Sasha Issenberg
The Tokushukai Medical Corporation operates more than 280 hospitals in Japan, enough for the company to often find itself described as the world’s largest hospital chain. In 2006, Tokushukai opened its first overseas facility, in Bulgaria, and I had been prepared for its incongruity amid the dreary blocks south of Sofia’s downtown. “If you drive there, you will drive through a really bad area, then you see there is some kind of an island,” Robert Gerl, the Munich‐based CEO of the Bavaria International Health Association, told me. Indeed, the Tokuda Hospital Sofia did stand out from a distance – a nine‐story ivory puzzle piece in a sort of corporatized‐Bauhaus style – although indoors there was little besides Japanese prints adorning random corridors to distinguish its unusual heritage.
It wasn’t until I walked through the orthopedics ward that I fully appreciated what kind of incongruity was possible within the modern hospital. Part of the reason Tokushukai officials had selected the Sofia site was the promise of serving patients throughout the region, but Tokuda began drawing them from other continents as well. Eastern Europe was becoming a destination for Middle Eastern knees, and Tokuda became popular with patients from Oman, one of several Persian Gulf states suffering from abnormally frequent joint injuries. (The culprits appear to be stress from repeated bending at prayer, along with the high rates of non‐fatal car accidents that typically accompany a country’s belated motorization.)
During a tour of the facility, a hospital staffer mentioned to me the significant number of knee surgery patients from Libya. As Libya’s civil war raged on, the country’s already limited medical system became even more overcrowded, and Tokuda contracted with authorities there to receive their patients. The staffer gestured toward an open door, and when I poked my head past the threshold, my eyes met those of a woman tucked into the bed, and then those of a man I assumed to be her husband hunched over her. His hand clasped hers, a gesture of comfort that appeared unable to weaken the uncertain fear frozen on her face. A head covering suggested the expectation of modesty, which I was clearly in the midst of defying. I didn’t know what to say, or in what language I would possibly say it, and neither did she. I moved along, wordlessly, steadied by the relief that I could not be the source of her anxiety. Here was a Libyan woman trapped in a Japanese hospital in the Bulgarian capital, all when at her most vulnerable. At this point, could the momentary intrusion of a strange American man with a notebook possibly faze her?
Medical tourism can best be defined as cross‐border travel for the primary purpose of securing treatment. The term may suggest carefree holidaymakers, but like the Libyan knee patient, many medical tourists are engaged in a uniquely modern form of rebellion, asserting an individual’s independence from the persistence of political geography.
For a long time, such “patients with passports” – as Harvard Law Professor I. Glenn Cohen called them in the title of his recent book on the legal and ethical dynamics of medical tourism – were only the unfavorably situated. They were wealthy patients stuck in underdeveloped countries, those unable to afford complex procedures where they live and desperate enough to hunt down a bargain, and patients suffering from peculiar maladies in places without the right specialists. Indeed, the most famous classical examples – Gulf sheiks flying to the Mayo Clinic on a private jet, or North Americans heading south for inexpensive breast implants – share in‐extremis attributes, either for care that is an absolute necessity or pure luxury. In short, people traveled for the same reasons tourists always have: to find what they are unable to get at home.
For medical tourists coming to the United States, that tends to be access to care. For American medical tourists heading elsewhere, it is usually lower costs. After all, the same system that produced the Mayo Clinic – and enough doctors, specialized equipment and empty beds to welcome the world’s well‐heeled walk‐in patients – leaves many local residents unable to afford even basic procedures. A 2014 study from the Commonwealth Fund concluded that American health care was both more expensive and less effective than that of ten other similarly industrialized western countries, economics that trickle down to individual patients. The National Center for Policy Analysis in 2007 estimated one with insurance could expect to pay $90,000 for a heart bypass in the United States, but only about $20,000 if traveling to Singapore, $12,000 in Thailand, and $10,000 in India. One of the 30 million Americans without medical insurance could expect to pay more than $200,000 for the procedure at a local hospital.
