santo Domingo and the CDC are aware of
several cases in which U.S. citizens experienced serious
complications or died following elective cosmetic surgery
in the Dominican Republic.’39 Though I did not locate
reports of U.S. citizens dying during or after having cos-
metic surgery in Peru, the U.S. Department of State
website for Peru states, ‘Over the last few years, at least
five American citizen visitors have died during liposuc-
tion operations in Peru. Others have suffered from
serious complications including coma. While some of
these deaths or complications occurred in ill-equipped,
makeshift clinics, travelers are urged to carefully assess
the risks of having this type of surgery performed over-
seas, even when opting for a treatment at one of the
better-known clinics.’40 If consular and embassy officials
encounter cases in which citizens from their countries
experience serious complications from surgery at interna-
tional medical facilities it is important that they docu-
ment and publicize this phenomenon. If the cases I review
are part of a trend noticed by embassy employees in
particular countries then government officials could play
an important role in protecting medical travelers by
better documenting and disclosing these cases. Further-
more, if officials staffing embassies located in destinations
for medical travel are encountering increased numbers of
citizens harmed while traveling abroad for medical care,
it is not evident that public awareness is increased by
posting information to the U.S. Department of State
website or the Centers for Disease Control and Preven-
tion website. The CDC’s, ‘Health Information for Inter-
national Travel 2010, or ‘Yellow Book’ as it is more
commonly known, mentions variations in international
quality of care and regulation of medical facilities and
provides practical advice for individuals considering trav-
eling abroad for health care.41 However, it is unclear
whether most prospective medical travelers are familiar
with this book or consult the U.S. State Department
website. If government agencies in the U.S. and elsewhere
have credible grounds for concern about the quality of
care their citizens are likely to receive when traveling to
particular health care destinations they should reassess
how to publicize this information. Of course, without
better tracking of clinical outcomes there will be little
reliable information available to communicate and
limited prospects for informed public debate about indi-
vidual and public implications of medical travel.
Fifth, drawing upon the news media reports that I
identify and summarize, it is not possible to reach con-
clusions about the quality of information provided to the
twenty-six individuals reported to have died after travel-
ing abroad for medical care. The news reports prompt
questions about information disclosure and the extent to
which patient decision-making was informed but they do
not provide insight into what information individuals
received before deciding to have surgery. However,
several recent publications raise troubling questions
about the quality of information provided by websites of
medical tourism companies and destination medical
facilities.42 These articles suggest that when prospective
medical travelers turn to websites for information about
risks and benefits of medical travel they are likely to
encounter information that emphasizes benefits of
medical care and pays limited attention to risks associ-
ated with surgery.43 Reports of post-operative complica-
tions experienced by medical travelers as well as accounts
of deaths reveal the importance of disclosing procedure-
related risks. Government agencies tasked with regulat-
ing advertising practices could play a role in investigating
content of websites of medical tourism facilitators and
destination hospitals and clinics. Though government
agencies lack capacity to regulate websites and other pro-
motional materials outside their domestic legal jurisdic-
tions, they nonetheless could alert citizens if international
medical tourism companies and destination health care
facilities are failing to disclose risks and making mislead-
ing claims about benefits of surgical procedures, patient
safety, and quality of care. More effective, targeted
responses by government regulatory bodies to the mar-
keting of health care at international medical facilities
might increase the likelihood that prospective medical
travelers have better access to information required to
make informed choices when deciding whether to have
particular procedures.44
39 U.S. Department of State. Dominican Republic Country Specific
Information. Available at: http://travel.state.gov/travel/cis_pa_tw/cis/
cis_1103.html [Accessed 10 Jan 2012].
40 U.S. Department of State. Peru Country Specific Information.
Available at: http://travel.state.gov/travel/cis_pa_tw/cis/cis_998.html
[Accessed 10 Jan 2012].
41 Centers for Disease Control and Prevention. CDC Health Informa-
tion for International Travel 2010. Available at: http://wwwnc.cdc.gov/
travel/content/yellowbook/home-2010.aspx [Accessed 10 Jan 2012].
42 R. Nassab et al. Cosmetic tourism: public opinion and analysis of
information and content available on the Internet. Aesthet Surg J 2010;
30: 465–469; A. Mason & K. Wright. Framing Medical Tourism: An
Examination of Appeal, Risk, Convalescence, Accreditation, and Inter-
activity in Medical Tourism Web Sites. J Health Commun 2010 Dec 15:
1–15. E. Sobo, E. Herlihy & M. Bicker. Selling medical travel to US
Patient-Consumers: The cultural appeal of website marketing messages.
Anthropology & Medicine 2010; 18.
43 K. Penney et al. Risk communication and informed consent in the
medical tourism industry: A thematic content analysis of canadian
broker websites. BMC Medical Ethics 2011; 12: 17. N. Lunt and P.
Carrera. Systematic review of websites for prospective medical tourists.
Tourism Review 2011; 66: 57–67.
44 J. Gilmartin. Contemporary cosmetic surgery: the potential risks and
relevance for practice. J Clin Nurs 2010; 20: 1801–1809.