No institution has pursued opportunity in medical tourism like Bumrungrad International Hospital, in Bangkok, Thailand. First opened in 1980 with 200 beds, it has expanded to several times that, claiming to serve 1.1 million patients annually, about half of them from abroad. For those from countries more developed than Thailand, Bumrungrad is a bargain. For those from countries less developed, Bumrungrad offers access to specialized expertise or equipment unavailable at home. In other cases, Thai doctors will perform specific procedures – most notably, sexual reassignment surgery – that law or custom preclude elsewhere. Bumrungrad now has thirty different specialized centers under its roof, but the hospital’s marketing materials tend to emphasize non‐medical capacities there, such as the two hotels it operates and a permanent visa‐processing center that the Thai Home Ministry has set up on‐site to facilitate extensions for patients. The hospital employs 109 interpreters, which it says covers the range of languages spoken by patients representing 190 countries. (Appropriately enough, “Bumrungrad” doesn’t mean anything in any known tongue, although it is more or less pronounceable in most of them.) In 2004, based on the success of Bumrungrad and many like‐minded Thai hospitals that have followed it, the government launched a marketing campaign branding Thailand the “Medical Hub of Asia.”
But despite Thailand’s claim, the impression that medicine revolves around any particular hospital or country has been unmasked as the type of fiction devised by investment‐promotion authorities and indulged by their ad agencies eager to promote someplace as “the medical capital of the world.” Due to developments as seemingly banal as the ability to quickly move high‐resolution X‐ray images as email attachments, patients can travel for care anywhere, even to hospitals that don’t have their own hotels connected by walkway.
Across the world, globalization has transformed the pursuit of better health outcomes. Linking high‐speed fiber optic networks via undersea cable has made possible the field known as telemedicine, in which the internet is used to facilitate long‐distance care through real‐time monitoring of patients. The integration of once geographically bounded labor markets has led doctors to outsource support tasks, like the reading of X‐rays, to countries where they can be completed at lower costs. (Many X‐rays taken in American clinics are viewed by Indian radiologists.) In the pharmaceutical industry, multinational corporations have proven able to simultaneously exploit advanced economies’ research capacity and legal systems to support innovation, and developing countries’ lower manufacturing costs to bring the resultant products cheaply to market.
But more than other high‐skilled services (like finance and law), most medical talent and infrastructure remain stubbornly grounded in place. When it comes to medical procedures, there is only so much marketers can do to shuttle goods or facilitate the delivery of services. Medical tourism has never demanded much beyond air travel and payments across currencies. Sometimes, as in the plentiful cases of Americans driving across the Mexican border and paying doctors and dentists in dollars, it requires neither.
In the years since Bumrungrad opened, medical tourism has become a dizzyingly multidirectional affair. While one can easily rationalize how Brazil found so much of its national identity tied up in a role as a provider of plastic surgery, many of the grooved routes of medical tourism don’t display a self‐evident logic. Emiratis fly to South Korea for organ transplants. Canadians travel to Costa Rica for checkups. Yemenis with heart disease often end up in India. Cypriots requiring bone‐marrow transplants go to Israel. Each pairing seems to be conjured from a game of Risk, which in its way makes sense, because the unique risk management involved in medical care has bonded countries that have never had particularly deep trade links, migration flows, or military or diplomatic ties.
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Among the regular cast of characters who populate the pages of Hungary’s newspapers and magazines, the one whose fame is hardest to understand in a country long proud of its disproportionate achievement in the field of Olympic medals and Nobel prizes may be the man usually identified simply as the prime minister’s dentist.
Béla Bátorfi’s rise to fame can be traced to the 2010 return of the conservative Fidesz party after eight years of Socialist Party dominance. Bátorfi, then forty‐one years old, had a thriving practice in a posh residential corner of Buda with a clientele that included an impressive slice of the Budapest political elite. Among his longtime clients was the new prime minister, Viktor Orbán, who had been his patient for almost twenty years. Orbán developed a reputation for ruthlessly punishing opponents and rewarding supporters, naming Fidesz loyalists to posts in the central bank and office of the chief prosecutor – departments that had been previously immune to partisan politics. “‘Orbán is putting his people everywhere,’ is a constant lament in Budapest,” the Economist itself lamented early in his term. Even the man who tended to the first family’s teeth stood to benefit.