Reports of Patient Deaths Following ‘Medical Tourism’ 29
© 2012 Blackwell Publishing Ltd.
Sixth, reports of complications and deaths related to
cosmetic surgery and bariatric surgery in both domestic
and international settings should prompt public debate
about the routinization and normalization of such pro-
cedures as liposuction, breast augmentation, and lap
band surgery.45 Though widely performed, these proce-
dures can result in surgical complications and even deaths
of patients. Better tracking of patient outcomes in both
domestic and international medical facilities might lead
to evidence-based calls for more restrictive use of particu-
lar surgical techniques. Practices of informed consent
ensure that risks and benefits are disclosed to prospective
patients but prior to information disclosure it is impor-
tant to ask the question of whether patients should be
exposed to some risks. Rather than asking whether
patients face greater risks when having cosmetic surgery
at international facilities instead of local medical centers,
it might be time to encourage a broader public conversa-
tion about risks patients face when undergoing various
cosmetic surgery procedures in both domestic and inter-
national settings.
Finally, news reports of the deaths of medical travelers
at facilities in Mexico combined with the absence of
reports of medical travel-related deaths from many well-
known destinations for medical travelers suggests the
importance of developing effective strategies for tracking
flows of medical travelers, documenting what procedures
they undergo, identifying what types of facilities they
visit, verifying the qualifications of treating physicians,
and evaluating the safety of particular practice environ-
ments. Though news media reports do not provide insight
into the relative risk of traveling to particular health care
destinations, I was struck by how many deaths are
reported to have occurred in Mexico and the absence of
reports of deaths of medical travelers in such countries as
Singapore and Thailand. This finding might be a product
of the search strategies I utilized, the databases I used, or
other factors. However, it is tempting to speculate
whether a relatively high number of cases of mortality in
cases traveling abroad for cosmetic surgery might occur
in a modest number of destination sites. If so, perhaps it
is possible to develop ‘channels’ or ‘gates’ that will help
protect medical travelers and increase the prospect that
they seek care at facilities recognized for promoting
patient safety.46 Steering medical travelers toward par-
ticular international medical facilities and away from spe-
cific hospitals and clinics might reduce the incidence of
morbidity and mortality in medical travelers. Rigorous
empirical research is needed to address this issue.
IMPORTANCE OF DOCUMENTING
CLINICAL OUTCOMES IN
MEDICAL TRAVEL
Despite sustained public and academic interest in medical
travel, or ‘medical tourism’ as the phenomenon is more
popularly known, there is limited academic analysis of
clinical outcomes in medical travelers.47 Proponents of
medical travel emphasize cost savings, high quality of care
at international facilities, expedited access to treatment,
choice in health services, and other benefits.48 In contrast,
critics express concerns that medical travelers enter a
poorly regulated global marketplace, are at risk of inad-
equate pre-operative counseling, substandard medical
care, and poorly coordinated post-operative treatment,
and exacerbate health inequities in the countries they
visit.49 Both proponents and critics of medical travel have
a limited body of case reports and very little comparative
research that they can use to support their claims.
The main reason why it is impossible to make
informed, evidence-based judgements about quality of
care and patient safety in medical travel is that there are
no databases tracking global flows of patients and docu-
menting clinical outcomes in individuals who leave their
local communities and arrange care at international
facilities. For example, despite various claims about the
annual number of U.S. residents travelling to medical
facilities outside the United States, there is no registry
tracking how many U.S. citizens leave the country for
care, why they go abroad for treatment, what kind of
treatment they seek, and what happens as a result of
obtaining health care outside the U.S. According to one
widely cited report produced by Deloitte, in 2007
approximately 750,000 US residents sought health care
outside the United States and an estimated 648,000 trav-
eled abroad in 2009.50 In contrast, drawing upon data
from the US Bureau of Economic Analysis and US Inter-
national Trade Administration as well as survey data,
Johnson and Garman estimate that between 50,000 to
121,000 US residents sought medical care outside the
United States in 2007.51 There are significant variations in
45 B. Coldiron, C. Healy & N. Bene. Office surgery incidents: what
seven years of Florida data show us. Dermatol Surg 2008; 34: 285–291.
46 I.G. Cohen. Protecting Patients with Passports: Medical Tourism
and the Patient-Protective Argument. Iowa Law Review 2010; 95:
1467–1567.
47 N. Lunt & P. Carrera. Medical tourism: assessing the evidence on
treatment abroad. Maturitas 2010; 66: 27–32.
48 D. Herrick. Medical Tourism: Global Competition in Health Care.
2007; NCPA Report No. 304. Available at: www.ncpa.org/pdfs/
st304 [Accessed 10 Jan 2012]; A. Mattoo & R. Rathindran. How
health insurance inhibits trade in health care. Health Aff 2006; 25:
358–368.
49 A. Whittaker. Pleasure and pain: Medical travel in Asia. Global
Public Health 2008; 3: 271–290.
50 Deloitte Center for Health Solutions. Medical tourism: update and
implications – 2009 report. Deloitte. 2009.
51 T. Johnson & A. Garman. Impact of medical travel on imports and
exports of medical services. Health Policy 2010; 98: 171–177; B.
Alleman et al. Medical Tourism Services Available to Residents of the
United States. J Gen Intern Med 2010; 26: 492–497.
30 Leigh Turner
© 2012 Blackwell Publishing Ltd.
estimates of how many U.S. residents seek health care
outside the U.S. every year. The situation is the same in
Australia, Canada, and elsewhere. Speculative claims
about the number of individuals traveling abroad for care
are widespread and rigorous quantification of medical
travel is scarce. Most health-related databases are built
for monitoring domestic medical care; they are not
designed to track patients across national borders. Devel-
oping databases capable of monitoring transnational
medical travel is challenging because the global market-
place for health services is decentralized and many pro-
cedures are performed in private, for-profit health care
facilities that do not report data to domestic databases.
Medical travelers make individual arrangements with
destination medical facilities or plan their trips with the
assistance of medical travel facilitators.52 They do not
organize trips with the aid of some centralized transna-
tional body or report their travel plans to domestic gov-
ernment agencies. Some cross-border medical care
involves government participation, such as when provin-
cial health systems in Canada make arrangements for
Canadian citizens to receive care at select facilities in the
United States. However, it appears that most medical
travel is based upon individual decisions to pay out-of-
pocket for care at international medical facilities. As
a result, building databases and better tracking
medical travelers and their clinical outcomes will be very
challenging.
Given the absence of databases tracking movement of
patients and documenting clinical outcomes in medical
travel, there is at present no credible basis for making
three types of empirical claims. First, it is not possible to
make accurate statements about how many individuals
leave their local community and travel abroad for
medical care. Second, there is no basis for making
evidence-based assertions about how many medical trav-
elers experience clinical benefits and how many experi-
ence surgical complications, infections, and other
treatment-related health problems. Third, because there
are no databases tracking how many individuals partici-
pate in medical travel and how many of these persons
experience benefits or harms as a result of traveling
abroad for care, there is considerable uncertainty con-
cerning whether individuals traveling to particular loca-
tions are at greater risk of experiencing complications
from treatment when they travel for care instead of vis-
iting domestic medical facilities.
Acknowledging that clinical registries and systematic
outcomes data in medical travel do not exist, and recog-
nizing that reliable quantitative studies are needed to
make judgements about relative patient safety and
quality of care when comparing medical travel to the
quality of care individuals should expect to receive at
domestic health care facilities, analysis of news media
articles describing the reported deaths of twenty-six
medical travelers reveals the importance of better docu-
menting clinical outcomes in medical travel. This analy-
sis, though it documents reported deaths of medical
travelers, cannot and should not be used to claim that
domestic medical care is ‘safe’ and medical travel is
‘unsafe’. Indeed, during my research I was struck by the
number of reports I found that described patients who
experienced serious complications or died after undergo-
ing cosmetic surgery in domestic health care facilities.
Noting the need for systemic efforts to track clinical out-
comes in medical travel, I hope this study provides a
meaningful complement to peer-reviewed publications
that describe medical complications in cosmetic surgery
travelers and individuals who have gone abroad for cos-
metic surgery but provide no accounts of patients who
died during surgery or shortly after receiving treatment.
If these news media accounts are accurate then peer-
reviewed publications are failing to identify, document,
and analyze deaths of patients who have traveled abroad
for cosmetic surgery and bariatric surgery. By describing
these cases I hope to promote increased interest in track-
ing medical travelers, studying clinical outcomes in
medical travel, and addressing in an empirically-informed
manner the many ethical, legal, and social issues gener-
ated by the emergence of a global marketplace in health
services.
CHALLENGES IN USING NEWS
MEDIA REPORTS
Numerous challenges are associated with attempting to
analyze news media accounts of deaths of medical trav-
elers. First, if journalists writing these narratives made
errors when crafting their accounts, these mistakes are
reproduced in the information I extracted, recorded, and
categorized. Journalists have limited time to prepare
news stories; the pressure to meet deadlines along with
other factors can lead to inaccurate reportage. Second,
when extracting information from news media accounts I
used the language reporters used when describing medical
procedures. For example, several articles describe
patients undergoing ‘tummy tucks’. I retained this lan-
guage even though the more accurate clinical term for
this procedure is ‘abdominoplasty’. It is possible that
terms used by reporters provide misleading descriptions
of the medical procedures individuals underwent. Third,
after searching for news media reports I was in some cases
able to supplement news media accounts by finding
obituaries, web-based posts written by individuals
claiming to be family members of deceased individuals,
52 N. Lunt, M. Hardey & R. Mannion. Nip, tuck and click: medical
tourism and the emergence of web-based health information. Open Med
Inform J 2010; 4: 1–11.
Reports of Patient Deaths Following ‘Medical Tourism’ 31
© 2012 Blackwell Publishing Ltd.
contributions to cosmetic surgery discussion boards, and,
in one case, detailed court records. In most instances, I
was unable to locate independent sources corroborating
claims made in news media accounts. In short, I acknowl-
edge that there are identifiable disadvantages to using
news media accounts when attempting to track deaths of
medical travelers. In future I hope to address some of
these constraints by contacting family members and
friends of the individuals identified in these news reports.