Bátorfi is indeed a specialist in oral surgery, with a dental degree from his country’s most celebrated medical college, Semmelweis University, and a masters from the University of Münster in Germany. But when his name appears in Hungarian newspapers it is rarely in direct connection to his proficiency with a drill or scalpel. Most frequently, Bátorfi is covered as a subject of political intrigue. When, in his second year in office, Orbán invited dental businesses to bid for a series of government tenders, Bátorfi entered and ultimately won everything for which he appeared to be eligible. (“It is possible to get the money through a complex application, but inevitably Viktor Orbán’s dentist’s company will be awarded the billion forints,” the news website Origo had predicted before one such grant process was complete.) Over the first four years of Orbán’s administration, 3 billion forints in contracts and state aid (equal to roughly 10 million dollars) have flowed from the federal government of Hungary to a congeries of companies and trade associations under Bátorfi’s influence. “Bátorfi has been Orbán’s dentist since 1992,” László Szűcs, a Bátorfi adviser, told the news magazine Heti Világgazdaság, defending his client’s right to bid for government tenders that he would eventually win. “Why wouldn’t he enter into a competition when any other business could compete?”
That sense of infinite possibility now infuses nearly everything Bátorfi does. He also chairs his own eponymous athletic club, based in the northeastern city of Eger, and presides over the Budapest Ironman competition as president of the Hungarian Triathlon Union. “He is expanding into the entertainment business, and could open a famous club in Eger with municipal or state assistance, or take part in a planned real‐estate development,” Heti Világgazdaság reported in the summer of 2014.
The patients responsible for the wealth amassed by the Bátorfi Dental Implant Clinic, however, were unlikely to have ever read about any of its proprietor’s political, sporting, or entrepreneurial exploits. Instead, they knew him only as the studious dentist with an unusually high number of advertisements in London media. “The proof of his work and competence are the more than 35,000 patients he has treated. Dr. Bátorfi is honest and always ready to share his knowledge and expertise with his patients,” declared an ad that Bátorfi placed in The Times to promote a clinic that he had branded the British‐Hungarian Medical Service. “What he lacked in bedside manner he made up for with efficiency,” a travel writer for the Telegraph wrote about a series of 2007 visits to Budapest for implant surgery, noting that by his second visit Bátorfi’s “communication skills had not progressed much beyond the ‘open now’ and ‘close now’ level, and his fast fingers seemed fatter than before.”
Unlike Orbán, Bátorfi’s patients from abroad typically saw the clinic’s self‐described master implantologist only once or twice, if ever. Much as luck had once placed a promising young parliamentarian into his dental chair years before he would make good in politics, a fortuitous connection had introduced Bátorfi to the practice of medical tourism years before the phrase meant much of anything to anyone.
In 2000, a Hungarian based in England had approached Bátorfi with a proposal. If he could persuade Brits to take advantage of cheap and available Hungarian dental work, would the dentist share with him a cut of the new business?
Bátorfi got a license to practice in the UK and rented an office in London. To Bátorfi’s surprise, the patients started coming, adventurous types willing to confront the unfamiliar in search of prices that – even with all travel expenses included – typically fell below half of what they might pay in Bristol or Belfast. “In the beginning, that an English dentist would recommend a Hungarian dentist was unbelievable,” Bátorfi marvels today.
He was nimble enough to reorient his practice to satisfy the new business. Recognizing that foreign customers would be most likely to travel for expensive treatments where they could realize the greatest savings, Bátorfi chose to pursue his masters in implantology, which includes some of oral surgery’s most complex procedures. Back in Budapest, he began setting his prices in British pounds and offering free chauffeur pickup at the airport. Bátorfi spent $150,000 per year on marketing, in addition to other extravagant gestures. About a decade ago, Bátorfi spent approximately $200,000 to acquire four pieces of equipment that László Szűcs calls “the Rolls‐Royce of dental chairs.” Szűcs claims that there are only four other existing versions of the same model, manufactured by the Japanese company Morita: one owned by Russian President Vladimir Putin, one by German Chancellor Angela Merkel, and two by a private Swedish clinic.
Since then, Bátorfi – who appears year‐round with a tan that gives the impression that he has uncovered a secret yacht passage from the Danube to the Mediterranean – has become the perfectly bronzed face of one of the most unexpectedly shimmering sectors of Hungary’s post‐communist economy. Between 2000 and 2008, the number of per‐capita dentists in Hungary increased by 56 percent. Many of them were eager to follow Bátorfi into the increasingly well‐defined sphere known as medical tourism, in which patients travel to another country with the primary purpose of securing treatment. Hungary has more dentists per head of population than any other country, according to London journalist David Hancock, who in 2006 wrote a guide for British patients called The Complete Medical Tourist. “And since the country joined the European Union their fellow Europeans have had plenty to smile about, too, because prices are considerably cheaper there than in neighboring countries like Austria and Germany,” Hancock wrote. “No wonder Hungarians smile a lot!”