Interviews with them might generate insights unavailable
in the newspaper reports I analyze and confirm whether
various details in news reports are accurate.
SEARCH TERMS, DATABASES,
SOURCES CONTAINED IN DATABASES,
AND BIAS
Decisions concerning choice of search terms inform what
articles are found in databases. Though I entered many
different search terms into the databases I used it is pos-
sible that my use of search terms introduced bias into the
search process and influenced the particular types of news
media reports that I found. In addition, decisions to
search particular databases presumably had an impact
upon what reports I found.
By conducting searches using ProQuest NewsStand,
Google, Google News, and Google News Archive, I
attempted to take a ‘wide angle’ approach to locating
reports of mortality in medical travel for cosmetic surgery
and bariatric surgery. However, use of these databases
likely introduced bias into my findings. For example, at
present ProQuest NewsStand includes 1394 news sources
from all over the world.53 The database contains such
major US news media sources as The New York Times, Los
Angeles Times, Wall Street Journal, and Washington Post.
It also contains articles from such ‘international’ newspa-
pers as The Guardian, The Globe and Mail, The Hindu,
Jerusalem Post, and South China Morning Post. Though
the database contains news sources from around the
world, it appears to have more news sources from the U.S.
than from other countries. While I did not deliberately
seek to find reports of patients who originated in particu-
lar countries and traveled to specific destinations, I think it
likely that my choice of English language databases com-
bined with the many U.S. news sources in the ProQuest
NewsStand database contributed to the number of reports
I found that described mortality in medical travelers from
the United States. It is possible that searches of databases
containing more newspaper articles from news media
sources based in countries other than the United States
might find additional reports of mortality in medical trav-
elers originating from countries other than the U.S.
I did not deliberately seek to find reports of deaths of
medical travelers in particular medical tourism destina-
tions. Though I did not focus on Mexico as a destination
for medical travelers, my searches identified numerous
reports of medical travelers from the U.S. who died during
or after having cosmetic surgery or bariatric surgery in
Mexico. Sandra Dibble, a reporter for The San Diego
Union-Tribune, has for many years alone and with her
colleagues written articles about Californians who have
traveled to hospitals and clinics in Mexico and either died
during or after surgery or returned to the U.S. with post-
operative complications. Several articles by Dibble are
used as sources for cases described in this article. What I
am unable to determine is whether news media coverage of
morbidity and mortality in medical travel is connected to
the actual incidence of morbidity and mortality at particu-
lar international medical facilities. It is conceivable that
Dibble has recognized a significant health news story,
understands that many residents of California travel to
Mexico for cosmetic surgery, dental care, and other pro-
cedures, and provides detailed coverage of cases where
U.S. citizens experience post-operative complications or
die after having surgery at clinics in Mexico. It is also
possible that journalists based in other settings are
unaware of incidents involving medical travel and mortal-
ity at medical facilities in countries other than Mexico,
decide not to write about such cases, or are aware of
reports of mortality in medical travelers but select other
stories to cover. Use of particular databases, choice of
search terms, and sources captured by these databases pre-
sumably all have an effect upon the news media reports
that I have identified. Given the number of reports describ-
ing mortality associated with surgery performed at medical
facilities in Mexico there is reason to be concerned about
the quality of care provided to some medical travelers at
particular medical facilities in Mexico. However, use of
databases to identify news media reports cannot be used to
establish with certainty whether some destinations for
medical travel are riskier and offer lower-quality care than
other international hospitals and clinics. What analysis of
news media reports can do is demonstrate the importance
of developing rigorous tools to assess clinical outcomes in
medical travel for cosmetic surgery and other procedures.
Though not the main purpose of this paper, I hope that my
choice of search terms, choice of which databases to
search, and findings prompt debate about how to effec-
tively track clinical outcomes in medical travel.
CORRELATION IS NOT CAUSATION
My summary of news reports of deaths of medical travel-
ers might lead some readers to assume that medical errors,
53 ProQuest Newspapers. Available at: http://proquest.umi.com.ezp1.
lib.umn.edu/pqdweb?RQT=317&TS=1321759744&clientId=2256&
SQ=*&PageNum=1&link=1 [Accessed 10 Jan 2012].
32 Leigh Turner
© 2012 Blackwell Publishing Ltd.
poor quality of care, or specific actions performed by
treating physicians must have caused the patients to die
during or shortly after surgery. To the contrary, while the
news reports I located generate serious concerns about the
quality of care some medical travelers receive when they go
abroad for surgery, news media accounts do not provide a
basis for establishing causality and legal responsibility and
cannot be used to make claims about medical negligence
or professional standards of care. Determinations of
medical negligence are established through legal proce-
dures and rules of evidence. According to news media
accounts, in four instances physicians were deemed to
have contributed to the deaths of patients. In a fifth case a
physician is charged with manslaughter but a verdict has
not yet been delivered. Whatever the merits of drawing
upon news media accounts, these narratives identify cor-
relations between surgical procedures and deaths and
prompt questions about quality of care, medical profes-
sionalism, and adequacy of treating facilities. However,
they do not establish causation. With the exception of the
four instances that resulted in successful legal action
against treating physicians, causality, the role of treating
health care providers, and the extent to which the health
care environment exposed patients to risk or helped shield
them from harm remain unknown. Many of the news
reports offered sharp criticisms of the care patients
received. While these accounts prompt legitimate con-
cerns about quality of care and treatment of cosmetic
surgery travelers, they do not lead to definitive conclusions
about conditions in clinics, patient selection and screening
criteria used prior to performing surgery, surgical tech-
nique, or post-operative care. It is conceivable that the
patients had underlying medical conditions and these pre-
viously unknown health problems played a deciding role
in the deaths of these individuals. In addition, it is possible
that adverse events occurred but treatment received by the
medical travelers fell within a reasonable, professional
standard of care. In short, it is important to exercise
caution when considering these news accounts. Having
noted this caveat, if these news reports are accurate, they
document twenty-six deaths that are nowhere acknowl-
edged or addressed in peer-reviewed scholarship concern-
ing medical travelers. Acknowledging the need for caution
in interpreting these news media reports, these cases
prompt questions about whether steps could have been
taken to better protect these patients from harm and
reduce risk of a fatal outcome following elective surgical
procedures.
CASE REPORTS DO NOT ESTABLISH
RELATIVE RISK
Just as it is important to avoid the error of confusing
correlation with causation, it also is important to note
that analysis of reports of deaths of medical travelers
cannot be used to support the claim that medical travel
poses greater risks to patients than obtaining care at
domestic health care facilities. While searching for
articles describing deaths of medical travelers I found
numerous news media reports summarizing deaths of
individuals who had undergone liposuction, breast aug-
mentation, and other cosmetic surgery procedures in
their home states within the U.S as well as in Australia
and Canada.54 Accurate datasets providing information
about clinical outcomes in patients undergoing care at
domestic health care facilities and in individuals obtain-
ing medical care at international sites are needed to make
credible assertions about whether relative risk of morbid-
ity and mortality is increased by leaving particular social
contexts and traveling to particular international clinics
and hospitals. Again, having noted this caveat, without
providing insight into relative risks these case reports
suggest that prospective medical travelers need to be
aware that elective cosmetic surgery procedures at inter-
national medical facilities have resulted in both morbidity
and mortality. The case reports also give credence to the
concept of developing strategies intended to minimize
risks individuals face when they travel abroad for medical
care.
CONCLUSION
Drawing upon news media accounts, I review twenty-six
reported cases of medical travelers who died during or
after undergoing cosmetic surgery or bariatric surgery.
Eleven of these individuals died after having cosmetic
surgery or bariatric surgery in Mexico and four died after
undergoing cosmetic surgery in the Dominican Republic.
In short, more that half of all identifiable cases can be
connected to health care facilities in two countries. In
four cases, physicians were fined, sued, or jailed. In a fifth
case, the physician is charged with manslaughter and
awaits trial. In the remaining cases it is not possible to
make assertions about medical negligence or malpractice.
Rather than asserting that most of these deaths were
caused by the quality of care patients received it is impor-
tant to note that claims must be limited to recognition of
a correlation between surgical interventions and patient
54 E. Fernandez & L. Williams. 1998. ‘If liposuction were a drug, it
would have been pulled from the market’. San Francisco Chronicle 13
September; E. Fernandez. 1998. When the desire to be thin is last wish
on Earth. San Francisco Chronicle 14 September 1998; S. Hewitt. 2007.
Cosmetic surgery death probe. Herald Sun 28 January; C. Blatchford.
2010. Prosecution portrays stunning failures in lipo death. The Globe
and Mail 22 July: A9; R. Cribb. 2010. Lipo death spurs look at hazy
rules. Toronto Star 24 July: GT1; J. Omarnicki. 2011. Inquiry opens on
plastic surgery death. Calgary Herald 19 January 2011; D. Lett. The
search for integrity in the cosmetic surgery market. CMAJ 2008; 178:
274–275.
Reports of Patient Deaths Following ‘Medical Tourism’ 33
© 2012 Blackwell Publishing Ltd.
deaths. If these news media reports are accurate, they
should be considered in conjunction with case reports of
post-operative complications in medical travelers.
Though it is not possible to claim on the basis of these
news media accounts that medical travelers are at greater
risk when obtaining medical care abroad than they are at
domestic health care facilities, it is possible to assert that
if these reports are credible then since 1993 at least
twenty-six medical travelers are reported to have died
during or after undergoing elective cosmetic surgery or
bariatric surgery. These deaths should prompt reflection
upon what strategies might improve patient safety,
quality of care, disclosure of information, quality of
advertising, and protection of patients in the global mar-
ketplace for health services. In addition, reports of these
deaths in news media but not in scholarly publications
should prompt questions about whether current peer-
reviewed scholarship addressing clinical outcomes in
medical travel is underreporting patient mortality.
Whether individuals die after undergoing cosmetic
surgery or bariatric surgery in domestic health facilities
or in international hospitals and clinics, it is important to
pose questions about whether patients are being
adequately protected and what might be done to reduce
the likelihood of additional cases of post-operative com-
plications and deaths. Both cosmetic surgery and bariat-
ric surgery are sometimes assumed to involve ‘minor’
procedures that do not generate concerns about patient
safety. To the contrary, both morbidity and mortality can
result from these procedures. Individuals considering cos-
metic surgery or bariatric surgery must be aware of the
possibility of risks to health and complications from
surgery in both domestic and international health care
facilities.
In the existing body of peer-reviewed articles on travel
for cosmetic surgery and bariatric surgery travel there are
no reports of deaths of patients at international medical
facilities. Rather, case reports are limited to instances of
patients returning to their local communities with post-
operative complications. This analysis of twenty-six news
media reports of travel for cosmetic surgery and bariatric
surgery suggests that accounts of post-operative morbid-
ity must be supplemented by reports of mortality.
Perhaps patients in both local and international settings
could be better protected from risk of injury and death if
cosmetic surgery and bariatric surgery were subjected to
better regulatory oversight. In addition, reports of deaths
of cosmetic surgery patients and bariatric surgery
patients are relevant to larger public conversations about
whether surgical techniques that have become routinized
and normalized need to be subjected to public debate and
better government scrutiny. Deaths of patients undergo-
ing elective surgical procedures, whether they occur in
domestic facilities or international hospitals and clinics,
should prompt us to ask whether they might have been
avoided.
The news reports that I review suggest the importance of
tracking clinical outcomes in medical travel. In addition,
they suggest the possibility that there is a serious gap in
contemporary scholarship addressing medical travel for
cosmetic surgery and bariatric surgery. The emergence of
a global marketplace in health services has not been
accompanied by the development of regulatory bodies
tasked with monitoring and regulating transnational
medical travel. At present, clinical databases and health
researchers are not systematically tracking global flows of
medical travelers and documenting clinical outcomes.
Better insight into the consequences of medical travel
would make a significant contribution to ethical analysis
of ‘medical tourism’. Critics of my effort to use news media
reports will argue that news accounts of deaths of medical
travelers consist of nothing more than unsubstantiated
anecdotes or exercises in sensationalistic journalism. I
appreciate the disadvantages associated with using news
media reports to document deaths of medical travelers.
Acknowledging the caution with which findings drawn
from news reports must be used, I suggest that the risks of
using these reports are outweighed by the risk of dismiss-
ing news reports of deaths of medical travelers.
Whatever the advantages and disadvantages of using
news reports describing deaths of medical travelers, this
approach suggests the value of using both normative
analyses and empirical research methods to address such
ethical issues as quality of information disclosure,
adequacy of patient consent, safety of particular surgical
procedures, and quality of post-operative care in medical
travel. If ‘what isn’t counted doesn’t count’, as some
health researchers state, there is a need to begin ‘count-
ing’ medical travelers and clinical outcomes and better
understanding what is happening in the global market-
place for medical travel.
Acknowledgements
The author wishes to thank Jeremy Snyder, Valorie Crooks, and an
anonymous reviewer for the feedback they provided in response to an
earlier version of this article. In addition, the author wishes to acknowl-
edge the reportage of the journalists who crafted the news media
accounts examined in this article.
Biography
Leigh Turner, PhD, is an Associate Professor at the University of Min-
nesota’s Center for Bioethics, School of Public Health, and College of
Pharmacy. His research examines ethical and social issues related to
transnational medical travel and globalization of health care. He is
co-editor of the forthcoming book, Medical Tourism: Risks and Con-
troversies in the Global Healthcare Market. Praeger will publish the
volume in 2012.
34 Leigh Turner
© 2012 Blackwell Publishing Ltd.
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The Real Cost of “Cosmetic Tourism” Cost
Analysis Study of “Cosmetic Tourism”
Complications Presenting to a Public Hospital
Ryan Livingston, MBBS, BmedSci, MRCS,a Paul Berlund, MBBS,b Jade Eccles-Smith,
MBBS,c and Raja Sawhney, MBBS FRACS (plast)d
aUniversity of Queensland, Plastic & Reconstructive Surgery Registrar Gold Coast University Hos-
pital, Queensland, Australia; bGold Coast University Hospital, Queensland, Australia; cBond Univer-
sity, Queensland, Australia; and dPlastic & Reconstructive Surgery Gold Coast University Hospital,
Queensland, Australia.
Correspondence: drryanlivingston@hotmail.co.uk
Keywords: cosmetic tourism, cost analysis, operations abroad, complications, medical tourism
Published July 28, 2015
“Cosmetic Tourism,” the process of traveling overseas for cosmetic procedures, is an
expanding global phenomenon. The model of care by which these services are delivered
can limit perioperative assessment and postoperative follow-up. Our aim was to estab-
lish the number and type of complications being treated by a secondary referral hospital
resulting from “cosmetic tourism” and the cost that has been incurred by the hospital
in a 1-year period. Retrospective cost analysis and chart review of patients admitted to
the hospital between the financial year of 2012 and 2013 were performed. Twelve “cos-
metic tourism” patients presented to the hospital, requiring admission during the study
period. Breast augmentation was the most common procedure and infected prosthesis
was the most common complication (n = 4). Complications ranged from infection,
pulmonary embolism to penile necrosis. The average cost of treating these patients was
$AUD 12 597.71. The overall financial burden of the complication to the hospital was
AUD$151 172.52. The “cosmetic tourism” model of care appears to be, in some cases,
suboptimal for patients and their regional hospitals. In the cases presented in this study,
it appears that care falls on the patients local hospital and home country to deal with the
complications from their surgery abroad. This incurs a financial cost to that hospital in
addition to redirecting medical resources that would otherwise be utilized for treating
noncosmetic complications, without any remuneration to the local provider.
Cosmetic tourism, the process of traveling overseas for cosmetic procedures, appears to
be an expanding global phenomenon.1 The general public’s perception of cosmetic tourism
is changing, with growing numbers considering traveling overseas for cosmetic procedures.
It appears in part because of the lower cost of surgery as well as the increased incidence of
313
ePlasty VOLUME 15
global travel and low-cost airfares.1 Despite this, there is a paucity of data and discussion
surrounding the incidence and management of complications, and the current model of
care used by these international providers. While the number of patients who are traveling
for procedures is currently unknown, media reports claim that up to 15 000 Australian
women are traveling overseas for cosmetic procedures each year.2 A basic Internet search
reveals an entire industry, which promotes cosmetic surgery at reduced prices. Recent
reports on mainstream current affair programs have been highlighting this emerging trend,
increasingly bringing cosmetic tourism into the limelight.3
The model of care by which these services are delivered limits preoperative assessment
and follow-up to a few days to a week. As a result, complications due to these procedures
tend to present after the patient has returned from his or her “holiday.” Complications
from these surgeries are not uncommon. In one study, 16.5% of patients experienced
complications, with 8.7% receiving further treatment in the publicly funded health system
on return home.4 There are reports that an increasing number of patients with complications
from such procedures are presenting to public hospitals.5
METHODS
The aim of the study was to establish the number and type of complications being treated by
a surgical unit at a secondary referral hospital. We also planned to perform a cost analysis
of treating such patients and determine the following: nature of the treatment; duration of
hospital admission; need for repeat surgical procedures; and follow-up.
We performed a retrospective analysis of patients presenting between the financial
year of June 2012 and June 2013 at the Gold Coast Hospital. The patient population
was identified using the ICD-10 AM (Australian modification) codes for complications
of surgery by the hospital case mix reporting service. Using a standardized pro forma, a
chart review was performed noting the patients’ demographics, location of surgery, type
of surgery, the complication that occurred, and the treatment required. With regard to
treatment, we noted the need for hospital admission and duration of stay, the number of
surgeries required, the intravenous use of antibiotic drugs and duration, as well as the
number of follow-up outpatient appointments attended.
The patient’s unique reference number was provided to the activity-based costing team.
Using the clinical costing system (sunrise decision support manager), patient-level costs
were calculated for each patient.
RESULTS
During the 1-year study period, 12 patients with “cosmetic tourism” complications who
presented to the emergency department were admitted to our hospital. All of the patients
had their operations performed in Thailand. Breast augmentation was the most common
procedure (n = 10). Four patients had multiple procedures (Table 1). In 2 cases, it was doc-
umented that the patients had undergone dental procedures shortly after cosmetic surgery.
It was not indicated whether the remaining patients in the study underwent dental treatment.
314
LIVINGSTON ET AL
Three patients were smokers, smoking not only through the perioperative period but also
through the postoperative recovery period.
The complications treated were varied, ranging from nipple or penile necrosis to
pulmonary embolism (Fig 1). The most common complication was infected implants after
breast augmentation (n = 4). The infective organisms found were mainly streptococci and
staphylococci species (Fig 2). A fungus was isolated in 1 patient. Multiresistant organisms
were not common (n = 1).
Inpatient admission averaged 6 days per complication with a range of 0 to 15 days.
The cohort had 67 inpatient days in total. On average, each patient had 1 operation (range,
0–5), and as a group 12 operations were performed. Two of the patients had documentation,
indicating private referral for ongoing care and surgery. Out of the patients who did not seek
private referral, 4 have not finished treatment and are still requiring further management or
surgery at the public hospital. On average, each required 5 outpatient reviews (range, 0-9).
Table 1. Cosmetic procedures performed abroad
Procedures No. of procedures
Breast augmentation 10
Labiaplasty 1
Penile augment 1
Chin lift 1
Mastopexy 3
Abdominoplasty 1
Brachioplasty 1
Liposuction 1
Multiple procedures (nonbreast) 4
Figure 1. Number and type of cosmetic complications.
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ePlasty VOLUME 15
Table 2. Treatment cost per patient
Patient number Cost, $AUD
1 9 812.64
2 1 190.28
3 14 753.68
4 2 695.92
5 1 819.06
6 10 667.91
7 8 168.67
8 4 472.44
9 23 029.60
10 33 060.02
11 24 186.83
12 17 315.47
Total 151 172.52
Figure 2. Organisms isolated in infected cases.
Cosmetic tourism complications presenting to this hospital in this study have a reported
cost of AUD$151 172.52. The most spent on a single patient was $AUD 33 060.02 and
average amount was $AUD12 597.71 (Table 2).
DISCUSSION
Our study has demonstrated a range of complications that have occurred as a result of
cosmetic surgery performed overseas. While our study focused on cosmetic treatments, the
authors believe that other specialties will begin to see an influx of complications from other
procedures such as in vitro fertilization, arthroplasty, and stem cell treatments.
316
LIVINGSTON ET AL
The patients treated in our department had acute complications that had the potential
for significant morbidity. Some people may argue that since these complications are the
result of elective cosmetic surgery performed in a different country, any complications are
an unnecessary burden on the health service. Introducing legislation to ensure that all these
patients have compulsory medical insurance would be one potential method of recouping
money spent on these patients’ complications.
Minimizing complications is essential and requires more than just surgical skill; ap-
propriate preoperative assessment and postoperative follow-up by the physician performing
the procedure. Our aim is not to criticize the surgical skill of our overseas colleagues; how-
ever, analyzing the model of care by which the service is being delivered is worthwhile.
Perioperative counseling could be deemed to be inadequate by our national standards and
there are unconfirmed reports from our patients that they were seen together in groups.
Postoperative follow-up is limited to the short period of time the patient spends in his or
her holiday location.
The American Society of Plastic Surgeons outlines many of these concerns in a briefing
paper, including the increased risk of having treatment overseas. The Society also suggests
that patients treat the perioperative time as a holiday and this can negatively impact a
patient’s healing process. Examples given in the briefing are increased smoking and alcohol
consumption, excessive sunbathing, swimming, and walking tours in addition to other
tourist activities.6 The risk of long haul flights pre- and postsurgery is also of concern.
Pulmonary embolism was a complication found in 1 of our study population returning from
Thailand.
Australian practitioners abide by stringent and heavily regulated guidelines. The stan-
dard of care provided by international providers may be different not only in pre- and
postoperative care, but also in regard to products, equipment, nursing staff, and medical
training. This is not something that can be regulated by Australia, as there are no systems
in place that the authors are aware of to do so. As such, quality of service outside of Aus-
tralia would be impossible to guarantee. Legal recourse for a complication from overseas
surgery would be arduous if not impossible even in cases of gross medical negligence .7
The introduction of “joint commission international” accreditation scheme in more recent
years takes a step to relieve some of these misgivings.8
Furthermore, the staffing ratio of doctors to patients in Thailand is less compared with
that of Australia. This may not just have ramifications for the Australian tourist but also
for the local Thai population that loses the skills of a locally practicing doctor that now
participates in medical tourism. On the “flip side,” it may be that the money from these types
of enterprises is of benefit to the foreign health system and economy and as a consequence
better medical equipment and services are a resource that the local populace can draw on.
The loss to the Australian economy from private medical tourism is obvious. If looking
at Thailand alone, 1.5 million foreigners were treated in their hospitals in 2009, making
their economy US$6 billion.8
For a patient opting to source procedures overseas, their initial contact in Australia is
often a broker, who locates a doctor to perform specific treatment, as well as organizing
flights and accommodation. The patient may have made a significant commitment toward
having the procedure even before they have a consultation with a doctor. This type of setup
has the potential to make it difficult for patients to withdraw even if they have second
thoughts about the intervention.
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ePlasty VOLUME 15
A concern for the authors was the number of patients who underwent dental treatment
during the postoperative period. The performance of dental procedures was clearly docu-
mented in 2 patients’ notes and may have occurred in others, but as there was a lack of
documentation, it made it difficult to assess. Dental procedures add an additional risk for
infective complications to implanted prostheses.9-11 Ongoing cigarette use was documented
in 3 of the patients’ charts. In our health service, these patients who continued to smoke
would have been likely to be refused the surgery they received, because of the significant
increased risk of postoperative complications.12
Multiresistant organisms in Asia such as multiresistant Staphylococcus aureus have a
higher prevalence than those in Australia. Some Asian countries have a prevalence bordering
on 70%.8 In our study population, 1 multiresistant organism was cultured.
Unfortunately, the exact numbers of people receiving cosmetic surgery abroad are not
known to the authors; neither are the numbers of Australians who return from cosmetic
holidays with complications. As such, it is not possible to accurately compare local and
“cosmetic tourism” complication rates. This would be a useful comparison to further
evaluate whether this model of care incurred an additional increased risk to the patient.
CONCLUSION
The financial burden of cosmetic tourism to our hospital over a 1-year period was
AUD$151 172.52. This figure, of course, cannot account for the emotional or psycho-
logical cost to patients whose surgical experience ends with significant complications or
morbidity. In conclusion, this study has demonstrated a range of complications as a result
of patients engaging in “cosmetic tourism.” We have shown that there is a financial burden
being incurred from these complications. These findings support the need for increased
public health strategies in the aims of prevention of morbidity and mortality and the future
management and education of patients engaging in “cosmetic tourism.”
Acknowledgments
We thank the members of the Gold Coast University Hospital for their help in this study.
In particular, we thank Erica Cole & the Finance Department.
Ethics Committee Approval
LNR HREC/13/QGC/96.
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